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Since the start of the HIV epidemic we have witnessed significant advances in our understanding of the impact of HIV disease worldwide. Further, breakthroughs in treatment and the rapid expansion of HIV care and treatment programs in heavily impacted countries over the past five years are potentially critical assets in a comprehensive approach to controlling the continued spread of HIV globally. A strategic approach to controlling the epidemic requires continued and comparable expansion and integration of care, treatment, and prevention programs. As every new infection involves transmission, whether vertically or horizontally, from a person already living with HIV/AIDS (PLWHA), integration of HIV prevention into HIV care settings has the potential to prevent thousands of new infections, as well as improve the lives of PLWHAs. In this paper, we highlight how to better utilize opportunities created by the antiretroviral (ARV) roll-out to achieve more effective prevention, particularly in Sub Saharan Africa. We offer specific recommendations for action in the domains of healthcare policy and practice in order to better utilize the advances in HIV treatment to advance HIV prevention.
Control of the global HIV/AIDS epidemic remains elusive as setbacks in some areas buffer the gains made in others. On the positive side, HIV incidence and prevalence have declined in specific populations in a number of high seroprevalence countries in Eastern and Southern Africa, and the WHO’s 2007 progress report on the goal of universal access to HIV/AIDS treatment estimates that approximately 2,000,000 individuals in poor and middle-income countries were receiving antiretroviral therapy (ART) at the end of 2006 . On the negative side, results from several prevention studies have been disappointing, including of a promising HIV vaccine candidate, two candidate microbicides and of the use of the diaphragm for HIV prevention [2,3]. Male circumcision for HIV-negative men in high seroprevalence countries driven by heterosexual transmission remains the only recently identified prevention strategy that has the potential to reduce HIV at the population level .
While there is an urgent need for new and effective prevention technologies, it is imperative that effective interventions currently available be widely utilized if we are to successfully slow the epidemic now. An increased emphasis on expanded HIV testing in many areas of the globe is a positive step, however, the transformation of increased testing into a true strategic approach to controlling the epidemic requires continued and comparable expansion of care, treatment, and prevention programs for all those identified with HIV. And it is important that in the context of social justice, all populations have safe access to these programs, including sexual adolescents and those with minority status such as sex workers, men who have sex with men, substance users (including injection drug users (IDUs), and undocumented immigrants and migrants. Since every new HIV infection involves transmission from a person already infected, identifying persons with HIV and enrolling and retaining them in a care system creates the opportunity to deliver biomedical and behavioral interventions that can potentially reduce both horizontal (person-to-person via sex and/or needles) and vertical (mother-to-child) transmission (MTCT) of HIV. According to the UNAIDS global epidemic update for 2007, there were 420,000 new infections in children of which the vast majority was via MTCT, with 2.1 million new infections in adults. Thus the ratio of new children to adult infections is about 1:5, or 17% of all infections globally. The report also indicated that approximately 70% of new infections take place in Sub-Saharan Africa, where the vast majority of HIV transmission is transmitted sexually among adults or from mother-to-child .
Salomon et al. , reporting on an epidemiological modeling exercise of varying implementation of prevention and treatment programs, argue for the need to fully fund and implement both in order to significantly impact the HIV epidemic over the next decade. To understand the potential synergies between care/treatment programs and effective prevention, it is important to review some basic biological, epidemiological and behavioral concepts:
The International AIDS conference in Durban, South Africa in 2000 marked the beginning of serious efforts to address the devastating effects of HIV/AIDS on those living with HIV/AIDS in resource limited countries. These efforts were catalyzed by grassroots mobilization focused on expanded treatment access. The success of the Brazilian national AIDS program became both a model and an inspiration . During the subsequent years, unprecedented energy, funding and planning were mobilized and have resulted in substantial increase in access to antiretroviral therapy in some of the poorest countries in the world.
This achievement is a potentially strategic asset in a comprehensive approach to controlling the epidemic. The challenge we address in this paper is how to better utilize opportunities created by the antiretroviral (ARV) roll-out to achieve more effective prevention with PLWHA. We propose that the appropriate response to the observation that we cannot treat our way out of the HIV/AIDS pandemic is to use the advances in treatment to advance prevention efforts . This strategy is based, in part, on the following observations:
The potential for direct integration of HIV prevention into HIV care and treatment programs include,
Failure to retain patients in care and for those on antiretroviral therapy failure to help them achieve high levels of treatment adherence has negative consequences for the individual in terms of disease progression and for public health in terms of the development and transmission of drug resistant strains of the virus [20–22]. In addition, some have raised concern that availability of effective HIV treatment may lead to a diminished sense of negative consequences of HIV infection and an increased complacency towards safer sex practices [23–26]. As the number of people on ART worldwide increase, so do the opportunities for emergence of viral resistance. This reality should not be considered a barrier to increased rollout, but rather underscores the need for the integration of safer sex counseling as well as adherence counseling into ART delivery programs.
There are many structural and contextual barriers impeding the implementation of effective, coordinated prevention and care programs for PLWHA, including the long-standing practice of separating prevention and treatment. In the U.S. model for example, prevention is the domain of public health and treatment is provided done through the medical care system. In resource-constrained countries, a similar model largely exists and, thus, it is imperative for an innovative public health approach to combine the two and build on existing strengths of each of these programs.
There are numerous other obstacles that have shaped and sometimes distorted the response to HIV/AIDS in different countries, covering a wide range of domains. In this paper, we focus on the most salient among these and offer recommendations for integrating HIV prevention into HIV care and treatment programs for PLWHA worldwide.
In many contexts, taboos associated with discussing sex, homosexuality, condoms and ART persist. These are deemed "foreign" and considerable stigma is associated with being HIV-infected. If patients feel a need to conceal their HIV-positive status within their social network, they may engage in efforts to hide their medications, change dosing schedules, or suppress observable side effects of treatment, all of which may have implications for adherence . Similarly, they may be reluctant to use condoms during sex for fear it may be interpreted by partners that they are HIV-positive, thus “outing” their status.
The lack of political will and ideologically motivated rather than evidence-based policy has impeded effective prevention and treatment efforts in some settings. For example, the Federal ban on needle exchange programs in the United States and the prohibition of delivery of methadone to opiate dependent people by the Russian government have driven vulnerable populations away from appropriate interventions has contributed to HIV transmission rates [28, 29]. Similarly, discriminatory policies such as the criminalization in many countries of sex work, same-sex sexual activity, and engaging in unprotected sex without disclosure of an HIV-positive status is likely to impede HIV prevention and treatment programs [30, 31]. More importantly, these taboos impede communication between patients and healthcare providers about sex and thus impede discussion of sexual risk reduction strategies. If patients are unable to comfortably discuss these issues with health care workers, they may abandon care rather than confront the disapproval of providers and counselors.
For many HIV-infected persons, pregnancy desire and intent is a motivating factor for engaging in unprotected sex, despite the presence of HIV . There is rowing evidence to suggest that HIV infection modifies, but does not remove, individuals’ desires to have children . While most attention to fertility desires among HIV-infected individuals has focused on women, there is mounting evidence to suggest both that HIV-infected men often desire children , and that they have a substantial influence over their female partners’ fertility-related behaviors. Thus, efforts to address fertility-related issues among HIV-infected individuals must target women and men alike. This is important as reproductive desires have an impact on both horizontal as well as vertical transmission of HIV.
Given the disproportionate impact of HIV on the reproductive lives and health of women, the failure to link HIV treatment programs to reproductive health services contributes to the disproportionate negative impact of HIV on women’s health . Basic components of primary healthcare, most notably access to effective forms of contraception, are often not provided as part of routine HIV care and treatment). The synergy between reproductive health care and HIV prevention activities has been slow to materialize on the ground. In light of evidence that preventing unwanted pregnancies among HIV infected women may be the most cost-effective forms of pMTCT , the failure to effectively integrate reproductive health care services to HIV care and treatment represents a substantial missed opportunity in HIV prevention. 
In most countries, even pMTCT programs, which come closest to linking HIV and reproductive health care services, struggle to bridge this divide and have been traditionally conceptualized as a stand-alone prevention intervention located within Maternal and Child Health services. There are conceptual, historical, and operational reasons for this situation, and these may contribute to the low coverage of pMTCT programs in many Sub-Saharan African countries. The integration of pMTCT with HIV care and treatment is likely to achieve clear positive outcomes for both prevention and treatment efforts.
The scale-up of ART programs in has challenged an already overstretched health care workforce in most settings, and, thus, attempts to provide more intensive HIV prevention support will necessarily add to this burden. In the US, a study demonstrated that in most HIV treatment and care settings there was no routine provision of safer-sex counseling directed at the very people who are able to transmit HIV to their uninfected partners .
An increasing emphasis in resource-limited settings has focused on “task-shifting” in an effort to ensure that specific tasks needed in the framework of HIV care and treatment are accomplished while initiating longer-term efforts to establish new cadres of workers and retain all levels of HCWs. Lay or peer counselors are an important cadre of workers that provide important programmatic activities such as HIV counseling, adherence support and community outreach. Relatively few systems have formal programs of behavioral prevention for positives, and an effort to bring such programs to scale will undoubtedly also demand the involvement of lay/peer counselors. While the deployment of lay counselors is laudable, it is important that in the context of competing demands on resources, that adequate emphasis be placed on appropriate training and supervision of these workers. Indeed, much of the counseling currently provided by lay personnel, is not based on any formal behavioral change theory and is largely limited to the dissemination of information rather than processing of patients' emotions and cognitions to alleviate distress and alter long-standing behavior patterns. In the absence of adequate supervision, training, and support for counselors, the possibility of null or iatrogenic effects exists .
Behavior change, whether directed towards HIV prevention or retention and adherence to care, does not lend itself to the strict algorithmic approach that has made it possible to rapidly expand HIV treatment programs. The challenge therefore remains for behavioral scientists to develop, test, and disseminate innovate methods to incorporate theoretically-based effective interventions into public health practice. Correspondingly, health care planners must be educated about the vital need for behavior change interventions if the espoused goals of universal access to care, treatment and prevention are to be met.
Adults and children living with HIV, and those at risk for acquiring HIV, have elevated rates of psychological distress and psychiatric co-morbid conditions, especially mood and anxiety disorders (including post-traumatic stress disorder), and substance use disorders) [39–41]. This psychiatric co-morbidity in the context of HIV can contribute to increased substance use and sexual risk behavior, poor treatment adherence, interpersonal violence, and other maladaptive behaviors, as well as more rapid disease progression and diminished health outcomes [42–45]. Substance abuse can contribute to poor immune functioning and disease progression among PLWHA. Among other problems, alcohol use can modify liver drug metabolism, thus complicating treatment for patients with HIV/HCV co-infection, as alcohol may compromise pegylated interferon therapy and favor liver disease progression . Similarly, mood disorders, particularly depression has been associated with HIV disease progression and poor quality of life among PLWHA [47,48].
It has become increasingly evident that mental health vulnerabilities “travel together” and contribute to ongoing HIV transmission in many regions of the world. Yet, as recently noted by Sweat and colleagues , the provision of psychosocial services for PLWHA pales in comparison with the growing needs of PLWHA living in impoverished and underserved communities. The high prevalence of comorbid medical and psychiatric conditions among PLWHA highlight the pressing need to co-locate different services and specialists to provide comprehensive care for individuals with special needs and overlapping medical and psychological conditions.
The unavailability of safe and easy access to Needle and Syringe Exchange Programs (NSEPs) and safe injecting environments for IDUs contributes to ongoing transmission of HIV in this population as well as continued spread of HIV through sex within their social and sexual networks [49,50]. Several studies have shown that once HIV-positive substance users have access to the necessary support, they are able to adhere to ARV regimens and hence experience treatment benefits despite the complex circumstances involved in their treatment [51,52].
With expansion of HIV treatment programs in resource-limited countries, there is an urgent need to formulate and test innovative management and preventive strategies among HIV-infected individuals with mental health and substance abuse problems in order to minimize loss to follow-up, improve adherence to ARV treatment, and help individuals and their partners live healthier and safer lives, as well as adopting behaviors to minimize risk of HIV transmission to others‥ The provision of ART without accompanying mental health and substance use services for those who need it hamper achieving lasting beneficial impact on the HIV epidemic.
Donors and Governments should be encouraged and assisted to more effectively integrate appropriate aspects of HIV prevention with HIV care and treatment. Ultimately, there is a need to expand the types of services delivered to HIV-infected individuals on the ground. Systems and operational research are critically important to understanding how this can be achieved in diverse countries based on the characteristics of their health care services. Although the goal of coordinated HIV services at the community level is the same across countries, each country’s planners will need to assess existing health systems and the burden and characteristics of their nation’s epidemic to develop an appropriate blend of linkages, co-location or totally integrated services. Donor funding should encourage flexibility and nurture the establishment of creative models of integrated programs. As an example, Brazil’s long term commitment to the integrated delivery of prevention and care to people living HIV/AIDS has been documented [14,53,54] and has demonstrated how the implementation of comprehensive prevention strategies can be successfully accomplished in a middle-income country. Further, a well-integrated and far-reaching system of monitoring and evaluation has been recently established in the country , paving the way for similar initiatives in other middle and hopefully low-income countries. This type of approach is compatible with the recommendation made by the Institute of Medicine regarding focus on integrated prevention and treatment efforts and support for behavioral prevention efforts .
Across countries, women come into contact more often with the health care system and are better positioned to help other family members access health care services (ref). Orienting services to the particular needs of women, which include care of their partners and children when appropriate, is a strategic way to improve adherence to care and treatment programs. Because of the disproportionate impact of the HIV epidemic on women (in both social and biomedical terms), the separation of prevention and care/treatment services is likely to exacerbate the negative consequences of HIV disease for women. Specifically, the triad of HIV care/treatment, pMTCT, and reproductive health care, should be coordinated at the policy, planning and operational levels as a seamless continuum. Integrated services would provide opportunities to deliver interventions across the spectrum of needs of HIV-infected women
In order to better support informed and appropriate sexual partnering and reproductive choices among HIV-positive individuals, and facilitate effective prevention interventions within care and treatment programs, interventions are required at two discrete points. First, at a policy level, clear and explicit statements are required to underscore the importance of free and informed sexual and reproductive choices among HIV-infected women and men (as among all individuals). For individuals considering whether to have a child, clear messages are required regarding the potential risks involved (including vertical transmission of HIV to the child, and possibly horizontal HIV transmission in the case of serodiscordant partnerships), as well as the magnitude of these risks relative to that of a safe pregnancy. Second, policies that support informed choice must be supported by services that allow individual choices to be enacted as safely as possible. Individuals who have decided to have a child require information regarding safe conception and childbearing; individuals who decide to not have a child require access to effective contraception, along with information on sexual risk reduction. Specific interventions for health care providers are needed as they often act as the principle ‘gatekeepers’ to health related information. Health care providers (including nurses, doctors and counselors) require relevant biomedical information on fertility and HIV infection. Many providers may benefit from values clarification interventions, which seek to distinguish between providers’ professional responsibilities and their personal beliefs. Also, standards of care guidelines are needed for routine sexual behavior assessments for all people living with HIV, in conjunction with HIV care and treatment, as well as routine screening for, and treatment of, all STIs.
Since international human rights law prohibits discrimination on the basis of HIV status all countries must ensure that no laws, policies or practices discriminate in access to prevention, care, treatment as well as reproductive and sexual health information and services on the grounds of HIV status, as well as race, color, gender, or national or social origin, . While law reform is a time-consuming political process requiring broad consensus among policy makers, law enforcement practitioners, healthcare professionals, and communities, there are specific policies that can be implemented to improve public health in terms of HIV. Safe access is needed to prevention strategies including sexual and reproductive health and HIV-related services for all people including adolescents and those with minority status such as sex workers, men who have sex with men, substance users (including IDUs), and undocumented immigrants and migrants. Availability of confidential youth-friendly health services for adolescents without legal and policy constraints is critical. In addition, programs are also needed to address the needs of minority and marginalized populations with HIV.
Various sexual risk reduction behavioral interventions have been shown to be effective among HIV-infected men, women, and adolescents [8, 57–59], although these studies have been conducted primarily in the U.S. and have not included evaluated their effect on HIV transmission or other biological outcomes. Thus, more research is needed that evaluates the effectiveness of various interventions on HIV acquisition as well as studies of effectiveness of the behavioral interventions that have been shown to be effective in the US in resource-limited countries. Even with limited data on the effectiveness of the behavioral interventions on HIV transmission and lack of data on their impact when implemented in a programmatic setting, offering prevention services to HIV-infected individuals is now recommended as an important approach to control of the HIV epidemic in the United States . Both the Institute of Medicine (IOM) and the Centers for Disease Control and Prevention (CDC) have advocated for the inclusion of “Prevention with Positives” programs in a coordinated national prevention strategy [55,61].
The development and dissemination of innovative tools is needed in order to assist in their use by a broad range of counselors and healthcare providers. For example, multimedia technology, such as use of laptops and pre-programmed psycho-educational materials as well as standardized training and tools have been used effectively in other health related interventions in resource poor settings, showing improvements in health behaviors among patients and enhanced cost-effectiveness when implemented by community health workers [62–65]. Such tools may have the advantage of: (1) use of videos and pictures to teach memorable lessons to patients, including those with poor literacy, about HIV care, adherence, and sexual practices, (2) improving quality control and consistency of delivery of intervention content, (3) and necessitating limited supervision and training
It is important to find ways to provide and sustain much needed mental health services for all individuals and families living with HIV, both in resource poor countries with limited mental health infrastructure, as well as in settings that already have the capacity and means. HIV treatment guidelines should include routine screening for mental illness as part of regular assessments and the provision of management for individuals with such conditions including appropriate medications and counseling interventions. Creative approaches are needed for provision of mental health services in settings where such services may be perceived as unfamiliar to the culture and the local capacity of health care system. For example, psychological support, particularly around issues such as disclosure, adherence, and sex can be provided by peer counselors, trained nursing staff, and lay counselors from the community. At other times we may need to build more formal mental health infrastructure (i.e., for treatment of psychiatric disorders). Innovative partnerships between community based organizations and clinical settings can assist in enhancing available resources. While it may be difficult for some to justify the provision of mental health or other psychosocial services when there are pressing physical needs (e.g., physical symptoms, food, shelter), to ignore the former may severely limit the ability to control transmission of HIV and to enable individuals and families to remain engaged in treatment programs. Similarly, due to its direct link to HIV transmission, there is a specific need to implement and sustain NSEPs as HIV prevention strategies, as well as ensuring availability of pharmacological and behavioral treatments for PLWHA coping with substance use disorders.
The rapid expansion of HIV treatment programs over the past five years has important lessons for all sectors of the global AIDS community. It has demonstrated that dramatic advances can be achieved by setting clear goals and numerical targets, by increased funding, and by exceptionally hard work by a broad coalition of stakeholders. It has also clarified the need for a global commitment to strengthening weak health care systems across the world. The evaluation of 3×5 done by the WHO, as well as the evaluation of PEPFAR done by the U.S. Institute of Medicine, should be disseminated and discussed as the HIV community plans for the IAS conference in Mexico City, in 2008. If commitments to universal access by 2010 are to be achieved, they must build on a critical assessment of successes and shortfalls of current efforts. This must include a discussion of how access to treatment can advance prevention endeavors. It is the responsibility of the global AIDS community, professionals, PLWHA and advocates, to develop a plan of action with clear timelines for achievement of an integrated approach to HIV prevention linked to care and treatment. While the demand made by activists at the Durban AIDS conference in 2000 that effective HIV treatment be made available to every person who needs it was dismissed by many as utopian, it may now be seen as visionary. The progress since that meeting has clarified the obstacles that must be overcome over the next decade at the international, governmental and community levels in order to fulfill this vision. If this momentum continues, it should serve as a catalyst for a new and more comprehensive approach that aims at control of spread of HIV through effective integration of HIV prevention with care and treatment. There is a need to learn the lessons from the past, renew and broaden the current vision, and set future concrete targets that link prevention with treatment efforts. As WHO Director-General Margaret Chan has said, “What gets measured, get’s done”.
Robert H. Remien, HIV Center for Clinical and Behavioral Studies, NY State Psychiatric Institute and Columbia University, New York, NY.
Alan Berkman, International Center for AIDS Care and Treatment Programs (ICAP) and Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY.
Landon Myer, Infectious Diseases Epidemiology Unit, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa.
Francisco I. Bastos, Oswaldo Cruz Foundation – FIOCRUZ, Rio de Janeiro, Brazil.
Ashraf Kagee, Department of Psychology, Stellenbosch University, Cape Town, South Africa.
Wafaa El-Sadr, International Center for AIDS Care and Treatment Programs (ICAP), Department of Epidemiology, Mailman School of Public Health, Columbia University, and Harlem Hospital Center, New York, NY.