HIV / AIDS. Prevention In Our Lives

Transcription

1 HIV / AIDS Prevention In Our Lives

2 Prevention In Our Lives: Produced by the Treatment Action Campaign. Authors: Published: September 2010

3 Conte n t s Introduction: Statistics on HIV in South Africa 2 Why Prevention? 4 Behavioural vs. Biomedical Prevention Behavioural 6 Biomedical 8 HIV Prevention and Gender 12 Prevention and Vulnerable Groups 14 What are the Obstacles? Milestones of HIV Prevention 16 CAPRISA 004 Microbicide Trial Research Studies 18 Challenges 21 Case Study Moving Forward

4 S t a t i s t i c s on HIV in South A f r i c a P a g e 2 South Africa has an HIV/AIDS epidemic. In order to contain this epidemic, it is important to understand and prioritize HIV prevention. To grasp the scale and impact of HIV in South Africa, consider the- national statistics: se HIV Prevalence: In 2009, an estimated 5.7 million South Africans were HIV positive This means that South Africa has the HIGHEST number of people living with HIV than anywhere else in the world Although HIV infection rates are decreasing every year, 1500 new individuals become infected with HIV every day in South Africa In 2009, it was estimated that 18 % of South Africa s population between the ages of 15 and 49 were infected with HIV This estimate ranges by province with HIV is most prevalent in KaZulu Natal and least prevalent in the Western Cape Causes of HIV Infection: The most common mode of HIV transmission in South Africa is heterosexual (male/female) sex. Sex between men Intravenous drug use Mother-to-child transmission Regional migration virus brought into country from abroad; infected persons may be unaware of HIV status and lack access to public health services. Lack of knowledge on safe sex and HIV; high-risk sexual behaviour

5 Who is Infected? According to the South African National HIV Prevalence, Incidence, Behaviour and Communication 2008 Survey, these are the groups most at risk of HIV: African females aged 20 to 34 33% infected African Males aged % infected Infants born to HIV positive mothers 16 % infected Young women aged 15 to % infected High risk drinkers 14 % infected People with disabilities 14 % infected Recreational drug users 11 % infected Men who have sex with men (MSM) 10 % infected Males aged 50 to 55 6% infected It is important to note that many people may not know their HIV status or may be unwilling to disclose their status publically which means that HIV statistics are never 100 % accurate. Many of these high-risk groups face social stigma and harsh laws. As a result, they are likely underrepresented in the statistics. Impact on the Community In 1990, before South Africa s HIV/AIDS epidemic had spread, average Life Expectancy was 62 years. In 2008, it was estimated that Life Expectancy has fallen to 51 years of age. In 2008, approximately 3.5 million deaths occurred as a result of HIV/AIDS In 2008, there were roughly 1.4 million children age 0-17 who were orphaned by AIDS High HIV prevalence in adults means that the country s working population is smaller and less productive

6 W hy P reve n t ion? P a g e 4 South Africa has made significant progress in making HIV Treatment available and affordable to those in need. In 2002, the national government finally overcame AIDS denialism and acknowledged the urgent need to make antiretroviral (ARV) drugs accessible to the South African population. By 2007, it was estimated that 460, 000 South Africans had access to ARV medication. In the same year, the South African government launched the National Strategic Plan (NSP) for HIV/AIDS and STIs which aims to have 80 percent of South Africans in need of ARVs covered by South Africa now has the highest public sector ARV program of any country in the world. However, HIV Treatment is by no means accessible to everyone who needs it. Today, over half of South Africans who need ARVs are still unable to access them. This means that the NSP targets are not likely to be reached by So if accessible treatment is still a priority...why focus on HIV prevention? Providing universal access to HIV treatment should remain a critical goal of governments, civil society organizations and individuals both locally and internationally. But, treatment alone cannot contain South Africa s HIV/ AIDS epidemic. The only way to eliminate the threat of HIV/AIDS is to combine HIV treatment, support and care services, with stronger efforts to prevent new HIV infections. Prevention is better than a cure: to date, there is no HIV/AIDS vaccine and we cannot be too hopeful that one will soon be available but HIV is a PREVENTABLE disease! A major reason why HIV is so prevalent, is because people lack the information and services needed to protect themselves against infection.

7 There are many different HIV prevention strategies that have been proven effective, and many additional prevention tools that are being researched, developed and tested. However, when the general population is not aware of their options, they are more likely to engage in high risk behaviour, like unprotected sex or intravenous drug use; they are more likely to go without routine HIV testing; they are more likely to unknowingly infect a sexual partner. Leadership is needed to prioritize HIV prevention and ensure that South Africans have access to the information, products and services needed for people to protect themselves and their partners. The South African government has recognized the need to scale-up their HIV prevention efforts. In April 2010, they launched the HIV Counselling and Testing (HCT) Campaign. The main objectives of the campaign are to encourage positive behaviour change and to test 1.5 million South Africans over the age of 15 by The Campaign acknowledges that HIV testing is crucial for both treatment and prevention. If people are found to be HIV positive they can begin a treatment regimen sooner and prevent infecting others, and if they are negative, they can be educated on how to remain uninfected. The HCT Campaign is an important initiative for South Africa. But there is a lot of advocacy work that still needs to be done. Existing prevention methods are often unavailable or used incorrectly, new and complex prevention technologies are emerging, groups that are vulnerable to HIV are consistently being ignored and many South Africans remain uneducated about sexual health and HIV. This guide will provide an overview of HIV prevention in South Africa today: what prevention tools are available, how different groups are effected, what research is being conducted, milestones and setbacks and future prospects.

8 B e h av i o u ra l vs. B iomedical H IV Preve n t ion Page 6 There are many different ways individuals can protect themselves against HIV. It can be confusing to navigate the various strategies and understand the difference between HIV prevention that is behavioural, or biomedical, in nature. It is important to note that there is no magic bullet for HIV prevention. Combining many prevention strategies, including both behavioural and biomedical, offers the best chance at protection against HIV. BEHAVIOURAL HIV PREVENTION Behaviour refers to the manner in which a person conducts themselves. Behaviour is very important when it comes to HIV prevention; the choices that an individual makes when it comes to things like sexual activity, alcohol consumption, and drug use, have a large influence on HIV infection and prevention. HIV prevention strategies that are behavioural include: Abstinence i.e. choosing to not engage in any sexual activity Condom use male and female condoms are roughly 98 % effective against HIV when used correctly. Remembering to put on a condom before sex, making the mutual decision to use protection, or (for women, especially) refusing to have unprotected sex can be a challenge for many people but it is one of the most effective ways to prevent HIV transmission.

9 Going for routine HIV testing and requesting that all partners be tested Faithfulness between sexual partners who have tested HIV negative. Limiting number of sexual partners A person is at a high risk of HIV if they have unprotected sex with multiple sexual partners in a short period of time. Choosing how many sexual partners one has is a right but it should be combined with responsible behaviour such as condom use and more frequent HIV testing. Responsible alcohol consumption. Alcohol is a depressant that slows down brain activity. As a result, alcohol is linked to high risk sexual behaviour and intravenous drug use which are both sources of HIV infection. Eliminating, or reducing harm of, intravenous drug use. The majority of HIV/ AIDS cases in Sub-Saharan Africa occur through sexual transmission; however, injecting drugs is another major way HIV can spread. Drug users who choose to share syringes or reuse needles become highly vulnerable to HIV infection. Drug use is also proven to cause riskier sexual behaviour.

10 B e h av i o u ra l vs. B iomedical H IV Preve n t ion Page 6 BIOMEDICAL HIV PREVENTION - Unlike behavioural prevention, biomedical HIV prevention methods use a medical intervention. This intervention may mean taking medication, like a pill or a gel, or it may mean having a medical procedure, such as Medical Male Circumcision (MMC). Vaccines Despite a great deal of research and funding, NO proven vaccine against HIV has been developed. It is unclear when, if ever, an HIV/AIDS vaccine would be available on the market. There is a vaccine against HPV (human papillomavirus) which is a common sexually transmitted infection. Research shows that HIV positive individuals are more likely to become infected with HPV due to their weak immune system. Recent studies also suggest that men with HPV are at a higher risk of becoming infected with HIV. As a result, the HPV vaccine could be an important tool for HIV prevention. Microbicides What are they? Microbicides is the name given to a new type of substance that is applied to the vagina or rectum to prevent the transmission of HIV and other sexually transmitted diseases (STIs). Microbicides take several different forms including: gels, creams, sponges, rings and films. Unlike condoms, microbicides are not necessarily contraceptive, which means they do not protect against pregnancy. There are many different types of microbicides being tested and therefore, it is still unclear how microbicides will impact HIV, STI and pregnancy prevention.

11 How do they work? Microbicides contain the same substances that are used in anti-retroviral (ARV) drugs for people living with HIV such as: tenofovir, dapivirine, and UC-781. ARVs work by slowing down or stopping viral infection in HIV positive people. Similarly, ARV-based microbicides work by blocking the reverse transcriptase viral protein that is needed for HIV to reproduce in the body. This means that an HIV negative person could use a microbicide to help prevent the virus from being transmitted. Post-Exposure Prophylaxis (PEP) PEP is when a person takes ARVs after being exposed to HIV. ARVs are taken for a month after the person is exposed to help block HIV from being transmitted. PEP is typically used by health care workers who may have come in contact with HIV positive blood. PEP is also used in other situations where people may have been exposed to the virus such as: after rape, when a condom breaks and one partner is HIV positive, or when sharing needles when one user is known to be HIV positive. Pre-Exposure Prophylaxis (PrEP) PrEP is when a person takes ARVs before they are in contact with the virus to avoid becoming infected. Prophylaxis is not a new concept. For example: Malaria pills are taken before a person travels to an area where there is a high risk of contracting the disease. By medicating oneself beforehand, they can greatly reduce their chance of becoming infected with malaria. Researchers are working to determine if ARVs could work in the same way to prevent HIV infection. A person from high risk groups or high risk areas, could take ARV pills in advance as one way to help protect themselves against HIV.

12 Medical Male Circumcision Voluntary Medical Male Circumcision (MMC) has been proven safe and effective as a means of HPV and HIV prevention for men. MMC is a worldwide procedure that surgically removes the foreskin of a male s penis. Three studies in Kenya, South Africa and Uganda showed that MMC can be up to 60 % effective in preventing new cases of HIV. Many governments and organizations have encouraged a scale-up of MMC campaigns. The procedure is cheap and easy to perform which makes it a vital prevention tool. However, MMC alone does not protect men against HIV; it must be used as part of a comprehensive HIV prevention strategy that includes condom use. What about Traditional Male Circumcision? Traditional Male Circumcision (TMC) must be differentiated from medical circumcision. TMC refers to circumcision procedures that are typically performed on boys in a non-sterile environment as part of a cultural or religious ritual. Males may undergo TMC voluntarily or through coercion. TMC does not have the same impact as MMC on HIV prevention. In TMC procedures, the amount of foreskin being removed may not be sufficient enough to reduce the risk of HIV TMC can actually increase a male s risk of HIV infection: Multiple circumcisions are often performed using the same knife which can spread the virus Traditional procedures often have complications such as infections or wounds that will not heal which makes these men more vulnerable to HIV Newly circumcised men may be encouraged to have sex before their wounds have fully healed

13 Treatment as Prevention Treatment as Prevention is when people who are HIV positive take ARV medication regularly. ARV treatment has many benefits like improving the quality of life and reducing the risk of mortality for people living with HIV. However, ARVs can also be a very important tool for HIV prevention. Following an ARV medication regimen lowers a person s chance of transmitting the virus to someone who is not infected. This is because the ARV medication can slow down or even eliminate the growth of the virus in the bloodstream. This does not mean that ARVs eliminate HIV from the body altogether but it would lower the rate of HIV transmission. Treatment as Prevention includes: Prevention of Mother-to-Child Transmission Putting HIV positive pregnant women on ARVs during pregnancy, delivery, and post-delivery limits the risk that they will transmit the virus to their infants. Without taking ARVs, the risk that the child will become infected is 30% but when ARVs are taken, the risk of mother-to-child transmission is only 2%. HIV Counselling and Testing Frequent HIV Counselling and Testing (HCT) means that HIV can be detected quickly. It means that people who have HIV can be put on treatment right away which will help prevent the spread of the virus. HCT also means that people who test HIV negative can take the proper measures to stay protected. The South African HCT Campaign aims to achieve these prevention benefits by encouraging all South Africans to seek testing and know their HIV status.

14 H IV Preve n t i o n & Gender Page 12 HIV is a gendered epidemic. This means that it effects men, women and LGBTI (lesbian, gay, bisexual, transgender and intersex) people differently for social reasons, as well as biological reasons. Gender inequality* helps explain why young women have become one of the most vulnerable groups to HIV. In Sub-Saharan Africa, women make up 60 % of all people living with HIV/AIDS. Therefore, it is very important to address these gender inequalities and how they relate to HIV prevention. Men Gender norms Throughout Africa, men are expected to be strong, fertile and in control. These public attitudes mean that many men can feel unmanly if they go for HIV testing, always using a condom or disclose their HIV status publically, for example. Male circumcision Voluntary male circumcision has many preventative benefits but it also comes with risks. In many cultures, circumcision is forced on young men and carried out in unsafe ways. Also, many men who are circumcised think that they no longer need to use condoms or take other measures to prevent HIV. Men need to understand the benefits and risks of MMC and understand that it is only one element of an effective HIV prevention strategy. *Gender inequality is the relative difference in power between men, women, and transgendered persons. In many societies, boys and girls are taught that men make the rules and women obey them.

15 Women Lack of reproductive health services many women are without access to HIV information and services that could help prevent against infection. Power to enforce condom use: Many women lack the power to enforce condom use by their male sexual partners due to fear of violence or being left etc. Sexual violence many women have been victims of abusive relationships, rape or coerced sexual activity. Sexual violence can physically increase a woman s risk of contracting HIV and makes it extremely difficult for her to demand that protection be used. Female condoms: Female condoms have been proven safe and effective as a method of HIV prevention. However, female condoms are not available or affordable to most South African women. As the only proven tool for prevention that is female-controlled, it is necessary to make female condoms accessible to all women. LGBTI Individuals The challenges faced by lesbians, gays, bisexuals, transgendered and intersex individuals are not the same. For example, gay men are much more vulnerable to HIV than lesbian women. Their challenges should not be lumped together but there are issues that each of these groups faces: Stigma and discrimination many LGBTI face discrimination from health care workers when they seek HIV prevention services like HIV testing. Limited sexual and reproductive health rights These groups face much more difficulty exercising their sexual and reproductive health rights than heterosexual men or women do. This means it is more difficult for them to access services, products and information that could prevent HIV infection.

16 P reve n t i o n a n d Vu l nera b l e G ro u p s Page 6 To date, HIV prevention efforts have often neglected the groups that are most vulnerable to HIV infection. Men Who Have Sex With Men Men who have sex with men (MSM) includes any men who engage in sexual activity with other men, regardless of whether they identify as heterosexual, homosexual or bisexual. MSM are highly vulnerable to HIV. In a 2006 study, it was estimated that MSM in Africa are up to 4 times more likely to be HIV positive compared to the general population. It is also estimated that only 1 in every 5 MSM has access to the HIV prevention, care, and treatment services needed. Intravenous Drug Users Intravenous Drug Users (IDU)s refer to people who inject drugs directly into their blood stream. There are at least 80,000 known IDU s in Sub-Saharan Africa and likely many more. IDU s are highly vulnerable to HIV through shared needles and syringes, as well as high-risk sexual activity.

17 Commercial Sex Workers Commercial Sex Workers (CSW) are male, female or transgendered individuals who sell sex for money. CSWs are at a high risk of HIV infection since they have multiple sexual partners and are not always willing or able to negotiate condom use. CSWs are also subjected to discrimination and stigma which keeps them from seeking out HIV testing and support services, and means they are more likely to infect their customers unknowingly. WHAT ARE THE OBSTACLES TO HIV PREVENTION? Members of these groups are rarely recognized by governments and HIV programme donors due to fear, stigma and discrimination. In many African countries, MSM, IDUs and CSWs are socially marginalized and/or illegal. South Africa has begun to take measures to address discrimination against vulnerable groups. However, in reality, little progress has been made: Sex work remains a criminal offence under the Sexual Offences Act of Decriminalizing the sex industry is needed to protect the safety and health of sex workers. Illicit drug use is also a punishable offense. This makes it difficult to run clean syringe and needle exchange programs. Although gay marriage was legalized in 2006 and tolerance of homosexuality has improved, stigma against MSM and LGBTIs remains very high throughout South Africa. Although the HCT Campaign acknowledges MSM, IDU and CSW as vulnerable groups, there is no explicit mention of how at-risk populations will be targeted for HIV counselling and testing. These factors make it extremely difficult for vulnerable groups to obtain public health services and products. Even when members of these groups do seek public health services, they often face discrimination by health care professionals, social workers etc. Without breaking down the stigma and discrimination against these most at-risk groups, it will be impossible to prevent the spread of HIV.

18 M i l e s to nes in HIV P reve n t ion Page 16 CAPRISA 004 TRIAL The CAPRISA 004 trial tested the safety and effectiveness of a vaginal microbicide gel in 889 HIV negative South African women. The following study results were reported at the 2010 Vienna International AIDS Conference: Safety: There were no major side effects in any of the women who used the gel; no safety concerns for women who became pregnant during the study; no evidence of drug resistance to tenofovir for women who became HIV positive over the course of the study; and no evidence that the participants decreased their use of other HIV preventative practices, such as condom use. Effectiveness: After 30 months of use, the tenofovir-based gel resulted in 39 % fewer HIV infections and 51% fewer herpes infections. These results certainly leave unanswered questions and require that research be done with a larger sample group and over a larger period of time before microbicide gels can truly be proven safe and effective. However, CAPRISA results marks a major milestone in biomedical prevention research because: It is the first positive result in a vaginal microbicide trial the trial shows that antiretroviral drugs can be used to prevent HIV in women The tenofovir microbicide gel and the CAPRISA study were developed by South African researchers which illustrates their innovation and commitment to HIV prevention CAPRISA 004 was the first microbicide trial to receive funding from the South African government The positive results show there is potential to make a female-controlled HIV prevention method available and that South African women are willing to use and adhere* to a microbicide product. * To adhere to something means that you stick with it over time. A tenofovir gel will only be effective against HIV if it is used correctly and continuously.

19 MMC CAMPAIGNS?

20 Curre n t S t u dies on P reve n t ion Page 18 Key Terms: Controlled trial This means that there is one group that takes the ARV medication and one group that takes a placebo drug Placebo drug a drug that looks like medication but contains no ARVs Double-blind This means that even the researchers involved do not know which participants are in the ARV group and which are in the placebo group Sample refers to the participants of the study VOICE Vaginal and Oral Interventions to Control the Epidemic What is the VOICE trial? The VOICE trial is testing the safety and effectiveness of a tenofovir microbicide gel and a Truvada PrEP oral tablet when taken by HIV negative women to prevent infection. It is a controlled, double-blind study. Who is involved? The study is being conducted by the Microbicides Trial Network. It includes a sample of 5000 women from across Southern Africa. When can we expect results? Results should be available in Fem-PrEP What is the Fem-PrEP trial? The Fem-PrEP controlled, double-blind trial is testing the safety and effectiveness of a Truvada pill in preventing HIV infection in women. Who is involved? The Fem-PrEP study is expected to have 3900 female participants from 6 African countries (Kenya, Zimbabwe, Tanzania, Malawi, South Africa and Zambia).

21 This sample will only include HIV negative women who are between the ages of and who are at a high risk of HIV infection. In addition to taking Truvada or a placebo pill, all participants will receive HIV counselling and condoms. The Fem-PrEP study is being sponsored by Family Health International. It is a phase III trial which means it has a longer duration and a bigger sample than Phase I and II studies before it. When can we expect results? The study began in May 2009 and is expected to be completed in Partners PrEP Study What is the Partners PrEP Study? The Partners PrEP Study is also testing the safety and effectiveness of ARV drugs in preventing HIV transmission. However, this Phase III double-blind study is looking at sexual partners where one person is HIV negative and the other is HIV positive (also known as: discordant couples). This trial is comparing the effectiveness of two different types of ARV medications: Truvada (pill) and tenofovir (pill). Who is involved? The study plans to enroll 4700 couples from Uganda and Kenya. The sample couples will be divided into 3 randomly assigned groups: one that will take Truvada, one that will take tenofovir, and one that will take an identical placebo drug. This study is being conducted by the University of Washington, the University of Nairobi and the Fred Hutchison Cancer Research Centre in Seattle, USA. When can we expect results? The results of the Partner PrEP study are expected to be available in 2012.

22 Status of Current PrEP Research

23 B i o m e d i c a l Re search C h a l l e nges Page 21 Communication Biomedical prevention research is complex. It includes many scientific and research terms that are hard for the general public to understand. Finding ways to effectively communicate what research is being done and what the results mean needs to be a big part of HIV prevention efforts. Time biomedical research is a long process. Before prevention products can be available on the market, they need to undergo many different levels of testing. For example, although CAPRISA 004 showed that a vaginal microbicide gel could help prevent HIV in women, it will be many years before this type of product is made available to women. Funding The global recession led to a cutback in HIV/AIDS spending. For example, instead of stepping up research efforts, there was a 3% decline in microbicide funding from 2008 to Without enough resources to do biomedical prevention research, it will be years before new prevention interventions, like microbicides, can be properly developed and made available to the public.

24 T r e a t m e n t A c t i o n C a m p a i g n