Blueprint: Dr. Kenneth Mayer on a menu of prevention in a global AIDS plan

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Dr. Kenneth Mayer provided care to people living with HIV since the beginning of the AIDS epidemic and developed some of the first cohort studies and prevention interventions dealing with the epidemic. As the founding medical research director of Fenway Health, he created a health research program with an international reputation for its community-based peer-reviewed work. He published some of the earliest data describing the prevalence of HIV among men who had sex with men in the early 1980s. He later co-authored the first paper showing that antiretroviral drugs suppressed HIV replication in semen. Since 1994, he has been the principal investigator of the only National Institutes of Health-funded HIV Prevention Research Clinical Trials Unit in New England focusing on biobehavioral prevention and chemoprophylaxis, as well as more than 20 other active research studies focusing on innovative approaches to HIV prevention. He is the co-chair of a National Institute of Allergy and Infectious Diseases-funded protocol evaluating a community-based prevention intervention for African-American men who have sex with men in 6 U.S. cities. He co-authored the first text on AIDS for the general public (“The AIDS Fact Book,” Bantam Press, 1983). A visiting professor at Harvard Medical School, Dr. Mayer also is an attending physician and director of HIV Prevention Research at Beth Israel Deaconess Hospital in Boston.

He answered these questions for Science Speaks’ Blueprint series.

In her address to the International AIDS Conference in July, Secretary Hillary Clinton called for the U.S. Office of the Global AIDS Coordinator  to create a blueprint — a plan for what the U.S. would contribute reach the goal of an AIDS-free generation — to be released by World AIDS Day in December. From your perspective as a scientist and clinician, what key elements should be a part of this blueprint?

The blueprint should reflect the current exciting period, because we now have the opportunity to dramatically slow down the spread of HIV across the planet in a substantial way. Key elements include strategies to increase the amount of testing. The majority of people who are infected don’t know it. The whole issue of testing relates to a couple of things. HIV is still highly stigmatized. To many people, even getting tested means you’ve done something wrong. There’s  also the problem that we don’t always make testing convenient. In some places in Africa they are starting to see results using mobile teams. Each country, each culture will have its own needs.

And then, if you test, and people find they are infected, do they have access to knowledgeable health professionals? Do they have access to treatment? So part of a successful blueprint will be the designation of  funds to train enough health care providers who are knowledgeable enough to get people into appropriate treatment. We now know that getting people to initiate treatment regardless of their CD4 count can both slow down  new transmissions and be beneficial to that person’s health.  But, many systems are not currently equipped to provide treatment for all HIV-infected people. So the blueprint has to figure out who’s going to make the decision of how to prioritize treatment, and how decisions will be made. If the medicines are not readily available, then the whole blueprint falls apart.

Then there’s the other part of the puzzle: If you test someone and he or she tests negative, you have to have training in place so counselors and clinicians can assess the person’s risk. Once that happens, if somebody is risky, it’s important to be able to make referrals to decrease the person’s risk. It may mean treating depression. It may mean making a referral for substance abuse treatment. It may mean addressing domestic violence. A subset of people may be  candidates for PrEP.

When policy makers talk about a combination prevention package, what interventions would you highlight as critical components of combination prevention?

Not everything  is needed by everybody. We need to  have a menu of things that are appropriate: staff that understand depression, substance abuse, domestic violence, PrEP.  Adult male circumcision will be another part of the prevention package.

Based on the latest research, what should global programs like PEPFAR be aiming for in terms of timing to initiate treatment in HIV-positive people?

The more the CD4 count number moves up to 500, the better. More countries are moving up to 350. In HPTN 052, the median CD4 count was in the 400s when participants started HAART in the early treatment group, who were less likely to transmit HIV to their partners. For discordant couples, you might want to start treatment at a higher CD4 count, because of the greater risk to partners.  But national treatment guideline decisions get back to resource issues.

Should OGAC and the blueprint put forth a prioritization process for use of U.S. tax dollars? What should the priorities be?  Are there elements of the current program that should be abandoned in favor of these priorities? If so, which ones?

I think you need to put in a prioritization process because the epidemic is heterogenous. There are different drivers in different parts of the world. So the priorities for Estonia and Uganda are going to be very different. Estonia, like other  former Soviet Union countries, has a raging injecting drug use epidemic. Opioid substitution therapies and needle exchange would have to be priorities there.  But if you take Uganda, there’s a small injection drug use issue, but a lot of sexual transmission, so you have to do things that decrease sexual transmission. Prioritization is important, but has to be local, not composed from Washington, DC.

What role should research play in the blueprint?  If you believe it should play a role, what research questions should be prioritized?

Research continues to have to be an important part of the blueprint because we don’t know all the answers and many of the findings on which we’re basing programs are fairly recent, so we have to watch them evolve over time. For example, treatment as prevention has to be watched to see if it continues to be effective over time.  Indications are that it remains an effective strategy,  but that’s the kind of thing that has to be monitored.  What’s the best way to offer treatment as prevention and PrEP  for couples who want to have children? What’s the best way to get people to get tested? To adhere to treatment? What’s the best way to monitor people on PrEP?

How can this blueprint address previous failures to reach affected populations with prevention, testing, and treatment?

It’s important for the blueprint to build in support for human rights throughout the process. Some failures to reach affected populations are because of members of those populations feeling highly vulnerable, and highly stigmatized. There are people who will not access prevention, testing and services because to acknowledge their sexuality can put them at great risk. If the people at these institutions are not perceived as culturally sensitive and knowledgeable, people at risk might not feel engaged. So part of the blueprint should be to assess what’s working and not and have the flexibility to change programs in response to noticing that certain populations are not engaging.

Should a blueprint set goals that seem certain to be attained, or aspirational goals that would be ideal – i.e. every infected person on treatment – with the risk of falling short?

I would lean more toward the aspirational side because we need to keep challenging ourselves given the gravity of the epidemic. We don’t want to be unrealistically idealistic, but what’s happened several times in the epidemic is that targets were met before they were anticipated. A notable example was the expectations when the scale up of treatment began. The acceptance of generic medication by PEPFAR made it much more feasible than expected, when the cost went from thousands of dollars to hundreds to put a person on treatment.

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