Treatment as Prevention….next steps

Sean Slavin

AFAO Health Promotion Program

Increasing treatment is now strategically embedded. TasP? more cautious.

The place of TasP

Balancing evidence and action

Already have good evidence – not perfect or complete, but it never is

Knowledge generated from clinical trials will always have limitations – they are not real world settings

We can move forward on resolving the political, ethical, health promotion & policy issues

Efforts so far to promote TasP

Value in maintaining distinction between treatment for clinical benefit & for prevention

• Priority in decision making should be individual health. This is particularly important at commencement.

• Condom use or changed sexual practice is an entirely feasible prevention approach prior to treatment.

• Treatment information delivered to PLHIV in the context of health maintenance is complex.

• Treatment as Prevention must include HIV negative people and this means the communication will be very different.

• Allows us to be clearer about the prevention benefits

Some questions…In combination? TasP is an element of combination prevention

understood as a population health approach. What does combination prevention look like for

individuals? Can TasP be a standalone risk reduction strategy? Can we imagine a health promotion campaign that

endorses condomless sex when TasP is effectively used instead?

Or is TasP like a vaccine? Offering a kind of herd immunity & no effect on individual behaviour.

Which target groups?

heterosexual couples? gay male couples? ‘stable’ or monogamous couples? Sex outside the relationship? Casual sex?

What does TasP consist of?

Treatment practices Monitoring practices A relationship agreement A roadmap for couples How might the neg partner be supportively

involved in treatment?

TasP and HIV negative people?

How should we communicate with HIV negative people about TasP?

Broader gay community? How should we support HIV positive people

using TasP to communicate with their sexual partners?

Are we sufficiently clear that TasP requires the informed consent of all participants in the sex?

Working with ‘undetectable’

Low level viremia? Viral load blips clinical v. psychological

significance. Is ‘undetectable’ the ‘new negative’?

HIV treatment and undetectable viral load

2004 2005 2006 2007 2008 2009 2010 2011 2012 20130%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

63.2%

86.8%74.8%

90.5%

HIV-positive men on treatment

Undetectable viral load (men on ART)

HIV-positive men represent ~9% of gay men in the national GCPS sample.

HIV treatment uptake has increased over last 10 yrs (p<.001) and last 3 yrs (p=.001).

Undetectable viral load has increased over last 10 years (p<.001) but has stabilised over last 3 yrs.

Source: Gay Community Periodic Surveys, unadjusted data from six states and territories (n>5,800).

Legal and ethical implications of TasP

Does TasP still require disclosure? HIV- person must consent TasP as a reasonable precaution against HIV

with a similar value to condoms? Criminal v. public health law

Next steps for AFAO…

Member consultations over the coming weeks Leading to the development of a guidance

document for community based health promotion

Aim to answer many of the questions posed today and provide practical suggestions for how to proceed

Finalised by the end of the year Expect my call.

In conclusion

TasP is a revolutionary technology To become a revolution in safe sex it must be

couched within a community based health promotion response

It’s time to get specific and think about programming.

It’s also time to be bold – clinical trials will never provide perfect evidence. We can develop a range of responses to uncertainty – political, social, cultural, sexual.