A range of HIV prevention, engagement, and care approaches were presented in Dryden and Manitoulin, ranging from biomedical prevention, to improved testing, to innovative telehealth interventions.
Mark Gilbert of the OHTN and Gordon Arbess of St. Michael’s Hospital spoke about new biomedical preventions, specifically PrEP (pre-exposure prophylaxis) and TasP (treatment as prevention).
- PrEP consists of an oral pill taken daily by people who are HIV-negative. Several clinical trials have found that taking PrEP consistently can reduce the risk of HIV infection by 90% or more; some studies also show that intermittent or event-driven use of PrEP (ie. taking the medication in a systematic way for a few days before AND after a high-risk encounter) can reduce HIV transmission.
- TasP refers to antiretroviral medication taken consistently by people who are HIV-positive. Several major studies (including HPTN-052, the PARTNER study, and the Opposites Attract study) have found that reducing viral loads to undetectable levels can prevent the transmission of HIV by 90 – 95% or more. In the PARTNER study, which involved both heterosexual and same sex couples, there were no new infections.
While PrEP and TASP can successfully reduce transmission, there are barriers to both prevention methods.
- With PrEP, patients might be unaware of the treatment option, or unsure of where to find it. It can also be difficult to encourage people to take a daily pill when there is no obvious benefit to how they feel. At the provider level, clinicians might be unsure of how to deliver the medication, or they might feel uncomfortable assessing a patient’s suitability for the drug (since this involves asking questions about sexual practices and substance use).
- With TasP, people might have mental health or addiction issues that make adherence difficult, or they may decide to delay the start of antiretroviral medication. Gordon Arbess stressed that HIV needs to be treated, and that there are no compelling reasons to delay the start of antiretroviral therapy. For example, the START trial compared HIV-positive individuals on treatment to those who delayed treatment. It found so many more complications among those who delayed treatment that the trial was ended, and all participants were encouraged to start antiretroviral therapy.
“The pendulum has swung towards treating HIV early with potent treatments that are now more easily tolerated.”
Mark Forsythe of M’Nendamowin Health Services noted the importance of education as a prevention tool – as well as the barriers to delivering HIV and HCV-related education in small communities. Many people in these communities may not be aware of the transmission risks they face, but the stigma attached to HIV and HCV means that they won’t attend education events. Forsythe stressed that avoiding anything related to HIV or HCV education is rational in a small community, but means that many people who need information don’t receive it.
“There’s an assumption that if I’m walking into a presentation on HIV or hep C, and someone sees me, they’re going to automatically assume I’m HIV or hep C positive. So getting education out there is really tricky, and you kind of have to hide it.”
One way to counter stigma is to test for HIV aggressively – to offer testing without waiting for people to ask for a test or for health care providers to screen for risk behaviours. Gordon Arbess described this as the approach taken in the United States, where the Centres for Disease Control has recommended one-time HIV screening for all Americans aged 13 – 64, regardless of risk factors. Arbess recommended this approach, especially for practitioners in areas where HIV is prevalent.
Connecting more people to testing was a major prevention initiative described by Laurie Ireland of Winnipeg’s Nine Circles Community Health Centre. Ireland noted that many people in Manitoba are diagnosed late, with very low CD4 counts. At the individual level, late diagnosis means missing the chance for early HIV treatment and the best prognosis; at the community level, late diagnosis increases the risk of onward transmission.
Ireland noted that, overall, HIV testing rates in Manitoba are very low (at roughly 5%), and that data shows clinicians testing for gonorrhea and chlamydia but not HIV – even though all are transmitted sexually. In response, the Manitoba HIV Program (which includes Nine Circles) has begun to advocate for more HIV testing in the province. The Program has been promoting HIV testing with:
- educational mail outs to primary care physicians, including a list of conditions that could indicate the presence of HIV infection
- HIV-related education to med school students and residents
- sexual health awareness sessions in local communities
- point-of-care testing training to all interested clinicians.
Once people in rural and remote areas are diagnosed, they face significantly more obstacles in accessing care than people in urban areas. This is especially true of specialist mental health care. To address this problem, Travis Lovejoy of Oregon Health and Science University described work his team has been doing in adapting existing in-person interventions for remote use.
Lovejoy’s team took two group therapies – supportive-expressive therapy and coping effectiveness training – and began to offer them over the phone. Groups were comprised of people living in different states and in different time zones – though all participants were living with HIV and depression. Lovejoy found that supportive expressive therapy worked best over the phone, and that people were able to feel connected and supported even though they were geographically far apart. Lovejoy noted that although the calls took time to organize and facilitate, the positive effects showed the potential that teletherapy can have in helping people living far from specialist mental health and HIV care.
- OHTN Evidence Review: HIV sexual transmission risk by people with suppressed HIV viral load
- OHTN Protecting Lives, Preventing HIV: PrEP Think Tank Report
- The START Trial (Strategic Timing of AntiRetroviral Treatment)
- CDC recommendations for HIV testing
- Ontario Guidelines for HIV testing (2008)
- Manitoba HIV Program: HIV testing recommendations and 2015 update
- Supportive-expressive and coping group teletherapies for HIV-infected older adults: A randomized clinical trial (telehealth intervention)