Enhancing HIV prevention requires addressing the complex relationship between prevention and treatment

Taking HIV Testing to Families: Designing a Family-Based Intervention to Facilitate HIV Testing, Disclosure, and Intergenerational Communication

INTRODUCTION

Facility-based HIV testing does not capture many adults and children who are at risk of HIV in South Africa. This underscores the need to provide targeted, age-appropriate HIV testing for children, adolescents, and adults who are not accessing health facilities. While home-based counseling and testing has been successfully delivered in multiple settings, it also often fails to engage adolescents. To date, the full potential for testing entire families and linking them to treatment has not been evaluated.

METHODS

The steps to expand a successful home-based counseling and testing model to a family-based counseling and testing approach in a high HIV prevalence context in rural South Africa are described. The primary aim of this family-based model is to increase uptake of HIV testing and linkage to care for all family members, through promoting family cohesion and intergenerational communication, increasing HIV disclosure in the family, and improving antiretroviral treatment uptake, adherence, and retention. We discuss the three-phased research approach that led to the development of the family-based counseling and testing intervention.

RESULTS

The family-based intervention is designed with a maximum of five sessions, depending on the configuration of the family (young, mixed, and older families). There is an optional additional session for high-risk or vulnerable family situations. These sessions encourage HIV testing of adults, children, and adolescents and disclosure of HIV status. Families with adolescents receive an intensive training session on intergenerational communication, identified as the key causal pathway to improve testing, linkage to care, disclosure, and reduced stigma for this group. The rationale for the focus on intergenerational communication is described in relation to our formative work as well as previous literature, and potential challenges with pilot testing the intervention are explored.

CONCLUSION

This paper maps the process for adapting a novel and largely successful home-based counseling and testing intervention for use with families. Expanding the successful home-based counseling and testing model to capture children, adolescents, and men could have significant impact, if the pilot is successful and scaled-up.

The promise of treatment as prevention for hepatitis C: Meeting the needs of people who inject drugs?

Treatment as prevention (TasP) is a concept common to the HIV sector. In this commentary we draw on the literature addressing HIV and HCV TasP, alongside qualitative HCV research, to critically appraise the promise of TasP for HCV and assess the needs of PWID in the future of HCV care. With the advent of highly effective direct-acting antiviral HCV treatments, TasP is now under consideration for HCV. A growing body of literature documents numerous social structural barriers to HCV treatment access and uptake for PWID, among whom HCV is highly prevalent. Yet these barriers - and suggestions for surmounting them - are rarely included in emergent literature on HCV TasP. Although HCV TasP has important advocacy potential for increasing treatment access among PWID, critical reflection on its implications are warranted. We outline potential limitations of TasP for HCV and the conditions under which it might be optimised. We argue that HCV treatment as a prevention strategy can only be realisable in a context of enhanced harm reduction access, meaningful community engagement, and enabling environment interventions informed by the needs and perspectives of PWID.

The Continuing Challenge of Reducing HIV Risk among Haitian Youth

There is a dire need for interventions that will address the multiple factors—poverty, substance use, early sexual debut, and violence—that influence Haitian youth’s engagement in risky behaviors. The deteriorating socioeconomic and political state of the country has had a deleterious effect on the sociocultural milieu and on the boundaries that have heretofore kept risky behaviors in check. Historically, the lakou system, a community-based approach that supports the family unit, has disintegrated, leading to the disruption of traditional parenting patterns. The unstable economic system has also led to the increasing use of children from poor families, who through the restavek system, are sent to work as servants in other households. The breakdown of traditional systems, coupled with the increasing economic and political instability, has had a significant effect on Haitian adolescents. Among boys, increased levels of substance use have been associated with multiple sex partnerships and very early sexual debut. Among girls, extremely high rates of sexual abuse and forced sex have led to relatively high levels of HIV. While the majority of them have been exposed to behavior change messages, behavior change itself has lagged because many adolescents do not accurately perceive their risk exposure. This review explores the risks of HIV transmission among Haitian youth, with a focus on vulnerability factors, including substance use, culture, and the socioeconomic context, and provides recommendations for intervention. An ecosystemic approach, designed specifically for Haitian youth and that takes environmental context and culture into account, is needed.

Epistemic fault lines in biomedical and social approaches to HIV prevention

This paper raises the question of how knowledge creation is organized in the area of HIV prevention and how this concatenation of expertise, resources, at-risk people and viruses shapes the knowledge used to impede the epidemic. It also seeks to trouble the discourses of biomedical pre-eminence in the field of HIV prevention by examining the claim for treatment as prevention, looking at evidence constructed through the biomedical frame and through the lens of the sociology of science. These questions lie within a larger socio-historical context of lagging worldwide attention and funding to prevention in the HIV area and, in particular, neglect of populations at greatest risk. Much contemporary HIV prevention research relies on a population science divided over an epistemic fault line from the communities and individuals who must make sense of the intrusion of a life-threatening disease into their pursuit of pleasure and intimacy. There are, nevertheless, lessons to be learned from prevention success stories among sex workers, injection drug users, and gay and bisexual men. The success stories point to a need for a robust social science agenda that examines: the ways that people are socially organized and networked; the popular strategies and folk wisdoms developed in the face of HIV risk; socio-historical movement of sexual and drug cultures; the dynamics of popular mobilization to advance health; the institutional sources of HIV discourses; and popular understandings of HIV technologies and messages.

The rapidly changing paradigm of HIV prevention: time to strengthen social and behavioural approaches

A decade after the world's leaders committed to fight the global HIV epidemic, UNAIDS notes progress in halting the spread of the virus. Access to treatment has in particular increased, with noticeable beneficial effects on HIV-related mortality. Further scaling-up treatment requires substantial human and financial resources and the continued investments that are required may further erode the limited resources for HIV prevention. Treatment can play a role in reducing the transmission of HIV, but treatment alone is not enough and cost-effective behavioural prevention approaches are available that in recent years have received less priority. HIV prevention may in the future benefit from novel biomedical approaches that are in development, including those that capitalize on the use of treatment. To date, evidence of effectiveness of biomedical prevention in real-life conditions is limited and, while they can increase prevention options, many biomedical prevention approaches will continue to rely on the behaviours of individuals and communities. These behaviors are shaped and constrained by the social, cultural, political and economic contexts that affect the vulnerability of individuals and communities. At the start of the 4(th) decade of the epidemic, it is timely to re-focus on strengthening the theory and practice of behavioural prevention of HIV.