User Perspective on ARV-Based HIV Prevention Suwat Chariyalertsak, MD., Dr.PH Research Institute for Health Sciences Chiang Mai University. Chiang Mai, Thailand ARV-based HIV Prevention in Practice : Social and Behavioural Aspects

Outlines Why user perspectives are important and crucial for the success of ARV- based HIV prevention strategy. What are different between HIV +ve and HIV-ve people who will use ARV drug. Understand barriers and motivators. Summary

Decrease in HIV Transmission Decrease in HIV Transmission Maintain Viral Suppression Suppression TreatTreat Enroll in Care Address concomitant concerns: depression, substance use, relationship dynamics Address concomitant concerns: depression, substance use, relationship dynamics Combination Antiretroviral Prevention HIV Negative TestTest Interventions to Increase HIV Testing PositivePreventionPositivePrevention Linkage To Care Linkage Adherence to ART ART Initiation. Risk Assessment PrEP, Adherence Counseling Counseling HIV Positive HPTN 065: Testing, Linkage to Care, Treatment

Is it so simple and easy to do as we design ? How can we make sure that it will really work as we think and we plan ? Clinical trials mostly will be very much different from program implementation in real health setting

Strategies to reduce HIV transmission Oral PrEP

Why user perspectives are crucial in HIV Treatment & Prevention Safe sex practices, using condom, reducing number of sex partners, these are easy to say BUT not easy to behave all the times. Taking pill(s) everyday, may be easy for someone, BUT mostly will not be so easy for most people with various of reasons. Most important, NOBODY can do it for them, they need to do it appropriately and correctly by themselves.

You can teach them how to use a condom but you can’t do it for them

You can show them how to take a pill(s) but they need to take and swallow it by him(her)self…

What we (researchers, clinicians, health care providers, policy makers, ect.) think it should be good for them to prevent HIV infection, BUT people may think and act differently from what we thought ; We said...Wear condom when you have sex will protect you from getting HIV. People think…Using condom with my sex partner mean I didn’t trust on them or I may have HIV in my body !

Partner types and condom use Survey on sexual behaviour in Cape Town, SA Published on November 28, 2013 by Wim Delva concurrent-sexual-relationships-in-cape-town-south-africa.html

We said... Taking one pill a day can reduce your chance to get HIV infection from your sex partners … People think… If my partner or people see me taking ARV drug, then they may think I have HIV infection ! OR I don’t think I have a risk during this week !

Who are the targets for ARV- based HIV Prevention HIV +ve person HIV -ve person One direction, no return

User perspectives between HIV +ve people and HIV –ve people toward ARV-based HIV Prevention: Are there the SAME or DIFFERENCE ?

What are benefits and harms For HIV +ve person Benefits –ARV drugs be used as TREATMENT. –From HPTN052 and others, being successful in viral suppression will help to reduce the chance of HIV transmission to their partners.. So call Treatment as Prevention (TasP)

What are benefits and harms For HIV +ve person Harms –Need to take for lifelong ! –May cause side effects from ARV drugs –Poor drug adherence can induce drug resistance and may be transmitted to others –Taking ARV drug can be stigmatized and discriminated by others and communities

What are benefits and harms For HIV -ve person Benefits –ARV drugs can reduce the chance of getting HIV infection from their risk behaviors BUT they will need to take it daily. –Not lifelong, taking ARV drug only when they still engage in any HIV risk behaviors… Can stop it when no more risks or can strictly using other HIV prevention methods ?

What are benefits and harms For HIV -ve person Harms –May cause side effects from ARV drug –If taking ARV drug when they are infected with HIV, then drug resistance can be developed. –Taking ARV drug can be stigmatized and discriminated by others and communities

How good we are doing now !

A new ambitious target 90 / 90 / 90 toward % of people having HIV test 90% of people living with HIV on ART treatment and care 90% of people on treatment with suppressed viral loads

Awareness of Serostatus Among People with HIV and Estimates of Transmission ~25% Unaware of Infection ~75% Aware of Infection ~46% New Infections ~54% New Infections New Sexual InfectionsPeople Living with HIV Accounting for: Marks, et al, AIDS 2006;20:

Late Access to ART in Thailand CD4 at newly HIV+ diagnosis and ART initiation, CD4 among newly diagnosed HIV+ (1) CD4 at ART initiation among newly ART PLHA (2) (1)The first CD4 that was tested within 3 m after the date of HIV+ diagnosis; only HIV+ reported under NAP and registered to care with CD4 test (2)CD4 that was tested during 6 month before ART initiation Median CD4 * Data from NAP, NHSO, Thailand

23,510 (6%) (71%) (82%) (43%) (56%) (38%) Cascade Accessing and Retention to Care-ART, NAP-Plus Monitoring System, NHSO, Thailand Data source: NAP-Plus Database, National Health Security Office

23 Cascade of HIV Services in China (2012)

Reducing onward transmission: Viral suppression among key population groups living with HIV in the United Kingdom. 19th Annual Conference of the British HIV Association (BHIVA) April 2013, Valerie Delpech, Alison Brown, Stephano Conti, Venkata Polavarapu, Zing Yin

A new ambitious target 90 / 90 / 90 90% of people having HIV test 90% of people living with HIV on Rx 90% of people on treatment with suppressed viral loads We need to begin by understanding ; PHLA, Key affected population, individual and communities how much they think and understand and be a part of our goal !

Barriers and Motivators How much users know about ARV drug.. either for Treatment or Prevention. How much important their know for drug adherence either for HIV +ve and HIV-ve person. ARV drug(s) do not replace other HIV prevention methods, it need to be combined with other prevention tools.

Barriers and Motivators What are their risk perception about HIV infection or risk of HIV transmission How much they concern about stigma and discrimination if they need to take ARV drug(s). User perspectives will be different among male, female, MSM, TG, PWID, MSW, FSW, youth, eldery, etc.. So it will need various intervention approach that be fitted to each specific group.

Summary If we want to end AIDS and HIV epidemic, we can not ignore user perspectives on ARV-based HIV prevention. Building strong user perspectives on using ARV-based as a part of HIV prevention is crucial and need to be designed to fitted with any specific target population.

How we can achieve ? Increase Knowledge Increase Adherence Reduce adverse effects How to implement Etc Please wait to hear from the remain speakers

Acknowledgement Jone de Wit, AIDS2014 Track D Co-Chair Peter Godfrey-Fausset, AIDS2014 Track C Co-Chair Veronica Noseda, France. Chairperson Albert Liu, USA. Co-Chair All speakers in this session Dr.Auchara TUC, Thailand Prof. Kenneth H Mayor Fenway, USA Prof. Chris Beyrer JHU, USA