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Px Wire: January-March 2018

Volume 11, Number 1

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2018: Countdowns and counting what matters

It is just about six weeks into 2018 and multiple clocks are already counting down to critical deadlines in the HIV prevention field and the broader global AIDS response. In this issue of Px Wire, AVAC focuses on some key milestones for the next quarter and the year ahead.

80 days, more or less, to HIV Prevention Roadmaps

In late 2017, UNAIDS launched the Global Prevention Coalition, a multi-country effort to accelerate progress in preventing new HIV diagnoses. As noted in AVAC Report 2017: Mixed Messages and How to Untangle Them, the world is alarmingly off track when it comes to meeting the 2020 target of less than 500,000 new annual HIV diagnoses. More than three times that many people were newly diagnosed in 2016—and now there’s just three years to go before the 2020 “Fast Track” deadline.

After the Coalition kickoff in October, country representatives headed home to design and implement “Hundred-Day” plans to accelerate progress in primary prevention. The clock started in November, then got reset due to the holiday season. In the first three months of 2018, countries are putting together or expanding working groups and technical plans for various components of primary HIV prevention—condoms, voluntary medical male circumcision, oral PrEP and evidence-based, rights-based programs focused on adolescent girls, young women and key populations.

What should advocates watch for?

  • Inclusion of civil society in the working groups designed to address key issues. Those working groups should pay attention to what has worked, in the country or region, when it comes to reaching populations with high rates of new diagnoses—e.g., men who have sex with men, adolescent girls and young women, sex workers, prisoners and others.
  • Are the programs that worked being brought to scale? Does the proposed number of people to be reached with a given strategy (i.e., coverage targets) match the community’s sense of how many people are in need?
  • Are new strategies, like oral PrEP, included in smart, ambitious ways? Are essential, existing strategies, especially VMMC, being taken to scale?
  • Are countries factoring in research? The Coalition did not prioritize research. That’s a major oversight. Today’s strategies can help turn the tide but new interventions that work in different ways—either long-acting or used only at the time of sex—are almost certainly needed to have a sustained impact.
Target Tracking for Epidemic Control

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Less than 30 days until PEPFAR COP Reviews

Country-based work tied to the Global Prevention Coalition is happening at the same time as the annual development of Country Operational Plans (COPs) that guide PEPFAR work. During this process, PEPFAR, government, implementers, civil society and other stakeholders look at the progress made to date against targets for treatment, virologic suppression, testing, prevention and more. The Washington DC-based headquarters for PEPFAR issues guidance for countries on what to look at and how to plan. Already this year, civil society provided robust advocacy for evidence-based prevention, especially for girls aged 9-14, a critical group to reach with strategies and support for remaining safe and healthy.

As we discussed in AVAC Report 2017, the number of young people living in East and Southern African countries has grown dramatically since the epidemic started. This “youth bulge” means more young people today face risk of HIV than 20 years ago. It also means current prevention efforts are, at best, keeping a tidal wave of new diagnoses at bay. How does this work? Check out our graphic below on the math behind the bulge.

What should advocates watch for?

  • Targets in the PEPFAR COPs that are at or close to “saturation” (reaching everyone with the service they need) for VMMC and testing linked to treatment and prevention for key populations.
  • Ambitious and thoughtful programs for delivering and supporting daily oral PrEP. These programs should meet the needs of different at-risk populations through a range of approaches to service delivery.
  • Advocates must also continue to be vigilant about programs for adolescent girls and young women—what is the money to be spent on, who is receiving it, what types of services are included and, most importantly, what do the girls and women receiving the services say about them?

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365 days to a result from the ECHO trial—or maybe less

In just about a year, the ECHO trial is expected to release results. The trial, which started in 2015 in Kenya, South Africa, Swaziland and Zambia, is investigating if any of three contraceptive methods—the injectable hormonal contraceptive DMPA (also known as Depo), the Jadelle implant and the copper intrauterine device (IUD)—adversely impact women’s risk of HIV. As AVAC has described in many resources (see www.avac.org/hc-hiv), this trial is designed to provide clarity where there hasn’t been any.

But whatever the result, there is no guarantee it will bring clear action if women and their allies do not begin to act now. If DMPA increases women’s risk of HIV, it will be imperative to do things that have largely been avoided by many countries for many years. This includes increasing the number of choices that women have for contraceptives, integrating HIV prevention and contraceptive provision services into one clinic and, more recently, providing oral PrEP—all of which are essential irrespective of ECHO’s outcome.

In 2018, AVAC and the International Community of Women Living with HIV East Africa (ICW EA) will be working closely with the ECHO investigators and advocates in the countries where ECHO is happening to share information and plan for various scenarios related to the trial results. This may seem complex: Trials can end early, they can have confusing or indeterminate results. However, the work is fairly simple. In every scenario, women want programs that provide contraceptives and HIV prevention at the same time. They want full information on the risks and bene ts of all methods, and they want to be treated with respect and dignity as they make decisions that are right for their bodies and their lives.

What should advocates watch for?

  • Opportunities to engage in, or initiate, conversations about contraceptive choice and HIV prevention in your community. This could be a talk about ECHO trial results, or an open-ended information sharing session.
  • Are the people who have the power to purchase and develop contraceptive and HIV prevention programs in your community acting in ways that suggest they will be prepared for various possible ECHO results? You can nd out by asking for a meeting or sending a simple set of questions. If they seem ready—find out how you can help. If not, figure out the next action step to get attention and resources. AVAC and ICW EA are here to help.

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Day Zero (present day): HIV prevention research activity at an (all-time?) high

Today there are seven efficacy trials of new HIV prevention strategies happening in 27 countries around the world. More than 25,000 people are enrolled in these trials, including nearly 11,000 women in sub-Saharan Africa. This is extraordinary, both in terms of the scale and scope of the effort, and because these trials are happening at a time when UNAIDS’ HIV Prevention 2020 Road Map, its plan for scaling up global prevention, omits research altogether. A massive undertaking that could offer up new strategies and new pathways to product development is, in some ways, hiding in plain sight.

Of course, it isn’t hiding at all. It’s happening in the same countries and communities where PrEP may or may not be rolling out, where women are struggling to get HIV prevention and contraceptives at the same clinic, and young people, particularly adolescent girls, are getting HIV at tragically high rates. The world cannot wait for the results of any of the trials to address these issues, but it also cannot ignore the fact that the trials themselves could offer up solutions that save money and lives over the long term.

What should advocates watch for?

  • Opportunities to inform clinical trials at every stage—from launch to sharing of results, and everything in-between. The Good Participatory Practice Guidelines provide a roadmap for this engagement, and advocates can use these guidelines to open conversations with trial sites and research sponsors (see www.avac.org/gpp).
  • Do you want to understand how communities were consulted, what a trial will do to leave a community better off, or what a positive result could mean? There is a global community of research advocates engaged in these same inquiries. Speak up, reach out and share what you learn.

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