Tuesday 2 June 2015

TasP and PrEP: AFAO Members Forum

The afternoon session on day one of the AFAO Members Forum involved robust discussions about pre-exposure prophylaxis (PrEP) and treatment as prevention (TasP). 

Presentations looked at key areas including research, clinical guidelines, regulation and advocacy, both in Australia and the international context.

TasP panel discussion. L-R: Colin Batrouney (VAC), Cam Cox (Scarlet Alliance),
Bridget Haire (AFAO), Robert Mitchell (NAPWHA), Karen Price (ACON)

TasP and health promotion: complex interactions

Sean Slavin (AFAO) outlines key issues
from his treatment as prevention paper
Sean Slavin opened the session by outlining key themes set out in his AFAO discussion paper on TasP, and considered the role of health promotion in informing both positive and negative people about the impact of HIV treatments on  transmission.

He raised important questions about the potential stigmatisation of people who don’t achieve undetectable viral loads and stressed that it must remain the right of the individual to decide when to commence treatment.

View presentation

This led into a panel discussion about the impact of TasP on HIV prevention, health promotion, people living and with HIV and affected communities.

Colin Batrouney from VAC considered the implications of TasP, PrEP and undetectable viral load (UVL) on health promotion. He said that while safe sex is a shared relational experience, biomedical interventions are an abstraction.

Within the context of sex, condom use is often non-verbal but the  nature of communications around concepts such as TasP and undetectable viral load requires far more complex interactions, which health promoters need to be aware of.

Robert Mitchell talked about the success of TasP being predicated on increasing testing and getting people onto treatment.  However, he said we must be cautious about setting up ‘good and bad’ dynamics around people’s viral load – as health promoter we must be very mindful of this.

Karen Price shared latest updates about the Ending  HIV ‘Drop Your Load’  campaign, which focuses on TasP and UVL.

She said that post-campaign research shows a significant shift in community attitudes and knowledge about these issues, with  82% of survey respondents saying that the that the campaign had improved their understanding of TasP and UVL.

View presentation

Bridget Haire (AFAO), Robert Mitchell (NAPWHA), Karen Price (ACON) during  TasP discussions  
Bridget Haire, AFAO President, described TasP as 'a magnificent human rights based approach to HIV prevention that is based around what the individual and their doctor consider best for their health'.

However, she said we must be aware of stigma against people with HIV who are untreated, or those who have detectable viral load, reminding us that condoms are still an effective prevention method in these circumstances.

Cam Cox (Scarlet Alliance) highlights
sex worker concerns about TasP and PrEP
She cautioned against authoritarian approaches to treatment, saying that the risks of TasP around human rights discourses are very real – for instance, in relation to the sex worker community.

Cam Cox from Scarlet Alliance echoes these concerns, alerting the audience to dangers for sex workers resulting from the general rollout of ‘test and treat’ and PrEP. He said that sex workers were very concerned about coercion, and the impact of TasP and other 'post condom' strategies on client negotiations.

PrEP research

Iryna from Kirby Institute discussed the latest research on PrEP saying that 'it is clearly one of the most effective interventions we have seen so far'.

She outlined the interim findings of two international PrEP studies – the UK PROUD study and French/Canadian Ipergay study– both of which involved high risk participants but showed high levels of protection from PrEP –even higher than expected.

She said the interim results suggest that perceptions PrEP is less effective in real world setting are probably unfounded.

Iryna Zablotska-Manos discusses research about PrEP's efficacy
She also said the PROUD study demonstrates that PrEP is cost effective, indicating that one new HIV infection is averted for every 13 people treated.

She noted that Australia is only the third country in the world to have PrEP guidelines in place. These are quite different to guidelines in place in the US and Africa, as they are tailored specifically to Australia’s epidemiology and risk factors.

During subsequent discussion, she clarified that while research places PrEP & TasP at “the top of the list’’ of HIV prevention measures, this does not mean we should abandon other approaches. She said strength should continue to be found in all available approaches, including condoms.

View presentation

PrEP approvals 

Anna Robert discusses PrEP regulation 
Anna Roberts from ASHM outlined  the complexities of the approval processes required to license PrEP for use in Australia. She said that although Gilead’s application to the TGA is likely to succeed, it will be long process that may take more than 12 months.

She raised some potential stumbling blocks, saying that politically PrEP could be seen as ‘subsidising sex’.  She also said that a change in PBAC leadership could affect the decision making progress and that cost effective modelling is difficult as we don’t know who long drugs will be used for.

View presentation

In the panel discussion on PrEP that followed there was much passionate debate. VAC and ACON called for strong community involvement in the scale up of PrEP demonstration projects across Australia, and the need for a cost benefit analysis of PrEP.

Michael Scott from Queensland AIDS Council (QuAC) said that community awareness about PrEP and PEP is still quite low in Queensland, explaining that QuAC is funding its own $40,000 PrEP campaign to address this issue, without any funding support from Government.

PrEP panel ( L-R): Joel Falcon (Scarlet Alliance), Nic Parkhill (ACON),
Michael Scott (QuAC)Chris Goough (AIVL), Anna Roberts (ASHM).

Not suitable for everyone

While all members agreed that PrEP is an extremely effective HIV prevention measure for gay men and other men who have sex with men, specific concerns were raised for sex workers and people who use drugs.

Joel Falcon from Scarlet Alliance raised concerns about downward pressure from brothel owners and operators that would force sex workers to take PrEP. He stressed that PrEP use must remain voluntary.

Chris Gough said that while AIVL supports the implementation of PrEP in Australia, people who inject drugs (PWID) should not be viewed as a priority population for PrEP. He cautioned against prioritising PrEP and TasP to the detriment other important advocacy areas for PWID, such as hep c, harm reduction and decriminalisation.

You can download a detailed forum report here.

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