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The STOP HIV/AIDS Project: Treatment as Prevention in the Real World

Spring 2012

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Examples of Programs

The complexity of a treatment as prevention initiative such as STOP is apparent in the number and diversity of local programs and policies that are being developed, evaluated and adapted at a very fast pace. For example, new programs that are funded through the Vancouver STOP Project are evaluated at six-month intervals -- if a program does not prove to be effective in that time, it may be abandoned while another program is developed and tested. Upwards of 41 pilot programs have been funded by the Vancouver STOP Project. Through this process of experimentation and evaluation, the aim is to find the right case mix of programs and services that will meet the goals of STOP.

Several programs have recently been implemented by STOP through Vancouver STOP Project and Northern Health, among others. These reflect the diversity of programs that may need to be incorporated into a successful treatment as prevention initiative. They include the following:

Seek:

  • Expanded HIV testing in hospitals. Physicians began offering confidential HIV tests to every patient requiring blood work admitted to four Vancouver hospitals. Informed consent is required. The goal of this program is to increase the number of people who are aware of their HIV status.

Link:

  • Enhancement of a peer-led program. Positive Living BC, a member-run community-based organization, developed Peer Navigators, a peer-led program that provides support to people living with HIV. One goal of this program is to link people living with HIV to, and help them navigate through, programs and services that might be useful to them.

Treat:

  • Expanded access to pharmacists with HIV expertise. Northern Health hired a full-time HIV pharmacist to enhance access to HIV treatment in northern B.C. Prior to this, prescribing physicians would have to order HIV medications from pharmacists in Vancouver, sometimes significantly delaying people's access to HIV medication.

Retain:

  • Creation of more housing units for people living with HIV. Twenty-five new affordable housing units became available to people living with HIV who face barriers to engaging in HIV treatment and care through Coast Mental Health. Providing affordable housing for people living with HIV who are either homeless or at risk for homelessness ensures a more stable environment, which should help to retain them in care.


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Strengths and Controversy With Implementation of STOP

STOP has already proven to be a catalyst for enhanced, positive collaboration among diverse B.C. stakeholder groups, as suggested by three key players: Chris Buchner (VCH), Ross Harvey (Positive Living BC) and Sam Milligan (Central Interior Northern Health Services). STOP is also seen by some as an opportunity to change course in our response to the HIV epidemic in Canada. As Chris Buchner (VCH) and Wayne Robert (Health Initiative for Men) have suggested, with this new funding, groups can try exciting new things and make a significant impact on the epidemic and the lives of people living with HIV.

However, Evin Jones, the executive director of the Pacific AIDS Network (PAN) points out that concerns have also been raised by PAN's member agencies that treatment as prevention projects, such as STOP, could lead to the "re-medicalization of HIV," meaning that HIV and related issues and behaviours may be defined purely in terms of health/illness and treated only through medical means. Related to this is a concern that the role community-based agencies play may shrink as a result.

More specific concerns related to STOP have focused on the evaluation of the project (what is being measured to determine "success") and the sustainability of the programs implemented with STOP funds, given that the project is a pilot. Further, some have raised concerns about the process of implementation to date, which in some cases has been less integrated across policy and program sectors. The pace at which STOP has been rolled out is impressive, but this pace may lead to challenges for program delivery on the ground.


STOP HIV/AIDS: A New Way Forward

While we do not yet know the long-term implications of the STOP HIV/AIDS project on the community-based response to HIV in B.C. or in the rest of Canada, we do know that the science behind treatment as prevention may increasingly challenge communities to take on this new approach. To ensure that HIV-related organizations and people living with HIV continue to play a major role in the response, we must not only understand the science, but also the successes of those who have tested this hypothesis. It is critical that we also anticipate and understand the ethical, programmatic and evaluative challenges related to the implementation of this new model.

For a more comprehensive discussion of the STOP HIV/AIDS pilot project, see "Views From the Front Lines."

Christie Johnston is the Manager of Community Prevention Programs at CATIE. She holds a Masters degree in Anthropology and International Relations. Before joining CATIE, Christie worked on a number of community-based research and knowledge exchange projects at the Ontario HIV Treatment Network (OHTN), AIDS Committee of Toronto (ACT) and abroad, and acted as Volunteer Program Coordinator for the AIDS 2006 Local Host Secretariat.


References

  1. Adam B. Epistemic fault lines in biomedical and social approaches to HIV prevention. Journal of the International AIDS Society. 2011;14(Suppl 2):S2.
  2. British Columbia Centre for Excellence in HIV/AIDS. U.S. Secretary of State Hillary Clinton endorses the made-in-BC strategy of treatment as prevention [Internet]. Vancouver: The Centre, St. Paul's Hospital; 2011 Nov 8 [cited 2011 Nov 25].
  3. CBC News. China chooses AIDS control model from B.C. [Internet]. CBC; 2011 Feb 24 [cited 2011 Nov 25].
  4. STOP HIV/AIDS Pilot Project [Internet]. STOP HIV/AIDS: Seek and Treat for Optimal Prevention of HIV/AIDS [cited 2011 Nov 25].
  5. Anglemyer A, Rutherford GW, Baggaley RC et al. Antiretroviral therapy for prevention of HIV transmission in HIV-discordant couples. Cochrane Database of Systematic Reviews. 2011;(8):CD009153.
  6. Donnell D, Baeten JM, Kiarie J et al. Heterosexual HIV-1 transmission after initiation of antiretroviral therapy: a prospective cohort analysis. The Lancet. 2010 Jun 12;375(9731):2092-2098.
  7. Cohen MS, Chen YQ, McCauley M et al. Prevention of HIV-1 infection with early antiretroviral therapy. The New England Journal of Medicine. 2011 Aug 11;365(6):493-505.
  8. Granich RM, Gilks CF, Dye C et al. Universal voluntary HIV testing with immediate antiretroviral therapy as a strategy for elimination of HIV: a mathematical model. The Lancet. 2009 Jan 3;373(9657):48-57.
  9. World Health Organization [Internet]. The treatment 2.0 framework for action: catalysing the next phase of treatment, care and support. 2011[cited 2011 Nov 25].
  10. Montaner JS, Hogg R, Wood E et al. The case for expanding access to highly active antiretroviral therapy to curb the growth of the HIV epidemic. The Lancet. 5;368(9534):531-6.
  11. Williams B, Wood R, Dukay V et al. Treatment as prevention: preparing the way. Journal of the International AIDS Society. 2011;14 Suppl 1:S6.
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This article was provided by Canadian AIDS Treatment Information Exchange. It is a part of the publication Prevention in Focus: Spotlight on Programming and Research. Visit CATIE's Web site to find out more about their activities, publications and services.
 
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