July 24, 2012
Jen Hecht and Justin Jones (photo: Reilly O'Neal).
Treatment as prevention is rapidly becoming a widely promoted strategy for "turning the tide" of the HIV/AIDS epidemic. But as the Fenway Institute's Kenneth Mayer observed in a lively debate on Monday, "It's not giving people pills and that's the end of the story."
To address the broader picture and explore ways to integrate treatment as prevention into whole-person services for people with HIV, Jen Hecht and Justin Jones of STOP AIDS Project (part of San Francisco AIDS Foundation) facilitated a community skills development workshop, titled "Beyond Doctors and Drugs: Adapting Evidence-Based, Treatment-as-Prevention Interventions to Peer-Based, Holistic, Client-Centered Services for People Living with HIV," that shared lessons learned from STOP AIDS Project's Positive Force program -- and drew three times the max number of participants.
Jen and Justin spoke with BETA about their perspectives on treatment as prevention, their experience facilitating the workshop, and their take on AIDS 2012 so far.
BETA: Why is the workshop's topic important at this particular moment?
Jen Hecht: HIV prevention is changing as we speak. A new paradigm is being developed in which there is a shift away from primary prevention with its focus on condom use, education, and behavior change, and toward biomedical "test and treat" models. There are advantages and disadvantages to these changes but they are real and are happening locally, nationally, and globally, and they are affecting policies and funding.
We have a unique opportunity to make sure that as these changes are happening, we can advocate for factors that we believe should be included and may get left out, including basic needs (housing, mental health services, and substance-use services), a holistic approach to overall well-being, and the inclusion of HIV-negative individuals in HIV prevention.
Justin Jones: Treatment as prevention (TAP) is a major theme of this year's International AIDS Conference. In San Francisco, we have already scaled up and rolled out interventions and services for it, and the rest of the country (and world) is either already in motion to follow suit or soon will be.
There are several issues with TAP, on its face. As a clinical intervention, TAP lends itself to the underlying belief that once a person is engaged in care, treatment adherent, and virally suppressed, he or she represents a total success; TAP does not take into account the myriad complicated needs with which HIV-positive people often present that are not necessarily specific to treatment adherence and engagement in care but are still key to their total well-being.
In addition, and again on its face, TAP's primary objective is the prevention of new HIV infections, consequently putting the onus for the end of HIV on people living with HIV/AIDS (PLWHA).
BETA: What did you want the workshop to accomplish?
Jen: We wanted the workshop to draw attention to how it is possible to work within the system of narrow funding and requirements from funders to develop a program that is outcomes-focused and that is inclusive of the broader needs of HIV-positive individuals. Broader needs can include addressing depression, isolation, food security, and housing, to name a few.
Justin: As the TAP ship sails full speed ahead on its current course, I hoped for our little 90-minute presentation -- our little headwind, to continue the metaphor -- to provide some tools and practical experience in adapting the clinical side of TAP into peer-based, holistic, client-centered services for PLWHA, perhaps adjusting the course of the ship, even if just a little, towards a better destination for PLWHA.
Jen and I only got a small chance to look over the evaluations so far, but they overwhelmingly looked positive. Perhaps even more importantly, we received requests for assistance, both in person and remotely, to help organizations in adapting TAP into their services.
BETA: What was your favorite moment during the workshop?
Justin: I loved how people had immediate questions following my presentation about how to enhance peer-based services through training of staff and volunteers -- and what that training might look like.
Jen: Feeling like the two presentations that Justin and I did were able to really complement each other and create a coherent whole.
Also, having to stand on a crate because I was too short to see over the podium.
Justin: We looked a tad ridiculous, but it worked!
BETA: In the process, did you learn anything new yourselves?
Jen: Absolutely. I had to step back and look at the big picture to figure out how to share a lot of information in a clear and concise way. And I had to look up lots of specific details about important research studies that I only knew the highlights of.
Justin: I learned that a lot of people are just as scared, concerned, and confused as we were two and a half years ago. Policymakers can pontificate all they want, but unless we provide adequate resources and training to the people who will deliver the services necessary for TAP to work, its future success could be in serious jeopardy.
BETA: Bonus question: What has most amazed you so far about AIDS 2012?
Justin: For all the policymakers who have framed TAP as a means to preventing new HIV infections and eventually ending HIV, Julio Montaner, a powerful voice in prevention, treatment, and policy, phrased the aims of TAP as I see them and more eloquently than I ever have. I'm paraphrasing, but he basically said: TAP is about preventing morbidities among PLWHA; it's about preventing mortality among PLWHA. It's a wonderful side effect that it also prevents new HIV infections. I was so delighted finally to hear someone in his position express that TAP is about the health and well-being of PLWHA first and about preventing transmission second.
Jen: That references to "combination prevention" haven't included either behavioral or structural interventions but seem to reference a combination of biomedical interventions. And that the conversation about "treatment as prevention" has taken over the whole of the HIV prevention dialogue so quickly and so completely. There are huge successes already in treatment as prevention that are laudable, but I think we are being ignorant if we don't also pay attention to the systems, the structures, and the lessons from the last 30 years.