New hope in AIDS prevention

Every December, APA hangs panels from the AIDS Memorial Quilt (www.aidsquilt.org) in our headquarters lobby to commemorate World AIDS Day. The panels bring to mind the long struggle to end the epidemic that has taken the lives of 25 million people worldwide. Unfortunately, the struggle continues.

The Centers for Disease Control and Prevention estimates that more than one million people are living with HIV in the United States, and more than 56,000 become infected each year. Sadly, one in five people living with HIV is unaware of their infection and thus unlikely to take advantage of antiretroviral treatment (ART).

The good news is that ART is effective in both treatment and prevention of HIV/AIDS. ART suppresses viral replication in blood and lymphoid tissues and in male and female genital tracts. Interest in the use of biomedical approaches to reduce HIV transmission has been growing steadily during the past 10 years as a result of the increased tolerability and decreased cost of ART, the ever-expanding range of medication options, and the multiple challenges of scaling up behavioral approaches to HIV prevention. This interest has skyrocketed in recent months with the release of new findings from the Pre-exposure Prophylaxis Initiative (iPrEx) trial and South African scientists associated with Caprisa, the Durban-based research center.

Caprisa announced in July that women who used a vaginal microbicidal gel containing tenofovir, an antiretroviral medication widely used to treat AIDS, were 39 percent less likely overall to contract HIV than those who used a placebo. Even more impressive, those who used the gel most regularly reduced their chances of infection by 54 percent. In November, scientists associated with the iPrEx trial revealed that the HIV infection rate in HIV-negative gay men who were given a daily preventative pill containing two HIV drugs (tenofovir, plus FTC) was reduced by 44 percent, compared with men given a placebo.

For many, the results from these two recent studies constitute game-changing events that suggest the need to prioritize biomedical over behavioral approaches to HIV prevention. Although biomedical approaches to HIV prevention, such as “test-link-and-treat strategies” and pre- and post-exposure prophylaxis are important tools in an overall strategy for HIV prevention, they should be combined with broad-scale implementation of evidence-based behavioral strategies including structural interventions that increase access to services, decrease costs, and reduce stigma and discrimination.

The unfortunate debate over the relative value of biomedical and behavioral approaches to HIV prevention is being played out in connection with implementation of the nation’s first comprehensive plan to address HIV/AIDS. President Barack Obama unveiled the National HIV/AIDS Strategy in July 2010 to guide our national efforts to reduce HIV/AIDS incidence, increase access to care and reduce HIV-related health disparities.

APA’s Ad Hoc Committee on Psychology and AIDS, Public Interest Government Relations Office and Public Interest Office on AIDS have outlined priorities for implementing the national strategy. In the document, titled National HIV/AIDS Strategy: Prioritizing Mental and Behavioral Health in Federal Implementation Efforts, APA stresses the importance of combining and integrating behavioral and biomedical approaches to HIV prevention and care. We also underscore the important contributions psychology has made and can continue to make in preventing new HIV infections, improving adherence to medication regimens and improving health outcomes for people living with HIV, especially those with mental health and/or substance abuse disorders.

APA has shared these priorities and recommendations with senior officials in the White House, the U.S. Department of Health and Human Services, and key leaders on health and HIV/AIDS in the House of Representatives and the Senate during a series of meetings. (See the Monitor’s February “Government Relations Update” for more.)

After nearly three decades of experience with HIV/AIDS, it is important to remember that our efforts to end this epidemic are most effective when we respectfully understand, utilize and integrate lessons learned from many fields of science.