CHICAGO — Real-time data on HIV hot spots, local ownership of HIV prevention efforts, and domestic financial investments are the key to effective implementation of HIV prevention methods, according to the team behind the Kenya HIV Prevention Revolution Roadmap.
In 2010, Kenyan officials saw that prevention was not reaching the people who needed it, said Nduku Kilonzo, PhD, from the National AIDS Control Council in Nairobi, Kenya.
The officials realized they needed to "think differently," she told the audience during a satellite conference here at HIV Research for Prevention (HIVR4P) 2016.
So in 2014, the Revolution Roadmap was launched. The goals — aligned with those of the Kenya AIDS Strategic Framework — were ambitious: to reduce new HIV infections by 75%, reduce AIDS-related mortality by 25%, and reduce HIV-related stigma and increase domestic funding of HIV programs, all by 2020.
It was clear that prevention could not be offered to everyone in the country in the same way, Dr Kilonzo explained. It had to be targeted with real-time data, it had to be guided by what people most at risk for HIV wanted and needed, and it had to be supported by resources and political will.
"It's one thing to have a document and put it out there. It's another to put that document into practice," she said. "You must have country ownership and a commitment that's matched between the county and the local officials."
The program is getting underway now. Resources and prevention programs are being shifted to the nine counties that account for 65% of new HIV cases in Kenya and away from the 10 counties that account for just 1% of infections.
High-prevalence counties will be offered intensive programs, including at-home HIV testing, test-and-treat services, pre-exposure prophylaxis (PrEP), and routine screenings for sexually transmitted infections. Programs will also include gender-based violence reduction programs, school programs for girls, and programs to reduce alcohol use and increase condom use.
Intensive data collection on the ground will help identify markers of hot spots and allow resources to be marshalled before an outbreak takes hold.
"We've learned, for instance, from prevention of mother-to-child transmission programs that we're seeing new infant diagnoses in areas where there are hot spots," said Nelly Mugo, MBChB, from the Kenya Medical Research Institute in Nairobi, who is cochair of the HIVR4P meeting.
"We're designing a tracking system to concentrate efforts where they need to be," she explained.
The Situation in the United States
HIV experts in the United States, where nearly 50,000 people become infected with HIV every year, will be watching how the Kenyan program unfolds.
To meet the UNAIDS 90-90-90 goals, 75% of gay and bisexual men in the United States, who account for 67% of all new cases of HIV, will need to be receiving suppressive antiretroviral treatment by 2020, according to the National Institutes of Health. Currently, only 57% of those men are receiving suppressive therapy.
"Siloing biomedical interventions off from what's needed to get people to use biomedical products is a big mistake," said Geoff Garnett, MD, from the Bill and Melinda Gates Foundation. "You need behavioral changes and structural changes for biomedical interventions to work," he told Medscape Medical News.
Presentations highlighting the need for change were conducted throughout the meeting.
Data from Atlanta showed that most new cases and late diagnoses of HIV were occurring south of Interstate 20, but all the free HIV testing sites, Ryan White HIV clinics, and sites where people could easily get PrEP were on the north side.
Interstate 20 "serves as a dividing line that highlights our racial and housing segregation in Atlanta," explained Patrick Sullivan, PhD, from Emory University in Atlanta, during his presentation.
Likewise, acute hepatitis C infections — a marker of injection drug use that can correlate with HIV outbreaks — were largely seen in rural areas of the United States, according to a study presented by John Brooks, MD, from the Centers for Disease Control and Prevention (CDC). However, there was no correlation between those areas of outbreaks and the location of legal syringe-exchange programs, which have been proven to reduce HIV infections among injection drug users.
Data on PrEP rollout in the United States are similar, said Dawn Smith, MD, also from the CDC. She explained that the local health departments that are most engaged in PrEP implementation are in the western states, but it is the southern states that need it most.
During a plenary session, Noel Gordon Jr, a program specialist at the Human Rights Campaign, showed two pie charts: one of the gay male populations in the United States most at risk for HIV, divided by race; and one of the proportion of PrEP prescriptions for tenofovir and emtricitabine (Truvada, Gilead), divided by race.
They were inversely related. White gay men made up 27% of new HIV cases but accounted for about 75% of PrEP prescriptions.
"PrEP utilization is not correlated with risk for contracting HIV in the United States," Gordon told Medscape Medical News.
Dr Kilonzo, Dr Mugo, Dr Garnett, Dr Sullivan, Dr Smith, and Noel Gordon have disclosed no relevant financial relationships.
HIV Research for Prevention 2016. Abstract SA.16. Presented October 21, 2016.
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Cite this: Real-Time Data Key to Kenya's HIV Prevention Roadmap - Medscape - Oct 28, 2016.