Clinical Effectiveness and Cost-Effectiveness of HIV Pre-Exposure Prophylaxis in Men Who Have Sex with Men: Risk Calculators for Real-World Decision-Making  

PLOS ONE
 

http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0108742

This article presents a new model for determining the risk of contracting HIV among men who have sex with men and the effectiveness of oral pre-exposure prophylaxis (PrEP) in preventing infection in this population. The model considers variations in infection risk and treatment efficacy based on factors such as condom use, HIV prevalence rates, and PrEP adherence. It also includes risk calculators for both the individual and population level, and can help guide clinical and public health decisions on PrEP interventions.

HIV Policy and Advocacy Monitor: Tell us about your organization and the work that it's doing.

Stop AIDS in Liberia (SAIL) is a Liberian nongovernmental organization that supports PLHIV to advocate for access to HIV treatment and care. In Liberia, the HIV epidemic primarily affects key populations, particularly sex workers and men who have sex with men. Our team provides a range of services, including prevention education, counseling and testing, and treatment referral services. We also partner with researchers and policy planners to advocate for smarter, more inclusive HIV programs and policies.

HIV Policy and Advocacy Monitor: Why did you get involved in policy and advocacy?

I've been living with HIV for the last 17 years. Shortly after my diagnosis, I helped form SAIL, the first network of PLHIV in Liberia. I quickly learned that to be a more effective advocate for HIV services, I needed to contribute to not just domestic, but also regional and global advocacy efforts. As part of this effort, I joined the Network of African People Living with HIV and AIDS that same year.

In 2002, I moved to Philadelphia to pursue my undergraduate studies in psychology. Once there, I began working with the Philadelphia Department of Health to learn about PLHIV advocacy for services and rights in the United States. I also volunteered for HealthGap, an advocacy organization dedicated to eliminating barriers to access to HIV treatment globally, and other U.S.-based organizations to further engage with U.S. HIV treatment advocacy and the global response to HIV.

HIV Policy and Advocacy Monitor: What prompted you to move back to Liberia in 2012?

Most people I knew in Liberia who were diagnosed with HIV around the same time as me have since died. Those I know who were more recently diagnosed have faced enormous stigma and discrimination. I realized there was a real need for advocates to help the growing number of PLHIV access the life-saving treatment they needed. I had just earned my degree and believed that I could use my education and advocacy experience in the United States to help PLHIV in Liberia and help strengthen SAIL. In 2012, Liberia was experiencing a major positive change with the election of President Johnson Sirleaf. Her presidency signaled new hope for marginalized groups, and for advocates for PLHIV, like myself, there was an opportunity to support an HIV and human rights agenda.

HIV Policy and Advocacy Monitor: What precautions are people taking against Ebola on a daily basis, and how is the epidemic affecting the provision of HIV services?

It seems as though every Liberian has had a friend or family member die of Ebola. Fear of becoming infected has crippled social interaction. People are no longer greeting each other as normal (with a handshake and hug) or riding public transportation. Many are now carrying their own chlorinated solutions or hand sanitizer everywhere they go. The vast majority of children's, family planning, urgent care, and HIV services have been disrupted by fear of Ebola transmission. Many healthcare providers have died from Ebola, including several of our leading HIV care providers. This has had a devastating effect on the provision of HIV services; those who are still working refuse to draw blood for diagnostics or offer other invasive procedures. We are developing emergency approaches to keep services for PLHIV available and viable. Our key priority is establishing a communication mechanism that can update PLHIV on how and where to access their daily treatment.

HIV Policy and Advocacy Monitor: Moving forward, what are the priority policy issues for SAIL?

In Liberia, the current challenge is keeping a minimal HIV program running. The next step is to scale up treatment and care. Considering the deadly nature of Ebola, programs and donor resources for HIV have been diverted to help respond to the outbreak. Our first priority is to ensure that the response to Ebola does not undermine the progress achieved by the Liberian HIV response. There has been panic since the Ebola outbreak started. Most of the health facilities in the country were initially closed down because providers were afraid to treat patients for fear that they were infected with Ebola. This made it difficult for PLHIV to access HIV care, treatment, and support services. Currently, few services are available; testing for CD4 cell count, viral load, and even other infections is nonexistent. The National AIDS Control Program continues to provide antiretroviral medication but only at its central office in Monrovia. This makes it difficult for PLHIV throughout the country to access treatment. In addition, many are afraid of having their status disclosed in a more public healthcare setting. Members of key populations, in particular, fear the stigma and discrimination they may face.

Our other policy priorities -- scaling up HIV treatment, improving HIV awareness, reducing stigma and discrimination toward key populations, and reforming policies that hinder sexual and reproductive health rights -- are on hold. Once we have put the constant fear and threat of Ebola behind us, we know Liberia will have to rebuild its HIV response and overall health system. We hope the lessons learned from Ebola-related stigma will encourage the rebuilding of the HIV response to allow for more compassionate and inclusive policies.

For additional information about the effect of Ebola on the HIV response in Liberia, read: http://www.nejm.org/doi/full/10.1056/NEJMp1413425