exploring strategies and perspectives to map pathways for the use of arvs as prevention

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From Revolution to Reality: How Will New Science Impact the U.S.

National HIV/AIDS Strategy?

Exploring Strategies and Perspectives to Map Pathways for the Use of ARVs as Prevention

Molly Morgan Jones, PhDSenior Analyst – RAND Europe

Sunday, July 22, 2012 – IAC

Today

• What is Mapping Pathways?• Why was this project developed?• What did Mapping Pathways do?• U.S. findings – focus on PrEP

– How do they inform the NHAS?– What next steps do the findings

suggest?

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This symposium is conducted in collaboration with and funded by Bristol-Myers Squibb with no editorial review of content.

What is Mapping Pathways?

• Multinational project, began 2011– South Africa, India, U.S.

• To review potential social, economic and clinical impacts of ARV-based prevention

• AIDS Foundation of Chicago, AIDS United, Desmond Tutu HIV Foundation, Naz India, RAND, Baird’s CMC

• Funding– Merck 2011– Merck and NIH (BTG Bridge) 2012

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Why Mapping Pathways?

• The project’s aim is to provide the research and analysis that communities and policymakers need in order to formulate coherent, evidence-based decisions for HIV/AIDS treatment and prevention strategies in the 21st century.

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What did Mapping Pathways do?

• 2011 – Data collection– Online survey (grassroots)– Stakeholder interviews

(grasstops)– Literature review (empirical

evidence base)– ExpertLens (where are the

fault lines?)• 2012 – Data dissemination

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“Grassroots” survey says…

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5.0%

47.1%44.4%

3.6%

Do you think that PrEP should be an important part of your coun-

try's HIV prevention plan? (n=363)

a) No, not at all important and should be given no attention

b) It is important, but there are other things that are more impor-tant

c) Very important and should be given lots of atten-tion

d) No opinion

11.3%

9.1%

11.6%

57.3%

10.7%

What do you believe people in your country think of PrEP?

(n=363)

a) They agree with me

b) They think that PrEP is more impor-tant than I think it is

c) They think that PrEP is less impor-tant than I think it is

d) They do not know enough to have an opinion about PrEP

e) No opinion

‘Simply put, insurance companies are not going to fund these

prevention strategies because of its' sexual

nature’

“Grassroots” survey says… PrEP

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‘I find it hard to understand why

people will take an expensive, less

effective pill than use condoms’

‘we don't have all the data on the impact of the

medications in the long run’

“Grasstops” interviews…

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What are the likely policy, programmatic impacts of PrEP?

“Grasstops” interviews… PrEP

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Cost effectiveness is important….We need to reach people who are so vulnerable they can’t negotiate condom usage regularly. We need to know if they could take medication regularly enough to be effective… we need to make sure people are actually negative when we administer the drug so we are not intervening with somebody who has already been infected…

“Grasstops” interviews…

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Does the evidence for PrEP support changing treatment guidelines?

ExpertLens – PrEP faultlines

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Family &

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unity structures

Health inequality &

disparity

Infrastructure & healthcare

Population-level HIV risk

Drug resistance

Unintended side effects

ExpertLens – PrEP

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oral PrEP PEP TLC+ microbicides

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ing

• Median scores showed agreement that PrEP had medium to strong science

• Respondents in mild agreement (12/28) that it was the last strategy they would allocate funding to

• Respondents were mixed on cost feasibility of PrEP

• Wide range of divergent views

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NHAS implications

• Reducing new infections– Communities want and need more information on PrEP (and other

ARV-based prevention strategies)– The real world is different from RCTs

• “iPrEx is very convincing but there are major concerns about its real world applicability’ (EL participant)

– Multiple components to monitor: • Risky behavior (is “risky” being re-defined?)• Drug resistance• Cost and resources• Health disparity

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NHAS implications

• Increasing access to care, optimizing health outcomes– Experts don’t necessarily believe PrEP will improve access

to care – Limited applicability in resource-limited settings?– Scarce literature on the indirect outcomes of PrEP and

other ARV strategies• Reducing HIV health-related disparities

– Disagreement in EL on PrEP effects – ‘Even after we have all the data and (if) we get approval,

PrEP will not be for everyone, it should only be used for specific high-risk individuals or serodiscordant couples, when all other prevention messages and modalities have failed.’

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Next steps• NIH ‘Be the Bridge Generation’ activities

– Led by AIDS United• Reflexive knowledge exchange workshops to map

pathways to decision making for communities• Presentations and publications • Agent-based modeling to provide grounded, dynamic,

real-time thinking about pathways

The contextual nature of decisionmaking is important. Initial scepticism about PrEP may be overcome, but

‘success’ is more than just a p-value.

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Thank you

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Molly Morgan [email protected]

Check out our posters“Synthesising the empirical evidence for ARV-based prevention strategies to map

pathways to sound prevention planning” MOPE590

“Mapping Pathways: Developing the evidence base for biomedical prevention strategies” MOPE591

mappingpathways.blogspot.com

exploring strategies and perspectives to map pathways for the use of arvs as prevention

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