The Nexus of HIV Prevention and Care

Having attended numerous HIV prevention conferences over the last several years, I can safely say that things are different this year. The 2011 HIV Prevention Conference has been intimately tied to the National HIV/AIDS Strategy and we are finally seeing the intersection of prevention and care at the forefront. Prevention language has shifted and with any new direction, there is excitement, uncertainty, and trepidation. What does this nexus of prevention and care mean for those community-based organizations that have been traditionally funded for HIV prevention services outside of clinical settings? What does a shift in resources mean to health departments that are already battling state budget cuts and an unfriendly political and economic environment? Where is the science going to take us in the coming months and years? All of these questions remain to be answered.

Day three of the conference began by answering one very important question, how do you engage hundreds of individuals at 8:30 am in a plenary session on the issues, challenges, and strategies related to comprehensive high-quality HIV care? You allow your panelists to argue (their position) while bantering with their colleagues, and encourage the audience to throw paper balls at each other! The morning session featured five HIV physicians from across the country debating a pro or con position on one of three issues related to improved access to HIV care: routine HIV testing, community viral load, and test and treat. While many of us have preconceived notions about these content areas and have an idea of what position we would already support, this session showed that there are indeed multiple sides to every issue. After hearing two sides present, the audience voted for the “winning argument” by tossing a piece of paper with his/her vote to another audience member.

While Dr. Polly Ross presented evidence that we are not testing the right people in clinical settings, Dr. Kathleen Clanon convinced the audience to support her view that routine HIV testing in clinical settings is of utmost importance. Dr. Clanon argued that routine testing does not stand alone, but rather is one part of a comprehensive approach to prevention and care. Too many individuals in this country receive an HIV positive result at the same time or very close to an AIDS diagnosis (concurrent diagnosis). Dr. Clanon stated that where she works in Oakland, California, the number of concurrent diagnoses is as high as 75% of all AIDS diagnoses.

Dr. Clanon also supported the view in favor of use of the community viral load as an access and prevention measure to show where HIV transmission is happening and to what degree. Dr. Clanon shared the San Francisco Department of Health data and mapping to demonstrate that the total community viral load can display how many people are infected in an area, while the mean community viral load can be used to pinpoint disparities and show areas where individuals are not accessing care and treatment. Dr. Myron Cohen however presented a series of counter arguments to the use of the community viral load as an accurate measure. He expressed concern that it is a single cross-sectional measure; not all patients remain in care and so individuals are missing from both the numerator and denominator; it does not account for acute infection, believed to be responsible for a large proportion of new infections; and in many cases, spatial geography may not be noted. In the end, Dr. Cohen gained the audience vote, but it became clear that ongoing discussions are needed to ensure that we are using data responsibly and understand what they can and cannot tell us.

The third debate, favoring test and treat, whereby individuals are diagnosed, linked into care and provided early antiretroviral therapy, was presented by Dr. Keith Rawlings. In the end, Dr. Michael Saag who was presenting the opposing argument, acknowledged that test and treat programs are an important tool in the prevention and care arsenal and he could not argue against them.

The panel presentation demonstrated that in order to move our work forward, respond to the goals outlined in the NHAS, and understand the intersection of prevention and care, we must also continue to educate ourselves and understand both sides to every issue.

Powers writes from the 2011 National HIV Prevention Conference, where JSI is represented at exhibit booths through its work with AIDS.gov (booth #227) and Centers for Disease Control (CDC)’s capacity-building efforts (booth#318). The conference is taking place a year after the release of President Obama’s National HIV/AIDS Strategy. The theme of the 2011 National HIV Prevention Conference is: “The Urgency of Now: Reduce incidence. Improve access. Promote equity.”

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