HIV: How does prevention reach people on the ground?

How successful prevention interventions are depends on the acceptance of the population. Trust needs to be built to ensure that interventions reach where they are needed.

Looking at programmes through the eyes of the patients

How successful prevention interventions are depends on the acceptance of the population. Trust needs to be built to ensure that interventions reach where they are needed. At the IAS, researchers discussed the factors that contribute to success.

Besides condoms, pre-exposure prophylaxis (PrEP) is one of the most important measures to prevent infections in HIV-negative people. Several active substances have been approved, also in the European Union. The World Health Organisation (WHO) speaks of "an additional prevention choice for people at substantial risk of HIV infection as part of combination HIV prevention approaches". But these medical considerations are not enough, because PrEP must also reach at-risk groups.

PrEP for all: What needs to change?

Some people would be advised against PrEP, said Dr. Renee Heffron of the University of Washington, USA, at the IAS symposium. She mentions pregnant and breastfeeding women in particular, but also adolescents under 18, people with drug abuse or on certain pharmacotherapies. This is because - depending on the active ingredient - there is hardly any data on PrEP in pregnancy. In addition, some pharmaceuticals pass into breast milk.

But social aspects also play a role. Social stigmatisation endangers PrEP programmes; social support, on the other hand, promotes measures, Heffron continues. "Fresh, modern measures", for example in social media, on the other hand, could improve acceptance. "Low-threshold measures also have a beneficial effect." In addition to pharmacies, mobile services, such as vehicles to supply people locally, have proven their worth. "However, preparations must also be affordable for everyone and separated from the concept of disease," Heffron demanded.

Mistrust in medicine and pharmacy

Dr. Oni Blackstock of Health Justice, USA, cites a strongly rooted mistrust of medicine and pharmacy among many people as a further problem from the field. This is not only due to scepticism about the alleged greed for profit of manufacturers, physicians or clinics. Many rejected "a system that promotes and perpetuates racism, classism, homophobia and transphobia". It should be noted that Blackstock reports experiences from the USA. All of this, he says, leads to negative behaviours such as lack of adherence to PrEP, HIV treatments or participation in HIV screening programmes.

"So far, there is little evidence from the literature on what to do about this," Blackstock says. As an example, she cites trainings to acquire cultural competencies for conversations. "Many interventions proved ineffective or were not tested in relation to HIV," the speaker points out. In some African countries, it has proven effective for members of a community who have expert status to inform - rather than completely unknown third parties from the outside.

Tips for better communication

Blackstock advises physicians to adapt their communication: "Ask open questions and analyse possible mistrust of patients. It is important to address scepticism openly, to look for reasons and to refute them argumentatively. As examples, she mentions: "What experiences have you had with the health system? And why have you lost confidence?" Her advice for difficult conversations:

It often pays to change perspective, as Dr. William Nutland makes clear in his talk. He is co-founder of the interest group and knows many men in the community. Here, medicine encounters completely different realities, the speaker said. "People want self-determination." That means they want to decide for themselves when they take PrEP, when they don't, and who they tell about it. In this respect, PrEP implants, which are currently being studied in clinical trials, are not desirable for all people. Many would even reject such depot drugs. It is simply a matter of not losing sight of the target group, as Nutland emphasises.

International AIDS Society Conferences (IAS) 2021, Symposium "Build it: But will they come? Prevention efficacy versus population effectiveness", 19 July 2021.