HIV prevention must be better targeted, according to David Holtgrave from Johns Hopkins Bloomberg School of Public Health in the US, and colleagues. Health care professionals need a more detailed analysis and understanding of the interplay between HIV risk behavior, access to treatment and treatment success among those living with HIV. The authors discuss their proposed framework in a study¹ in a special issue of Springer's journal AIDS and Behavior. The special issue, "Turning the Tide Together: Advances in Behavioral Interventions Research"² is freely available online and will be published in July to coincide with the XIX International AIDS Conference in Washington, DC, from 22 – 27 July 2012.
The National Institutes of Health recently reported a major breakthrough in the fight against HIV. Research showed that treating individuals with HIV with anti-retroviral therapy—so called 'treatment as prevention'—could reduce the risk of transmission of the virus to healthy heterosexual partners by up to 96 percent. Although these results have been heralded as "the beginning of the end of AIDS," the research finds that this treatment needs to take a wider perspective and consider the full range of HIV-risk behaviors.
Holtgrave and colleagues' paper identifies the critical role that HIV-related risk behavior plays in determining the ultimate impact of treatment as prevention. The authors describe the size of the population at risk for HIV and identify three subgroups of people living with the disease. These subgroups include: those who are unaware of their serostatus; those who are aware of their status and do not engage in risky behavior; and those who are aware of their serostatus and are engaging in risky behavior. While all of the subgroups may transmit the virus, they vary considerably in terms of awareness of their serostatus and risk behaviors, as well as the rate at which they could transmit HIV.
For each of these subgroups the researchers identified the most relevant approach: 'testing and linkage to care'; 'treatment as prevention'; and/or 'treatment as clinical care'. They note that the impact 'treatment as prevention' might have on the spread of HIV will depend heavily on which subgroup is targeted for this approach.
The authors conclude, "The framework we describe helps us to move more toward 'complementary prevention' in which the best interventions from all domains are chosen to address clients' specific clinical needs and to address public health needs of averting new infections. HIV prevention needs an approach that is truly synergistic, resulting in an effect that is more than the sum of the intervention's parts."