Providing a range of prevention options: In conversation with Linda-Gail Bekker

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Original content from our Mapping Pathways blog team
We need options. Not everyone in the world is a good pill taker. Like so many things in life, we may realise that people need different prevention options since they have different personalities.
In the final part of this five-part series,Linda-Gail Bekker of the Desmond Tutu HIV Centre, a Mapping Pathways partner organisation,speaks about the importance of adherence, both in clinical trials andthe real world, and the challenges and issues facing adolescents. Read partsone, two, three and four
MP: You havementioned adolescents as a particular vulnerable group in South Africa. In an interviewconducted earlier this year, your colleague, Dr. Melissa Wallace, also talkedabout adolescents as an especially at-risk group. What are some factors thatmake them so vulnerable?
LGB: Oneparticular reason why adolescents are highly at risk for HIV is because manyare at the stage of their lives where they may be experimenting with theirsexuality. They may also find themselves in relationships where negotiatingcondoms may be incredibly difficult.
This maybe the case with younger women whose relationships canbe with older men and young MSM outing themselves for the first time and whomay then choose to go out with older men. In that situation, being able to use a PrEP tablet discreetly and undertheir own control could be a life-saving step.
So putting prevention into the hands of the vulnerablebecomes a very important tool. But we can only do this if we are sure it’s safein this population, which requires carefully run clinical research in order toadequately test the product in the relevant populations.
This requires resources and investment from sponsors and fundingagencies even though this is often regarded as “high risk investment”. In thatregard, I’m delighted that we’ll be starting an MP3 project (methods ofprevention) based on a grant awarded to us by the NationalInstitutes of Health (NIH) to look at PrEP and other biomedical preventionmodalities in adolescents between 14-17 years old.

MP: Adherenceis an issue that has come up quite a bit this year, from M2012 to AIDS 2012. Howmuch are people talking about adherence and about taking lessons learned from trialsinto the real world?
LGB: Adherence isthe Achilles heel of the HIV prevention and treatment worlds. This is wherebiology meets behavior. We know that the pill is efficacious – PartnersPrEP showed that beautifully. In fact, every single one of the clinicaltrials has shown that once adherence increases there is a direct correlationwith efficacy in the results. Starting with the 39% in the CAPRISA study leading onto 44% in the iPrExstudy and going on to an astounding 75% in the Partners PrEP study – each onehad an increased overall adherence rate and with this an increase in point efficacy,so the correlation appears to be a real phenomenon.
In addition, the sub-studies done in every trial showed thathigh adherers within a study had a better efficacy compared to the loweradherers. So we can quite confidently say there is a robust relationshipbetween adherence and efficacy.
So how do we get people to adhere? Motivations play a greatrole. Partners PrEP which enrolled discordant couples had a great in-built motivationthat one was protecting a loved one by taking the pill, which may be the reasonwe saw particularly high adherence for that population.
I think we also need to understand that not everybody inthis world is a good pill-taker. There will be those who just cannot bringthemselves to swallow pills on a daily basis. So PrEP may not be a very goodidea for them. In that situation, maybe a rectal microbicide or a microbicidethat’s part of a lubricant may work very well for that individual.
We need options. If we get to that stage in the future whereother prevention technologies are available, like getting a shot in the armthat lasts three months, then we need that option on the table too. Like somany things in life, we may realise that people need different prevention optionssince they have different personalities.
MP: What are someof your final thoughts on what needs to happen to stem the HIV epidemic?
LGB: We need tohave conversations on several different levels: ethical, scientific, publichealth, politics and priorities. Different countries and communities will be atdifferent places. Some of the hard questions are : Who pays? How will we implementthis prevention strategy? Is this strategy for the generalised epidemic or isit only for selected key populations? Who are the key populations? What are thesocial factors that make them vulnerable? Is this ethical? Does it make soundpublic health sense? What wont be afforded if we go this route? Who willbenefit if we do?
Those are all very hard questions but they deserve to beasked and certainly require ongoing dialogue. This brings us back to theMapping Pathway- we have been contributing to the dialogue through thisproject. We also need to do the modeling exercises and implement somefeasibility type projects and then continue to raise more questions., It’s awonderful thing that we are at a point where we can actually have theseconversations. They are not hypothetical questions anymore. It is urgent tohave these discussions in such a way that the next steps become clear andinfections can be averted before too much more time is lost.
Linda-GailBekker is deputy director of the Desmond Tutu HIV Centre at the Institute ofInfectious Disease and Molecular Medicine, University of Cape Town. She alsoserves as the chief operating officer of the Desmond Tutu HIV Foundation, aMapping Pathways partner organisation. 
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