Searching for comprehensive solutions: In conversation with Linda-Gail Bekker

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Original content from our Mapping Pathways blog team

"The days of behaviourists, clinicians, scientists and legal policymakers being in separate rooms are over. We have to get into one room and work this problem out together."


In the fourth of this five-part series, Linda-GailBekker of the Desmond Tutu HIV Centre, a Mapping Pathways partner organisation,speaks about her involvement in the HPTN 067 study and about issues that make HIV the complicated problem it is. Read parts one, two and three
MP: What are someof the other issues that make HIV the complicated problem that it is?
LGB: For 30years, many people thought HIV was a behavioural issue only - that usingcondoms, abstaining and being faithful would sort the whole problem out. On theother hand, the biomedically thinking people scrambled around trying to findsomething that worked, without a whole lot of success. Now the biomedicalprotagonists  have tools that work, suchas PrEPand microbicides. The obvious mistake to be avoided at all cost would be tothrow the behavioural science out and go entirely with the biomedical tools.  This is a trap that medical people often fall into: (and Iam one of them!!) they love to fix things with pills and find it easier tooffer something tangible to a patient rather than wait for them to change theirbehaviour.  But pills and microbicideswill not work unless they get to the people that need them and those people havethe ability to take them. For example, if there’s a structural component in oneslife that is a barrier, such as a violent partner, ones ability to reduce one’srisk may be compromised.
The days of behaviourists, clinicians, scientists and legalpolicymakers being in separate rooms are over. We have to get into one room andwork this problem out together otherwise we may again end up with failure becausewe’re not coming up with comprehensive solutions. After 30 years thinking abouta multi-sectoral approach seems the only way to go about it.
MP: Please tellus a little about the ADAPT study that you are involved in.
LGB: The HIVPrevention Trials Network (HPTN) is funding the ADAPT study, also known as HPTN 067, in threesites. Cape Town, which I am PI of, is looking at women who have sex with men,while Bangkok and Harlem are enrolling  MSM.My site has enrolled 180 at-risk women who have sex with men and we are in theprocess of follow-ups with them.
The women are randomised to daily PrEP, intermittent PrEPand event-driven PrEP using Truvada. The pillsare put into a ‘wise pill carrier’ and when it is opened to take a dose, asignal goes to the server.  Our staffcall up the young women weekly to discuss what happened over the week. It is anintense study for the participants since they have to share intimate data withsite staff on a regular basis but the idea is to look at feasibility andsuitability to people of these various dosing modalities to see what works,what doesn’t work, and what people can actually adhere to. It has really neededcommitted participants and caring site staff with a great deal of trust betweenthem!
The primary goal is to discover if people can use the pillsthe way they are meant to be used. There obviously are other issues likelooking at side effects, safety and other data but the primary end point isfeasibility and acceptability of a dosing strategy.

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. 
Stay tuned to the blog as we bring you the final part of our conversation with Linda-Gail, where she speaks about her the importance of adherence, both in clinical trials and the real world, and the challenges and issues facing adolescents. 

Stay tuned for the Mapping Pathways monograph, coming in early 2013


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