Time for a conversation about HIV prevention
From the Incidence 0 Archives
📢 First published: 20-Mar-2011
☑️ Reviewed: 27-Aug-2024
HIV prevention as we know it and have done it for the last 30 years is failing to put an end to the HIV epidemic. At best current prevention strategies appear to be containing HIV incidence at a rate of 2.7 million new infections a year after a peak at 3.5 million in 1996.
The recent acknowledgment that there is more to HIV prevention than the ABC of behaviour change and condoms and that key vulnerable populations have been largely ignored by prevention interventions (injecting drug users, men who have sex with men) is a welcome but late awakening.
Nevertheless, thirty years into the epidemic and in the absence of a cure or any other efficient means to protect oneself, there are still men and women who cannot or will not use condoms in situations where they are at risk of being infected. The reasons behind putting oneself at risk are multiple, complex and often beyond human rational decision making or their control.
In trying to address each of them, often in turn, independently and above all within the narrow epidemiological context of HIV, attempts at preventing HIV infection have resulted in limited outcomes and the fragmentation of the scarce resources allocated to target a global epidemic.
To date, of the prevention interventions tested in clinical trials, only four have shown a positive outcome: male circumcision, a complex and costly combination vaccine, an anti-retroviral-based microbicide whose efficacy hinges on adherence and a daily oral PrEP using antiretrovirals commonly used to treat HIV-positive people.
The vaccine trial was the "Thai" RV144 trial, the microbicides trial was CAPRISA-004 and the PrEP trials was iPrEX.
Though these clinical studies open the way to more powerful interventions they are not good enough on their own to crush the current level of HIV infection and raise a number of questions and challenges.
Incidence 0 aims at supporting and advancing the development of no-nonsense evidence-based HIV prevention interventions by providing a critical analysis of existing and new HIV prevention approaches and technologies.
No question should be ignored, no perspective disregarded. All opinions are worth considering because all those involved and dedicated to fighting the spread of HIV have one thing in common: they all want to bring HIV incidence down to zero.
- Nearly 14 years later, the HIV epidemic persists with 1.3 million people acquiring HIV in 2023 (nearly half that of 2011) but several ambitious targets remained unmet. Nonetheless, significant progress has been achieved, particularly with oral PrEP, which has been a game changer, and more recently with long-acting ARVs, which are expected to shift the paradigm in HIV prevention. The definitive confirmation that individuals on treatment with an undetectable viral load are not infectious (U=U) has also made a substantial impact, though it has not yet brought the epidemic under control.
- Unfortunately, despite the initial optimism generated by RV144, an effective HIV vaccine remains elusive, with four subsequent efficacy trials failing to deliver on a vaccine.
- While microbicide research did not produce a definitive solution and has largely wanned, it laid the groundwork for the Dapivirine Ring, now recommended by the WHO as a new prevention option for women at substantial risk of HIV infection.
- PrEP has enabled tremendous progress, but its full benefits remain unrealized due to persistent access limitations in many countries and settings. New PrEP options face even greater access challenges.
- Remarkably, HIV prevention has shifted from a focus on tools and "the narrow epidemiological context of HIV" to a people-centered approach, placing individuals at the heart of prevention strategies and their development.
- Once again, biomedical HIV prevention is at a turning point with the advent of LA-PrEP. Its efficacy and simplicity have the potential to revolutionize the field, but challenges remain, with access being a significant concern. As such, discussions about HIV prevention are more crucial than ever. A one-size-fits-all approach will not suffice, especially if we aim to reduce incidence to zero.