Three ways to turn science into practice to reduce HIV among key populations

Written by Rose Wilcher, Director, Research Utilization, FHI 360, and Hally Mahler, Project Director, LINKAGES

This blog post was originally featured on FHI 360’s Degrees.


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Photo: Jessica Scranton, FHI 360

Next week, leading scientists and cutting-edge thinkers will gather at the International AIDS Society’s 9th IAS Conference on HIV Science in Paris to discuss the latest scientific discoveries in HIV prevention, care and treatment. These discoveries hold the potential to accelerate progress toward the global 90-90-90 targets set forth by the Joint United Nations Programme on HIV/AIDS (UNAIDS). And, they are especially important for key populations — including men who have sex with men, sex workers, transgender people and people who inject drugs — who shoulder a disproportionate burden of HIV. UNAIDS estimates that 45% percent of all new HIV infections among adults worldwide occur among these key populations and their sex partners. Reaching these groups with new technologies and approaches is essential to ending the epidemic.

The headway on display at IAS will, we hope, leave us feeling optimistic. However, science cannot have impact unless it is applied in policy and programs. We are working to translate evidence of what works into widespread practice for key populations through the Linkages across the Continuum of HIV Services for Key Populations Affected by HIV (LINKAGES) project, which is funded by the U.S. Agency for International Development (USAID) and the U.S. President’s Emergency Fund for AIDS Relief (PEPFAR). But progress is slower than it should be, largely because the issues that drive the spread of HIV in key population communities — unrelenting stigma, discrimination, violence and, in many cases, criminalization — also mean that these groups are often the last to benefit from scientific discoveries.

To ensure that new technologies and emerging evidence-based practices reach those who want and need them most, we should do three things.

We need more community-led demand for the latest evidence-based innovations. Even the most compelling evidence does not put itself into practice, especially for the benefit of the most marginalized. When members of key populations demand access to innovations that could make a difference in their lives, that is often the needed catalyst to move research to practice. Organizations led by key populations are chronically underfunded and undervalued, but their voice and engagement are critical to ensuring that evidence-based practices reach them in a way that is safe, appropriate and responsive to their needs.

For example, great strides have been made in recent years using pre-exposure prophylaxis (PrEP) as a new HIV prevention option, and it is sure to be a hot topic at the IAS conference. But, PrEP implementation, particularly for key populations, is complex and moving slowly. The International Treatment Preparedness Coalition (ITPC), a LINKAGES partner, recently convened a global think tank meeting with stakeholders representing the communities that are most affected by HIV to discuss how best to increase access to PrEP. “This was the first time that people from different communities from across the globe sat together in one room to discuss how to demand PrEP on their own terms,” said Solange Baptiste, executive director of ITPC. The discussions at that meeting are informing an upcoming global policy brief and an activist toolkit on PrEP that can accelerate implementation.

We must create an environment that enables the delivery and uptake of evidence-based interventions among those who need them most. Even when the latest prevention, care and treatment options and services are available, stigma, violence and discrimination from health care providers, family members, police, and partners hinder access to services. In many of the countries where LINKAGES works, including Botswana, Cameroon, the Dominican Republic, Kenya, Malawi and Suriname, we are systematically integrating violence prevention and response into HIV programming for key populations. We are working to mitigate stigma in health care facilities through the introduction of a text-message-based quality assurance tool that gathers information about key populations’ experiences of stigma and discrimination at health facilities and assesses overall client satisfaction with the care they received.

But, work to dismantle stigma and address violence against key populations, including through policy and legal reforms, always needs more attention. We will miss opportunities for the science to have maximum impact if the environment in which the science needs to be applied is not also progressing.

We need to accompany these efforts with the generation of more evidence through implementation science. Such investments will build collective knowledge about how to introduce proven interventions in real-world contexts, thereby speeding up the pace of replication and implementation at scale.

At the IAS conference, LINKAGES and colleagues from USAID, the U.S. Centers for Disease Control and Prevention (CDC) and amfAR will convene a satellite session that will present findings from implementation science studies focused on key populations that were conducted in Brazil, Peru, Senegal, South Africa and Thailand. Taken together, these studies contribute important new evidence about how to enhance uptake of and retention in services for key populations, across the HIV prevention, care and treatment cascade. They also illustrate how valuable implementation science is to ensuring that proven interventions achieve results through widespread implementation.

The evidence base on HIV and key populations has grown tremendously in the past several years, and more will come to the fore at the IAS conference. We will be participating with an eye toward how we can move the science into practice so that it benefits as many people as possible, as quickly as possible. The science holds much promise; we cannot let implementation lag.

Keeping the Focus on Key Populations: CLAC with LINKAGES Overhauls Important Online Resource Hub

LINKAGES joins The Global Forum on MSM & HIV (MSMGF) in celebrating the release of the redesigned website for the Community Action and Leadership Collaborative (CLAC).

Below is a reposting of the press release from the MSMGF on the recent release of the newly designed CLAC.

CLACThe MSMGF is proud to announce the launch of a redesigned website for the Community Action and Leadership Collaborative (CLAC). As a member of CLAC, the MSMGF has collaborated with the USAID– and PEPFAR-supported LINKAGES project to update and maintain a resource library for key population-related policy and practice. It will serve as an online hub for accessing the best information and resources on HIV for sex workers, men who have sex with men (MSM), people who inject drugs, and transgender people. The library contains a curated set of tools and materials to serve a range of audiences working to address the needs of key populations, including policymakers, advocates, program planners and implementers, health care workers, and peer educators. This includes linking beneficiaries with tools and resources that build and strengthen communities with a focus on organizational and technical capacity.

“We are happy to see this improved resource library in support of key population-focused work,” said Dr. George Ayala, Executive Director of MSMGF.

“The partnership between CLAC and LINKAGES, ensures greater coverage of vital information and tools that can support scale-up of evidence-informed and rights-based approaches for addressing HIV among men who have sex with men, sex workers, people who inject drugs and transgender people.”

CLAC is a unique collaboration between AIDS and Rights Alliance for Southern Africa (ARASA), the Global Network of People Living with HIV (GNP+), Global Action for Trans* Equality (GATE), the Global Forum on MSM & HIV (MSMGF), the Global Network for Sex Work Projects (NSWP), the International Network of People Who Use Drugs (INPUD), and the International Treatment Preparedness Coalition (ITPC). Working together, we are able to link our first-hand knowledge of key populations to strong expertise in the areas of prevention, HIV and tuberculosis treatment access, human rights and community engaged programming.

“Knowledge sharing is fundamental for creating action at scale,” said Kevin Osborne, LINKAGES Project Director. “LINKAGES is thrilled to have worked with CLAC to strengthen this important resource library where policymakers, funders, advocates, implementers and other stakeholders can go to access accurate and up-to-date tools, share lessons and promote best practices on HIV prevention, care and treatment for key populations.”
The new, redesigned CLAC website can be reached at www.clac.cab.

New Look at PrEP Study Points to Efficacy for Transgender Women

Below is a reposting of the press release from UC San Francisco (UCSF) on the findings of a recent PrEP study. Access to the full research article published by the Lancet can be found here: http://bit.ly/PrEPLancet 

In a new look at the groundbreaking iPrEx (Pre-exposure Prophylaxis Initiative) trial for people at high risk of HIV infection, UC San Francisco researchers have identified strong evidence of efficacy for transgender women when PrEP, a two-drug antiretroviral used to prevent HIV, is used consistently.

“We re-examined the data using a more sophisticated method for determining which participants in the trial were transgender women and found a larger number than the original analysis,” said study senior author, Robert M. Grant, MD, UCSF professor of medicine. In addition, we looked at blood levels of the drug in a sub-group of participants.  We found no drug in the transgender women who became infected. And, no transgender woman participant with drug levels equal to four or more doses a week became infected with HIV.  While this analysis did not include a large enough sample group to draw firm conclusions, we did find strong evidence pointing to efficacy.  Additional research designed specifically for transgender women is needed to confirm this finding.”

The study enrolled 2,499 HIV negative gay and bisexual men and transgender women in Peru, Ecuador, Brazil, Thailand, South Africa and the United States between 2007 and 2011, with an open label extension that ended in 2013.  The new analysis identified 339 transgender women participants,310 more than originally included in the initial report of the trial.

Compared with men who have sex with men (MSM) in the iPrEx study, transgender women had lower drug levels in their blood and were less likely to take PrEP on a daily basis.  While MSM who reported sexual practices with the highest risk of contracting HIV were more likely to have PrEP detected in their blood, the opposite was true for transgender women.

“We think that one factor leading to lower rates of pill-taking may be due to either a fear of, or lack of information about drug-drug interactions between PrEP and gender-affirming hormone medications. For transgender women, their gender-affirming medications are a higher priority,” said study first author, Madeline B. Deutsch, MD MPH, assistant clinical professor of Family and Community Medicine at the UCSF Center of Excellence For Transgender Health.  “And while there may be a negative behavioral interaction between the two therapies that is affecting pill-taking, we have no evidence to date for a biological interaction between the two, though further research is needed.”

The iPrEx trial in 2010 was the first to show efficacy for a daily single pill oral antiretroviral medication consisting of emtricitabane and tenfovir disoproxil fumarate for use in HIV negative gay and bisexual men.  On an intent-to-treat basis, efficacy was not found for the transgender women in the trial.

The FDA approved and the U.S. Centers for Disease Control and Prevention recommends this medication for use in gay and bisexual men and heterosexual men and women at risk for acquiring HIV.  The U.S. CDC recommendations for PrEP use do not mention transgender women.

Transgender women are at high risk of HIV infection.  An analysis from 2008 found that over a quarter of transgender women in the U.S. are HIV positive.  A 2013 analysis looking at fifteen countries found a fifth of transgender women are HIV positive.  And, the U.S. Centers for Disease Control and Prevention reported that transgender women have the highest percentage of new infections of any sub-group in their testing programs.

“Transgender women face several structural barriers including lack of legal protection against discrimination and resulting difficulties in employment, access to income, food and housing.  They desperately need a tool that they control, one they can use without their partners’ consent or knowledge,” said Deutsch.

PrEP research and interventions are generally designed to encourage MSM to participate and consider use of PrEP.   No evidence based HIV prevention interventions specifically designed for transgender women exist.

“When transgender women take PrEP as prescribed, it appears to work, but to retain and encourage PrEP use, research should be conducted and interventions should be delivered in gender affirming environments.  One example would be to integrate PrEP delivery with gender affirming services, including provision of gender affirming hormone therapies.  Social marketing campaigns and PrEP delivery programs should not lump transgender women in with MSM but should be explicitly designed to support transgender women,” said study co-author JoAnne Keatley, MSW, director of the UCSF Center of Excellence for Transgender Health.

The study’s co-authors are Suwat Chariyalertsak, MD, from the University of Chiang Mai, Thailand; Esper G. Kallas, MD, University of Sao Paolo, Brazil; Juan Guanira, MD, IMMENSA, Lima, Peru; Vanessa McMahan, the Gladstone Institutes, San Francisco; and Jae Sevelius, PhD, and David V. Glidden, PhD, from the University of California, San Francisco.

The National Institutes of Health and the Bill and Melinda Gates Foundation funded this research.

The UCSF Center of Excellence for Transgender Health is dedicated to increasing access to comprehensive, effective, and affirming healthcare for trans communities.

About UCSF: UC San Francisco (UCSF) is a leading university dedicated to promoting health worldwide through advanced biomedical research, graduate-level education in the life sciences and health professions, and excellence in patient care. It includes top-ranked graduate schools of dentistry, medicine, nursing and pharmacy, a graduate division with nationally renowned programs in basic, biomedical, translational and population sciences, as well as a preeminent biomedical research enterprise and two top-ranked hospitals, UCSF Medical Center and UCSF Benioff Children’s Hospital San Francisco. Please visit www.ucsf.edu/news.