HIV Treatment as Prevention in Jamaica and Barbados

Abstract

This discursive article introduces HIV treatment as prevention (TasP) and identifies various models for its extrapolation to wider population levels. Drawing on HIV surveillance data for Jamaica and Barbados, the article identifies significant gaps in HIV response programming in relation to testing, antiretroviral treatment coverage, and treatment adherence, thereby highlighting the disparity between assumptions and prerequisites for TasP success. These gaps are attributable, in large part, to sociocultural impediments and structural barriers, severe resource constraints, declining political will, and the redefinition of HIV as a manageable, chronic health issue. Antiretroviral treatment and TasP can realize success only within a combination prevention frame that addresses structural factors, including stigma and discrimination, gender inequality and gender-based violence, social inequality, and poverty. The remedicalization of the response compromises outcomes and undermines the continued potential of HIV programming as an entry point for the promotion of sexual, health, and human rights.

Introduction and Rationale

Treatment as prevention (TasP) is championed as a “paradigm shift” and a “game changer” in the HIV/AIDS response. In 2008, a group of Swiss scientists issued a consensus stating that HIV-positive persons on effective antiretroviral (ARV) treatment, with undetectable viral loads and free from other sexually transmitted infections (STIs), have a negligible risk of transmitting HIV. ¹ Following evidence from 2 subsequent landmark studies,^2,3 TasP has captured the imaginations of HIV practitioners and advocates. Treatment as prevention euphoria peaked at the 2012 World AIDS Conference in Washington, where it took center stage as having the potential to dramatically alter the landscape of the epidemic and, ultimately, to bring an end to HIV&AIDS. But TasP has not evaded controversy; initial alarmist responses denounced it as “irresponsible” and “misleading.” The World Health Organization urged caution and further research before implementation. ⁴ Furthermore, TasP rollout is hampered by resource constraints, logistical barriers, persistent stigma, and structural drivers of HIV.

In this article, we explore the potential and challenges of TasP in the context of Jamaica and Barbados. We begin by situating TasP within the wider frame of HIV prevention. The main section of the article then strikes a note of caution by identifying the epidemiological, resource, sociocultural, and political constraints to TasP and widens the frame to interrogate the possible consequences of centering TasP in HIV response programming.

HIV Prevention and the Promise of TasP

What is clear after more than a decade of treatment and care is that public health approaches, centered on a liberal discourse of personal autonomy and moral responsibility, have inherent limitations for prevention. Historically, national campaigns across the Caribbean have promoted the ABC strategy (abstinence, faithful relationships, and condom use) premised on the understanding that individuals would make rational choices to prolong their lives by adopting safe sexual practices. All they needed was knowledge. Questionnaire surveys confirm high levels of knowledge of HIV transmission and impacts on health,^5,6 even though gaps and concerns persist, ^{7 (pp19,23)} and there is some evidence in Jamaica of knowledge decline. ⁸ The point is that knowledge, though necessary, is not sufficient for sexual behavior change and a disconnect between knowledge and practices—the so-called KAP gap^9,10—persists.

Rethinking HIV&AIDS from personal risk to social vulnerability took the response into the wider context of gender inequality, stigma and discrimination, sexual abuse and violence, and poverty and social exclusion. Grappling with these complex structural drivers of social and sexual behavior appears to be overwhelming, beyond the capacity of HIV programming. ¹¹ TasP, on the other hand, is much less dependent on sexual behavior change.

Optimism around TasP is explained in large part by frustration over poor results of HIV prevention to date. Lives have been prolonged especially since the introduction of highly active antiretroviral therapy (HAART) in Barbados in 2002 and Jamaica in 2004. AIDS-related mortality has been dramatically reduced, in Barbados by 80% since 2001, ¹² and in Jamaica by 40% between 2004 and 2008. ¹³ Nevertheless, high rates of infection persist. The average annual number of new HIV cases recorded in Barbados during the 2000s was 156 compared to 153.5 in the previous decade. In 2010, 135 new cases were recorded. ¹² In Jamaica, there has been an estimated decrease in new HIV infections by 25% in the past decade. However, approximately 2600 new HIV infections were estimated to occur in 2012.^8,13 There is reason for cautious optimism in both countries; however HIV drug resistance and other threats impede progress.

Treatment as prevention is one of several medical HIV prevention options already being implemented, among which are pre- and postexposure prophylaxis, circumcision, and prevention of mother-to-child transmission (PMTCT). Arguably, PMTCT qualifies as the success story in Caribbean HIV prevention. In Barbados, rates were down to 0 in 2010^12,14 and in Jamaica to less than 5%. ¹⁵ But this intervention, along with circumcision, delivers protection to select social groups, namely, to pregnant women and to men, while TasP pledges prevention for whole populations.

Although neither a cure nor a vaccine, the potential of TasP is far-reaching. The appeal lies in its simple logic and apparent ease of implementation. All that is required is the extension of what is already in place, that is, the upscale of testing and treatment. The tension between HIV treatment and prevention disappears as treatment becomes prevention. Promised benefits are widespread operating as they do at several levels—persons living with HIV can lead “normal” sexual, conjugal, and family lives; sexual partners in serodiscordant relationships are protected; the “community viral load” is significantly reduced; and, by extension, the twin epidemics of HIV and AIDS come to an end. However, there are many factors that necessitate further in-depth analysis and may constrain success as this prevention methodology is adopted within the Caribbean context.

Assumptions and Prerequisites of TasP

While evaluating the recent prevention studies, one of the concerns is their external validity. The HIV epidemics in both Barbados and Jamaica have been described as mixed, showing features of both generalized and concentrated epidemics, with prevalence rates of less than 1% in the antenatal clinic populations. This is in stark contrast to the populations selected for the majority of prevention trials, heavily weighted toward sub-Saharan Africa, that have generalized epidemics and high prevalence rates. Initial insight into the generalizability of the TasP research findings has already shown the need for caution. Wilson ¹⁶ indicates that despite increased HIV testing and antiretroviral therapy (ART) coverage rates among men having sex with men in Australia and France, TasP has had limited impact on HIV incidence.

The Testing, Treatment, and Viral Load Suppression Continuum

Several mathematical modeling exercises have been conducted to investigate multiple parameters necessary for TasP success. Eaton and coresearchers ¹⁷ presented a comparison of 12 such models. Consistent results among the models for short-term outcomes (8 years) were found and indicated that, with an 80% ART coverage rate for all individuals with CD4 counts less than 350 cells/mm³, a potential reduction in HIV incidence of between 35% and 54% could be realized. However, there are several assumptions in these models that are not in keeping with real-world scenarios, including Barbados and Jamaica.

The success of TasP is based on assumptions of continuity in HIV care, from testing and the detection of new cases, to linkage to treatment and treatment adherence, to viral load suppression. ¹⁸ Models of TasP generally assume that 100% of the population is tested and that 100% of those found to be positive are linked to care. Although data gaps for Jamaica and Barbados hinder a full understanding of the potential of TasP, sufficient information exists to suggest caution. In Jamaica, the Joint United Nations Programme on HIV/AIDS (UNAIDS) estimated in 2010 that only 50% of persons infected with HIV are aware of their status, even with more than 250,000 tests being conducted annually. Though the relevant figure for Barbados is less up to date, it has been estimated that 1 in 4 persons is unaware of their HIV status. ¹⁹ There has, however, been a notable expansion in the number of individuals tested in recent years, from 14,403 tests in 2000 to 26,045 by 2010. ⁷ These figures are likely to be inflated since they do not account for retesting the same blood sample or for persons testing more than once in a particular year. In both countries, the policy shift from voluntary counseling and testing to routine provider-initiated testing and counseling (PITC) in public health clinics should result in a significant expansion in the numbers tested.

There is, however, deep concern in both countries over late presentation for testing, often not until opportunistic infections have appeared. In Barbados, nearly one-third (32%) of new HIV-infected patients were severely immunocompromised, ¹² men significantly more so than their female counterparts. ¹² In general, women living with HIV are diagnosed earlier and live longer. However, in Jamaica, comparative analysis of all HIV cases reported between 1988 and 2008 ²⁰ showed a significant decline in individuals diagnosed with AIDS or reported as death due to AIDS, from 30% prior to 1995 to 13.9% between 2004 and 2008 (P < .0001), with men and older individuals being more likely to be diagnosed with AIDS or reported as death due to AIDS.

The Barbados record of testing to treatment linkage remains problematic and has been described as “the biggest challenge” in the HIV continuum. Over the recent 10-year period, the proportion of persons diagnosed with HIV who are linked to treatment was 55%. ²¹ In 2010, of the 135 new HIV cases, 91 (67.4%) registered with the Ladymeade Reference Unit (LRU), the national HIV treatment center, within 6 months of diagnosis. Whether the remaining persons died or sought treatment elsewhere or opted not to be treated is not known. ⁷ National data related to linkage to care in Jamaica is currently unavailable, but it is safe to say that shortfalls in both countries make the modeled assumptions of 100% linkage unrealistic, especially in the near future. Home-testing kits may increase HIV diagnosis, but in the absence of professional counseling and encouragement, persons testing positive may be less likely to transition to treatment.

Another challenge to TasP success is the timing of HIV diagnosis. New HIV testing has significantly reduced the window period for false negative results, which can occur for approximately 2 weeks. This has been achieved by detecting not only HIV-associated antibodies but the p24 HIV antigen that is detectable as early as 2 weeks after exposure. The impact of detecting HIV early in its course in the context of HIV transmission and, ultimately, TasP effectiveness has been highlighted. Cohen et al ² calculated that acutely infected individuals were high transmitters for up to 5 months and that this period could account for 38% of all new infections. High rates of HIV transmission during this early acute infection stage point to the need to persist with sexual behavior change interventions. This is of particular importance in settings with cultural patterns of early sexual initiation and concurrent sexual partners and therefore high risk of numerous sexual contacts within this acute phase, as is the case in Jamaica and Barbados.

The models also assume a treatment coverage rate of at least 80% and lost to follow-up rates of between 1% and 2% annually. In Barbados, with the introduction of HAART in 2002, HIV-infected persons receiving public health treatment within 1 year of diagnosis have risen from 60.6% to 78.4% by 2009. ¹² In 2011, 80.7% of eligible adults and children were receiving ART. ⁷ A recent study indicates that, once persons have accessed treatment, results are more positive, with 75% retained in care and 94% of them with viral load suppression. ²¹ However, there is some suggestion that “medical fatigue” may be an emerging factor affecting coverage rates. ⁷ Jamaica has also seen ever-increasing numbers of individuals receiving ART with an annual increase of between 1000 and 1500 following the introduction of HAART in 2004. Presently, approximately 60% of those eligible are accessing ART. ¹⁵ Data from the HIV treatment database in Jamaica also suggest that attrition rates at 1 year in care are between 10% and 31%. Many persons diagnosed as HIV positive may not present to treatment programs. ²² Members of the general public may be less receptive to starting lifelong ART when they show no signs of disease, in contrast, for example, to mothers-to-be who are generally highly motivated to protect their unborn children.

At the final stage in the HIV treatment cascade, TasP also relies on ART being 100% effective in reducing viral loads to an undetectable level. However, taking into consideration the Jamaican and Barbadian context where the self-reported adherence to ART is between 50% and 75%^23,24 and transmitted HIV resistance may be as high as 12%, ²⁵ this seems to be unlikely. Sexually transmitted infections also complicate the issue by significantly increasing HIV transmission risk by as much as 5 to 10 times. For Jamaica, reports indicate an increasing incidence of genital discharge among men and women of all ages, ²⁶ and while STI rates vary widely depending on risk group, they escalate to as high as 40% in female sex workers with genital ulcer disease. ²⁷

Structural Barriers

Stigma and discrimination, gender inequality and gender-based violence, the criminalization of sexual practices associated with HIV transmission (including sex between men and sex work), poverty, and human rights abuses are strong deterrents to testing, treatment uptake, and ART adherence.^28,29 Stigma and discrimination drive key populations underground and restrict their access to treatment and care. ⁷ The potential of TasP is impeded by structural factors at every stage in the treatment and care continuum.

Unlike other stigmatized diseases, HIV is generally asymptomatic for several years after initial infection. Individuals can and do hide and deny their HIV status, even to themselves, and may continue sexual practices as before. Economic dependency and the fear of intimate partner violence deter women from disclosure to their partners and from accessing testing and treatment. The “othering” of HIV as a disease of gay men and sex workers and, therefore, not a threat to the general population once persons stay clear of these “vectors” facilitates denial. ³⁰ In Jamaica, most persons testing positive had not considered themselves at risk of HIV infection. ³¹ HIV stigma is intensified by association with sexual immorality—with heterosexual multiple partnering and transactional sex—but more significantly with “deviant” homosexual practices, already heavily stigmatized by the church, the state, and the general public in Barbados and Jamaica and the target of violent attacks.^32–34

Stigma and social exclusion also compromise the care and support considered essential to ensure access to and adherence with treatment. Even in public health clinics, there are reports of stigmatizing attitudes and discriminatory practices including testing without consent, breaches in confidentiality, and the outright refusal to provide treatment and care.^35,36 Evidence of HIV provider stigma is mixed, with reports of “warmth,” “comfort,” and “feelings of sympathy” as well as “distancing” and “condemnation.” ³⁷ From Jamaica, there are similar reports concerning care in the home. Family members and sexual partners assume heavy burdens of care, but persons living with HIV also report daily episodes of shunning, scorning, and violence. ³⁸ Family carers, mostly women, may by association be targeted by stigma.^37,38 Social stigma also promotes self-stigma manifested as harmful psychological effects of depression and worthlessness and physical effects of self-harm, suicidal tendencies, and social isolation, ³¹ all of which impede access to treatment and care and undermine TasP.

There is a general assumption that HIV stigma will decline as knowledge reduces the fear of transmission, as HIV affects the wider population assumed to be heteronormative, as testing and treatment rollout becomes more widespread, and as HIV becomes a treatable chronic disease in the public imagination. The evidence from the Caribbean is unclear as yet, but a recent report from South Africa shows no association between the increased availability of ART and a reduction in stigma. ³⁹ As a result of persistent stigma, engaging hard to reach populations in HIV programming continues to be a major barrier to success and a potential challenge to TasP rollout.

Resource Constraints

Jamaica and Barbados, with well-developed public health outreach systems, have done well by providing HIV testing, treatment, and care at no cost to clients. In Barbados, there is a decentralized system of HIV testing and counseling in 8 polyclinics distributed across the country supplemented by outreach community testing at period intervals. ⁷ Additionally, the LRU that opened in 2002 provides comprehensive medical care, including ART, for persons living with HIV. In Jamaica, testing is also decentralized. Currently, there are 23 treatment sites across the country at public health clinics as well as numerous community-based testing activities. All sites are equipped to provide PITC, ART, and counseling services. ¹⁵

However, the present global economic crisis, compounded by mounting debt repayment obligations, places heavy demands on local resources. In both countries, cuts in international donor funding for HIV require respective governments to make up the shortfall at the same time that they are facing severe fiscal constraints. The threat to HIV program sustainability is serious, not least to the supply of ARV drugs and other treatment drugs. The challenge to maintain supplies and avoid “stock outs” is fundamental to the HIV treatment and prevention. The impact of TasP in the short run is likely to increase costs as countries realize the goals of universal testing (in accordance with the PITC model), treatment, and care, though in the long run economic benefits should accrue in proportion to the decline in new HIV infections.

Political Will

In both Jamaica and Barbados, the urgency that characterized the initial response to HIV has waned. Diminishing political will and the emergence of so-called “AIDS fatigue” among officials and within general populations have been noted. In Barbados, for example, the National HIV/AIDS Commission has been relocated from the Prime Minister’s office to the Ministry of Family, Culture Sports, and Youth. In Jamaica, the National HIV/STI Programme is expected to merge with the National Family Planning Board.

The change in attitude toward HIV coincides with a growing perception that the epidemics have “stabilized” and the “AIDS problem has been solved” as a result of surveillance evidence of reduced AIDS-related mortality and some indication of declines in new HIV cases. HIV appears to be sidelined as other health concerns take center stage. Among the many consequences are the shift in attention of Caribbean governments to chronic noncommunicable diseases, the redefinition of HIV from an epidemic with a death sentence to a manageable chronic health condition, and the re-medicalization of the HIV response. ⁴⁰ Another trend is the location of HIV programming within the wider frame of Sexual and Reproductive Health (SRH). While this might be welcomed as exemplifying the transition from a traditional vertical response to disease to an integrated horizontal one within a comprehensive SRH framework, the impact for HIV should be problematized. The Caribbean epidemics are far from over. The concerns are is that the prominence of HIV on the health and social development agenda will decline as it becomes one of many public health issues, that resources are being diverted and spread too thinly, and that the response loses sight of critical social and structural dimensions, in particular stigma and discrimination.

Evidence from the Caribbean is mixed making it difficult, if not impossible, to predict the outcomes of TasP programs. At this stage of ART in the Caribbean, the most that can be predicted with some promise of success are viral load reductions among compliant individuals and interventions with discordant couples. But these are possible only with small-scale samples in clinical settings, and the allure of TasP lies in its potential for HIV prevention in total populations.

The Way Forward

For TasP to fulfill its promise as a sustainable prevention strategy for wider population and, ultimately, for the elimination of HIV, thinking and responses must move outside the comfort zone of mathematical modeling and beyond intimate interventions in clinic settings. Testing, treatment, and counseling on the scale required for TasP to be successful cannot be effective without continued attention to wider contextual realities. These challenges point to the need for closer evaluation to assess the potential of TasP country by country, by examining resource capacity, political commitment, and structural barriers. It is also important not to give up on behavorial change interventions while continuing to address structural drivers including gender inequality, stigma and discrimination, violence, and poverty that promote risky sexual and social behavior and undermine human, sexual, and reproductive rights. Dependence on biomedical intervention, even when supplemented by education, information, and communication (IEC) and by care and support strategies, has failed to stem the spread of HIV. Antiretroviral therapy and TasP can only be effective within the context of combination prevention programming that integrates biomedical, behavioral, and structural dimensions of HIV.