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1. ARV Treatment as Prevention
Kane Race
University of Sydney

2. Axiomatic
• ARV drugs have multiple applications that are worked
out through experimentation (official & unofficial)
• Effects of ARVs depend on practice and extend beyond
individual body
• Difficult to predict how drugs will be taken up in
different contexts
• As well as benefits, how they are taken up will produce
new and different problems

3. Preventive effects of ARVs …
• Already exploited in some sexual contexts
– Entry of VL into risk calculations from 1996
• Where treatment uptake has been high,
expected decrease in HIV incidence offset by ‘risk
compensation’ (e.g. Australia)
– No difference in risk among people taking ARVs
– BUT significantly higher risk practice across the board
among those who believed ARVs reduce risk of HIV
transmission

4. Prevention tools and techniques
• Increasing ‘prevention options’ does not always add more
layers of protection; tend to be used as substitutes for one
another
• Educational needs increase with introduction of new options
• Use of ARV/VL to inform sexual practice may be practical at
an individual partner level where decision is informed and
shared (but more knowledge on contextual factors, eg. Stis, needed)
• What about in other contexts? E.g. no disclosure
• What infrastructure is needed to make it work well?

5. Official uses of ARV as prevention
• PMTC (perinatal)
• PEP
• PREP (in trial) (incl. topical application)
• ATP (Anema 2008; Granich 2009)

6. Private prevention tools
• Advantage: don’t require knowledge, consent,
negotiation, cooperation with partners
– (e.g. female controlled, allows safer condomless sex)
• Disadvantage: don’t require knowledge,
consent, negotiation, cooperation with partners
– (lessens impetus for structural change around gender,
sexual practice, open discussion of sex, etc.)
• Toxicity and burden of toxicity (borne by certain
groups)

7. Granich paper, Lancet 2009
• Modelled effect of ‘universal voluntary testing
with immediate ARV’ on HIV incidence in
generalized epidemic
• Finds substantial decrease in HIV incidence
(‘elimination’) when TiRx is adopted
• But is this positive prevention??

8. • May have advantage of expediting treatment
access, increasing testing & improving follow‐
up with treatment
• BUT
• Prioritizes population health over clinical need
– No data on effects or sustainability over long term
• Requires substantial infrastructure &
resources
• Prone to abuse

9. What is left out of model?
• Possibility of reconstituted infectivity through
– STIs
– Treatment failure
– Poor adherence
• Possibility of risk compensation
• To work as intended, this technology requires new forms of
sustained behavioural change (i.e. does not eliminate the problem
of behavioural change, but in fact multiplies it)
• Model assumes universal uptake of testing
– (but what is ‘universal voluntary testing’??)

10. TiRx for prevention purposes
• Has the potential to be used coercively against ‘key
populations’
• Who will be targeted and prioritized and how? Will
public health calculations trump clinical need?
• Will viral load testing be part of this package? CD4?
• What is the effect on PLWHA of framing treatment as
prevention? (adherence, autonomy, confidentiality, etc.)

11. Barriers to testing
& risks of testing positive
• Safe disclosure not guaranteed in many contexts
• Particular risks for women
– Relationship breakdown
– Violence
– Being neglected or disowned by families/communities
– Stigma and discrimination: employment etc.
• Zambia 1999 study: 37% willing to test, 3.7% came
forward, only half returned for test results
• Some positive events. More research needed on effect
of testing positive in different contexts

12. Model conditions
• What needs to be modeled & emulated are the elements
of policy and social contexts where testing and treatment
uptake is voluntary and high
• Such conditions are completely overlooked in the Granich
study
• Voluntariness cannot be assumed, it is a social
achievement
• More research and programmatic action is needed on the
environmental elements and social conditions that
enhance voluntary access to testing, treatment and care

13. Affective climates of HIV prevention
• Affective climates of HIV prevention (fear, trust,
evasion, openness, secrecy, support, suspicion, concern, hope,
enabling or disabling environments)
• Affect the capacities of PLWHA
• (including untested/future positives).
• Shaped by policy and legal environment, social norms,
contextual factors, collective discourse
• effect the willingness to test and access care over the long
term, as well as willingness and inclination to care for the self
and others
• This in turn impacts the preventive spin‐offs of treatment

14. P. Sendziuk, Learning to Trust
• ‘Identify & contain’ strategies versus ‘Community
education, protection, empowerment’
• Identify & Contain strategies are not positive
prevention
• Do the principles of positive prevention (esp.
human right elements) need to extend to
untested/ future positives?