HIV Care
How HIV care promotes prevention Theo Smart looks at HIV care and support services which are well placed to promote Positive Health, Dignity, and Prevention (PHDP)
Zero new infections Zero new infections is a rallying cry for HIV preven- tion embraced by UNAIDS, civil society, and networks of people living with HIV (PLHIV). But it is a very tall order – given all the time, money, and effort that has gone into HIV prevention efforts with less than dramatic returns – one that would seem to only be achievable once new and highly effective tools, like a vaccine, are developed or with radically different prevention ap- proaches. And yet, since the release of clinical trial data from the HPTN 052 study showing the significant preven- tion benefits of antiretroviral treatment (ART),1
hopes
have been raised that a highly effective prevention tool is already available in ART, and that ART for preven- tion could move programmes much closer to ambitious HIV prevention targets – provided treatment coverage is wide enough. This in turn, has led to an increased emphasis on HIV counselling and testing (HCT) to iden- tify people living with HIV, and the expansion of HIV treatment services at the primary healthcare level, and to remote and rural sites. The renewed emphasis on providing universal access to HCT and ART is very welcome, but the manner in which ART for prevention is implemented could pose some dangers to PLHIV, which could in turn hinder programmatic success. One danger is that the strategy could inadvertently reinforce the common and de- humanising message that PLHIV alone are to blame for HIV transmission – and, moreover, that they must be found and put on treatment to protect the public’s health, rather than treatment being given for the well- being of the PLHIV and their families. Additionally, with a rush to increase enrolment into ART programmes – in an era of dwindling international funding support for health – there is a danger that health services could focus too narrowly on testing and treatment, with little consideration given to care, support, and protection services needed by people who test positive and their families. Without providing the essential components of care for a person who tests positive with HIV, still a life-threatening and highly stigmatised disease in many settings, no matter how great the promise of ART for prevention, people will continue to be reluctant to test. Furthermore, a large proportion of those who do test positive will never present for treatment, and many of those who do start on ART will present with advanced HIV disease or will drop out of care. PLHIV from across the globe have responded to these and other issues by proposing a new policy frame-
Theo Smart, Editor, HIV and AIDS Treatment in Practice at NAM, London, UK
22 Africa Health work,6 Positive Health, Dignity and Prevention (PHDP),7
which could help HIV programmes improve the welfare of PLHIV and in so doing, also help realise the promise of ART for prevention.
A recent report from the Global Network of People
Living with HIV and UNAIDS, describes the policies, programmes, and services needed to protect the rights and security of people living with HIV and to address their needs holistically.2
Most critically, PLHIV should
be engaged as partners in the HIV response, and not merely patients. They need information and support to make their own, well-informed choices about when to start treatment for their own health and how to prevent the spread of HIV. PLHIV have the right to a healthy sex- life, having children, and access to non-judgemental information on HIV prevention. Aside from the legislative and policy elements that
may need to be put in place to protect the rights of PLHIV, most of the key requirements for PHDP involve the very activities that HIV care and support services including palliative care teams specialise at providing, such as: • the promotion of holistic health and wellness, including universal access to HIV counselling and testing (HCT);
• effective linkages and timely access to voluntary ART and monitoring, as well as services to support adher- ence and retention in care;
• support services to help ameliorate poverty and food insecurity and, where possible, link clients with educational or employment opportunities;
• provision of mental and psychosocial support for PLHIV who desire it, especially for those experienc- ing social exclusion, gender inequality, HIV stigma and discrimination, or oppression due to their risk behaviours, gender identity or sexual orientation;
• services addressing the specific needs of young people living with HIV, and women whether or not they choose to have children. While all of these together may go beyond the scope of services typically offered by the public sector, community-based HIV care services including palliative care and home-based care approaches, could and are responding to the PHDP needs of PLHIV from diagnosis onwards. There are numerous examples where elements of HIV care, or palliative approaches have resulted in bet- ter uptake of HIV testing and counselling, increased en- rolment in care, better retention in care, a higher quality of care with greater client satisfaction, and finally better outcomes.
A number of studies have reported that nurse-led or lay counsellor-led home-based care teams trained to
July 2012
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