Are we going to close social gaps in HIV? Likely effects of behavioral HIV-prevention interventions on health disparities

Disparities in attention to HIV-prevention information

Compared to European-Americans, African-Americans have greater probability of becoming infected with HIV, as well as worse outcomes when they become infected. Therefore, adequate health communications should ensure that they capture the attention of African-Americans and do not perpetuate disadvantages relative to European-Americans. The objective of this report was to examine if racial disparities in attention to health information parallel racial disparities in health outcomes. Participants were clients of a public health clinic (Study 1 n = 64; Study 2 n = 55). Unobtrusive observation in a public health waiting room, message reading times, and response-time on a modified flanker task were used to examine attention to HIV- and flu-information across racial groups. In Study 1, participants were observed for the duration of their time in a public health clinic waiting room (average duration: 31 min). In Study 2, participants completed tasks in a private room at the public health clinic (average duration: 21 min). Across all attention measures, results suggest an interaction between race and information type on attention to health information. In particular, African-Americans differentially attended to information as a function of information type, with decreased attention to HIV- versus flu-information. In contrast, European-Americans attended equally to both HIV- and flu-information. As such, disparities in attention yielded less access to certain health information for African- than European-Americans in a health setting. The identified disparities in attention are particularly problematic because they disadvantage African-Americans at a time of great effort to correct racial disparities. Modifying the framing of health information in ways that ensure attention by all racial groups may be a strategy to increase attention, and thereby reduce disparities in health outcomes. Future research should find solutions that increase attentional access to health communications for all groups.

The promises and challenges of pre-exposure prophylaxis as part of the emerging paradigm of combination HIV prevention

INTRODUCTION

Towards the end of the twentieth century, significant success was achieved in reducing incidence in several global HIV epidemics through ongoing prevention strategies. However, further progress in risk reduction was uncertain. For one thing, it was clear that social vulnerability had to be addressed, through research on interventions addressing health systems and other structural barriers. As soon as antiretroviral treatment became available, researchers started to conceive that antiretrovirals might play a role in decreasing either susceptibility in uninfected people or infectiousness among people living with HIV. In this paper we focus on the origin, present status, and potential contribution of pre-exposure prophylaxis (PrEP) within the combination HIV prevention framework.

DISCUSSION

After a phase of controversy, PrEP efficacy trials took off. By 2015, daily oral PrEP, using tenofovir alone or in combination with emtricitabine, has been proven efficacious, though efficacy seems heavily contingent upon adherence to pill uptake. Initial demonstration projects after release of efficacy results have shown that PrEP can be implemented in real settings and adherence can be high, leading to high effectiveness. Despite its substantial potential, beliefs persist about unfeasibility in real-life settings due to stigma, cost, adherence, and potential risk compensation barriers.

CONCLUSIONS

The strategic synergy of behavioural change communication, biomedical strategies (including PrEP), and structural programmes is providing the basis for the combination HIV prevention framework. If PrEP is to ever become a key component of that framework, several negative beliefs must be confronted based on emerging evidence; moreover, research gaps regarding PrEP implementation must be filled, and appropriate prioritization strategies must be set up. Those challenges are significant, proportional to the impact that PrEP implementation may have in the global response to HIV.