Making Access to HIV prevention services a reality for all those in need
(CNS): Despite safe and effective HIV prevention options such as male and female condoms among others, and considerable thrust on research and development of new HIV prevention technologies, new HIV infections continue to occur daily. Milly Katana from Wisdom Centre, who has been a noted AIDS advocate, had successfully put the spotlight on making access to HIV prevention services a reality for all those in need, at the International Microbicides Conference (M2012) in Sydney, Australia. Incidentally the theme of the conference is “From Discovery to Delivery.”
Milly Katana has more than ten years' experience in health program design and implementation, financial management, community capacity development, organizational development, and managing skills building processes.
The key issue is balancing between the research and work on access issues, said Milly Katana. “Every woman and man irrespective of where they live, or their age, race or tribe, loves to be protected from HIV as they go about their reproductive lives. We have made many missteps since the onslaught of the HIV epidemic in the 19th century in the Congo Basin forests and the highlands of Eastern Africa, the bustling cites of the Americas and Europe. Some of these missteps we have made unintentionally; and we beg to be forgiven. Others we made intentionally in the quest of being self-centred or in an attempt to conform to scientific precisions or culturally induced biases” said Milly Katana.
PEOPLE ON WHOM ARV WERE TESTED GOT THEM AFTER 15 YEARS DELAY
Although people in Uganda where Milly comes from, contributed meaningfully in the development of an antiretroviral drug (AZT or Zidovudine) for public health sake, it took over 15 years for some of these very people to get access to the life-extending drug. Such delays are missteps that shouldn't have happened. The ARV therapy is still inaccessible to many people living with HIV in need of it. “What I am saying now is to draw lessons from our recent past as we develop a product that is intended to be used by poor or young women who may not have financial stability yet are at risk of contracting HIV” said Milly Katana.
THINK OF ACCESS AS R&D PROGRESSES
“We might have a very exciting opportunity in the form of microbicides (currently under research), to put in the hands of women for HIV prevention. As we build the boat, we should also be talking about how we are going to sail in it. It should not be like we build the boat today and then realize later on that there is no water to sail it in! We should be talking about what form the product will take, what distribution channels shall we use (once microbicide becomes available after research and development), for whom are we making these products for and whom we need to engage at this point in time to get this potentially successful product into use” said Milly Katana.
MICROBICIDES OFFER A HOPE FOR WOMEN
“For those of us who are still surviving the epidemic, microbicides offer an opportunity to salvage the situation. For us women living with HIV, we have some hope in form of treatment. Those that have not contracted the virus, they have fewer practical options. As we talk about access, we should constantly remember that the ultimate goal of doing research on microbicides is to put the power for preventing HIV in the hands of women. The stakes regarding prevention of HIV among women are very high. This calls for fearlessness among champions of women controlled prevention technologies. Very exciting work is currently underway with some promising breakthrough results. It is now that we must start thinking of what happens once we get successful products and what form should the products take. This is because, women do not have as much information on microbicides today, than when they did when we first started thinking about these products. The roadmap should be sketched well before the products make headlines in major scientific journals” said Milly Katana.
25 YEARS DELAY IN ROLLING OUT MALE CIRCUMCISION TO PREVENT HIVAdded Milly: “We should be able to draw lessons from recent history of delayed operationalization of successful interventions ranging from ARVs for therapeutic purposes to prevention technologies like safe medical male circumcision (SMMC) and condoms which are until now still faced with accessibility hurdles. As early as 1986, there were studies that showed that SMMC reduced the incidence of HIV among male clients of female sex workers in Pumwani neighbourhoods of Nairobi. It took almost 25 years to start rolling out Safe Medical Male Circumcision as a prevention technology! Therefore, as we continue the search for products that will put hope into women's hands, we should at the same time have accessibility issues into consideration. Major lessons exist from current products like Pre-Exposure Prophylaxis (PreP) and the non-injectable hormonal contraceptives.”
Some of the considerations for getting the products available to women and men should employ both conventional and non-conventional marketing strategies. However this should be with a distinctive perspective as these are no ordinary consumer products such as soft drinks.
The access strategy should address short term and long term measures. Short term measures should focus on post-trial access for women who participate in trials that indicate protective effects of the products. “It is outright injustice for women that participate in the clinical trials having to wait for years before they can get the products that they helped in testing. The long term access strategy can be summarized into 4 Ps: the product, price of the product, the place of outlet and promotion details” said Milly Katana.
“The highest burden of HIV is in developing countries. The most vulnerable individuals are young women who may have little independence in terms of not only their sexuality but also housing. The product therefore should be easy to store in very basic forms that accord majority of the users the necessary privacy while maintaining the potency of the products. For example, a product that may need refrigeration makes privacy lost as young women do not own personal fridges. The point of use should also be independent of the sexual activity. This is because most women have minimal negotiation power over their sexuality. In addition, the products should have minimal monitoring requirements so that their use is less dependent on specialized personnel who are in very short supply the world over” said Milly Katana.
“In as much as substantial investment is going into finding products that will put hope into women's hands, it is total injustice to imagine that the women will bear the costs of production, research as well as give profits to the producers. These are products that should be produced in public health interests. It is therefore now that the public sector must start strategizing on how to finance the products so that they are affordable to the users. With more than 2 million people infected with HIV annually, it is criminal to deny any woman access to a protective product simply because she can't afford its cost” said Milly Katana.
OUTLET WHERE PRODUCT IS AVAILABLE
“Bearing in mind who is most at risk to contracting HIV, the distribution must target where these individuals can easily access the products. This calls for aligning with systems that are strong, not the weak one that have failed us now and again. It is here that private engagements should be launched so as to leverage the wide distribution networks for consumer goods. Women will be too happy to get the microbicides alongside their daily groceries on the market stalls. In addition, research should be directed at coming up with product that have minimal storage complexities so as to make them available through a wide range of outlets. Similarly, policy engagements need to start now so that most of the foreseeable distribution hurdles are addressed before products leave the production lines. Some of the hurdles include licensure requirements and clinical monitoring. In as much as the products are so far thought to be ARV based, we should have products that require minimal or no clinical monitoring requirements. Again lessons can be drawn from other topical products that are used independent of clinical supervision” said Milly Katana.
“In order to facilitate access, products that will turn the tide of the HIV epidemic should address misconceptions related to their use. This should be done in constant consultation with women who are going to use the products. Most of the trials that are currently underway have inbuilt education activities to address community concerns and myths, as well as provider biases. At the roll-out level, such misconceptions should be addressed even before the products leave the production lines as well as on an ongoing basis. This should involve clear messages for different sections of the population ranging from potential users, policy makers, the financiers, and the distributors. This is calls for a solid partnership between researchers, communities and public health policy makers including ministries of health, to identify such misconceptions so that strategies to address them start right away” said Milly Katana.
Milly Katana's messages from the M2012 are clear and strong: “The world, especially the women folk is desperate for a technology that will put the power for preventing new HIV infections in the hands of women. As research is under way, critical thinking must be made to come up with product that will not only be user friendly but affordable by all women irrespective of which part of the world they live in. Such a product must be easy to handle and facilitated by sound promotion efforts that are reinforcing existing proven interventions including treatment as prevention, PrEP, post-exposure prophylaxis (PEP), [HIV] vaccines when they become available and indeed SMMC.”
Bobby Ramakant – CNS
(The author is the Director (Policy and Programmes), Citizen News Service (CNS) and a World Health Organization (WHO) Director-General's WNTD Awardee 2008. He writes extensively on health and development for CNS. Email: email@example.com, website: www.citizen-news.org)