Choice: Making sure the voices of marginalized populations are heard in designing effective HIV interventions
HIV affects people of all nationalities, genders, ages, socioeconomic classes, and sexual orientations. We have made significant strides in HIV prevention, with an 18% decrease in new HIV transmissions worldwide from 2010 to 2018, according to UNAID estimates. However, HIV does not threaten all people equally—HIV is much more prevalent in certain regions and populations. HIV remains a major public health challenge, with the WHO estimating nearly 1 million HIV-related deaths in 2017. With so many diverse populations affected, which biomedical prevention tools should be prioritized in the product development pipeline and move forward through clinical studies and eventual roll-out in communities?
This is a question that came up frequently this past October when HIV researchers from around the world gathered in Madrid, Spain, for the annual HIV Research for Prevention (HIV R4P) meeting. We were in attendance along with many of our colleagues from RTI, and several of us presented some of the work RTI has been doing on HIV prevention.
In presentations and informal conversations at this year’s meeting, the importance of choice came up frequently as a resounding theme. The effectiveness of a prevention method depends on whether people are willing and able to use it, and it suits their lifestyle and they can integrate it into their lives.
Our findings from the QUATRO study demonstrated how preferences vary between and among populations reinforcing the importance of developing multiple methods of HIV prevention. In this study, we tested the acceptance and use of four different vaginal products for HIV prevention among young women in two countries in Sub-Saharan Africa. Participants’ ratings of the methods were evenly distributed across all four methods. These results echo findings from the iPrevent study which investigated youth’s preferences for long-acting PrEP in Cape Town, South Africa. Though, overall, duration of protection was the most important characteristic, with preference for longer-acting products, preferences for delivery form varied by gender. Young women had a stronger preference for injections and preferred to receive products at a health clinic, while males were more open to implants when they offered longer duration protection than injections. Youth exhibited a keen interest in informing the design of long-acting PrEP, highlighting potential for these products to fill important gaps in the existing toolbox and expand choice.
For HIV prevention to be truly successful, we need to make interventions accessible and address a range of needs among diverse users. Work should be supported in developing a variety of interventions, including longer-acting, systemic-solutions such as injections, implants and vaccines as well as shorter-acting locally-applied or on-demand solutions like vaginal rings, films and oral tablets. The ultimate success of novel biomedical interventions with at-risk populations, including individuals in low- and middle-income countries, sex workers, men who have sex with men (MSM), and transgender individuals, will require asking them about their needs and listening to their input when designing prevention methods. As highlighted by our research in Quatro and iPrevent, engaging end-users to understand their needs, preferences and priorities for prevention is valuable to informing the design of next generation prevention options.
By Elizabeth Montgomery and Alexandra Minnis
“The significant role of partner’s gang membership in increasing pregnancy risk highlights the importance of addressing the reproductive health needs of gang-involved youth. Focusing on pregnancy intentions, including those of male partners, remains an important area for intervention.”
"I hope that my work will contribute towards the end of the HIV pandemic & the empowerment of women globally."
"I think my work is interesting and challenging, and most importantly, I have an incredible network of smart, talented colleagues in South Africa, Zimbabwe, Malawi, Kenya and Uganda – many of whom I consider to be friends."