By Sharanya Sekaram for bakamoono.lk
July 2016, the now landmark PARTNER study was released Journal of the American Medical Association (JAMA). The study enrolled 1166 couples where one partner was HIV positive and on ART, and the other was HIV negative, and the main result was that there were no HIV transmissions after the couples had sex without condoms more than 58,000 times. This sparked a campaign from The Terrence Higgins Trust, called ‘Can’t Pass It On’, stating – “Medical evidence has shown that people on effective HIV treatment can’t pass it on. If everyone knew this, we could bring an end to stigma around HIV. Not only that, but we could stop HIV transmissions all together”. This information completely changed the discourse around HIV treatment and transmission, and the way in which the global goal of zero new HIV infections by 2030 can be achieved.
“In Sri Lanka, prevalence of HIV is low”, say Dr. Sisira Liayanage (Director, National STI/AIDS Control Program Sri Lanka), referring to the NSACP’s data that states by the end of 2016 there were 3900 adults and children estimated to be living with HIV. The prevalence among adults (i.e. those over the age of 15), is under 0.1%. Infections however are on the rise; UNAIDS reported that the Asia Pacific region, Sri Lanka has the second highest increase of new infections between 2010 and 2015, behind India and Bangladesh both of whom showed a decrease in new infections during the same period. Dr. Liyanage stated that this increase can be attributed to the increase in the number of people being tested, and the national goal is to reach zero new HIV infections by 2025.
Understanding Testing
In Sri Lanka, testing and provision of treatment of HIV is covered by the Government and can be accessed through any one of the STI clinics across the country. From what we now know about the effectiveness of HIV treatment, ensuring that everyone is first tested is the logical first step. Dr. Liyanage agreed noting that the Government policy has been “test and treat” since 2016. Madu Dissanayake, Director of Policy and Advocacy, Family Planning Association of Sri Lanka and Niluka Perera of Youth Voices Count however both highlighted reluctance to get tested as the first major obstacle hindering the national goal, highlighting fears of stigma, discrimination, and the quality of life as issues. Dr. Liyanage agreed that this is a challenge but with particular regard to those who did not fall under the definition of Key Populations, saying, “There is a stigma to getting tested for HIV due to the notion that in doing so you will be viewed as sexually promiscuous or have to discuss your sex life with doctors”, echoing the stigma that Key Populations face. He felt that fear of quality of life when living with HIV and access to treatment were not pressing issues as to why people showed reluctance to get tested, rather that it was the stigma and shame associated with assumptions of what your lifestyle must be, in order for you to be at risk. He emphasized that the normalizing of HIV testing is key. Perera emphasized the lack of knowledge and information around treatment, what treatment is accessible and its effectiveness also contributes to the reluctance to get tested, “Some people are scared to get tested and start treatment due to lack of knowledge/information and stigma. People are not aware that it is a manageable condition because there are no public conversations about HIV”.
Perera felt that self-testing technology (through saliva testing for example) could play an effective role in helping alleviate this stigma, a suggestion that was echoed by Dr. Liyanage. The argument was that this would allow people to confidentially find out their HIV status, but must be coupled with clear information about what treatment could be accessed. “Knowledge itself won’t help [in encouraging people to get tested], knowledge is there, what needs to happen is a transition of that knowledgeto a regular attitude that helps people change their behavior” points out Diassanayake, saying that a multi-sectoral approach, especially engaging the private sector is a key factor in overcoming this issue. She also touched on the need to share evidence of people more strongly living quality lives while being HIV positive to normalize its reality and encourage people to find out their own status and access treatment, “discrimination is still there and this is one of the greatest barriers we face”.
Understanding Treatment
Dr. Liyanage said once someone is diagnosed with HIV they are placed on Antiretroviral Therapy and Perera affirmed this. However, getting all those who have been diagnosed on treatment has proved to be a second major obstacle to achieving the national goal of zero new HIV infections by 2025.
Post-exposure prophylaxis (PEP) according to the NSACP’s 2016 Annual Report has only been administered to healthcare workers who have been exposed to the risk of contracting HIV through accidental needle injuries etc. According to Dr. Liyanage if someone outside of the health sector wishes to access PEP they need to consult a doctor and give their history for an assessment to be made if the treatment should be administrated, and that this is sufficient due to the low prevalence rate of HIV reducing the need to access treatment.
Bakamoono spoke to a sero-discordant couple on their options regarding treatment and they highlighted their inability to access Pre-Exposure Prophylaxis (PrEP) which they feel is a key need to help prevent HIV transmissions.
Perera in discussing treatment options emphasized that there was a clear need for the availability of PrEP and PEP to be made saying that despite the low prevalence of HIV, the stigma around living with HIV has hindered people from getting tested and thus increases the risk of HIV transmission through unprotected sexual intercourse.
When asked about such requests being made for PrEP to be made available as part of the harm reduction approach in Sri Lanka, Dr. Liyanage stated that PrEP it should be made available via consultations with doctors and its full implementation is being considered. The concerns lie around those accessing it as a first resort rather than looking at protection through condoms etc. as well as a potential resistance to treatment being developed biologically. He mentioned that in consultation with doctors through prescription PrEP can be accessed in Sri Lanka and the debate lies around the free availability of it without a prescription. The reluctance to do so according to Dr. Liayange is also that there is no clear demand from the HIV positive community.
Dissanayake stated, “We need a better understanding of our sexual behavior and the need of making PrEP available before we request for it. Without a clear understanding of this we cannot ask the Government to provide something ad hoc as it will then be very easy for them to take it away”. However, studies including one looking specifically at the sexual behavior of young adults in Sri Lanka and its implications for HIV treatment have been already conducted and published.
Cost was highlighted as a key concern, Dissanayake said PrEP would cost up to USD500 per person, per month. When contacted, the Asia Pacific Network of People Living with HIV/AIDS informed us Truvada (the drug used to administer PrEP) in India can be purchased for USD20 per person per month, and APCOM said “In Thailand, the PrEP costs for 30 Baht per day or 1000 Baht per month. That is an estimated cost of 0.9 USD per day or 30.3 USD per month”. When asked for clarification, Dissanayake said the cost of USD 500 was according to the figures shared at the International AIDS Conference held in Paris this year. The fact that this number is said to have been shared at IAS is concerning given that ART, including those used for PrEP have been sold for less than a dollar per capsule at least since 2015. This figure of USD 500 therefore appears arbitrary and perplexing at this stage.
Treatment Literacy
Treatment literacy is vital for the HIV positive community to understand their options and ensure that they are accessing the treatment they should be. Aidsmap defines it“as understanding the major issues related to an illness or disease – such as the science, treatment, side-effects, and guidelines – so that the patient can be more responsible for their own care”. In light of what we now know about transmission of HIV from those on effective treatment, this becomes all the more vital.
Dr. Liyanage felt that those who consult closely with their doctors as per reports are well aware of their options. Dissanayake however, referenced a need to improve the levels of treatment literacy among the HIV positive community, pointing out that that “knowledge of the availability of the drugs, the success case stories, where, how treatment can be accessed and that it is covered by the Government will have an immense impact on getting more people on treatment”, highlighting the need to improve the trust between the HIV positive community and their doctors as being key aspects to re-asses.
Can’t Pass it on Campaign quotes Dr. Christian Jessen saying, “Scientific evidence shows that people on effective treatment for HIV are not infectious. This is because the treatment will reduce the amount of the virus in their blood to such a low level that it is no longer able to infect someone via the usual routes. That’s a really important and remarkable thing for a number of reasons. First of all, it means there should be no new HIV infections. We can stop HIV being passed on by encouraging people to get tested and treated. Secondly, it should take away all the stigma, and it really does allow people to have relationships and live normal lives without fear. But the reality is so far from what most people’s awareness of HIV is, and there’s still so much work to do before people are up to date with what HIV means today”.
For Sri Lanka, much work remains to be done with regards to treatment and people accessing treatment to ensure that the national goal of zero new HIV infections by 2025. This includes rigorously evaluating the cost of treatment, especially given that the cost is pegged at USD 20 in India; the country that produces antiretroviral therapy purchased by the Sri Lankan government. Furthermore, conversations around dual protection (condoms and ART) must be had, yet fears of promiscuity with the introduction of PrEP may lead to moral policing. HIV, and more particularly AIDS, has been used in the past as a deterrent to unsafe sex. Now that those on effective treatment can’t pass on the virus, our focus must be testing leading to treatment. This is the most sensible way forward as highlighted by the Director of NSACP. It is time to find another bogey-man if our aim is to scare people into having safe sex. We suggest that comprehensive information leads to informed decision making. What more can we ask for?