To stop AIDS we must reach the ‘mobile population’

Janet Seeley LSHTM feature, 2018;

This expert opinion, written by STRIVE research director, Professor Janet Seeley, was originally published by LSHTM here.

If everyone living with HIV takes an HIV test and knows their status, and if everyone with an HIV-positive test begins antiretroviral therapy (ART) HIV treatment rapidly, this enhances their chance of living a healthy life into old age. That treatment can also reduce the amount of virus in a person’s body to such a low level that they will not pass the virus on to others.

This is universal test and treat, a strategy aimed at getting everyone who is living with HIV on to treatment and thus significantly increasing the proportion of people who are aware of their HIV status and receiving that treatment.

That will, in the words of UNAIDS, be `the End of AIDS’ – the goal to stop people dying because of AIDS by 2030.

It sounds simple – but ensuring that everyone can access a test and then, if HIV-positive, access treatment – is a huge task.  Despite great progress in the last decade, reducing HIV infection is difficult.  In 2017 in eastern and southern Africa about 20 million people living were living with HIV; approximately 13 million of these people were on ART.  HIV-related causes accounted for about 400,000 deaths there in 2017.

Globally ‘Test and Treat’ is effective when it can reach people, and that often depends on where people are and when.  Time must be found to visit designated clinics during opening hours.  For the many people who travel regularly for work or family reasons, perhaps staying away for several months or travelling most of the days each week, getting to a clinic can be hard.

In 2017 25 million sub-Saharan African people lived outside their country of birth.  Countless others move for short and longer time periods within their own countries for work.

This ‘mobile population’ presents particular challenges for engagement and retention in healthcare, but there is a dearth of knowledge about these diverse populations and which strategies work to link them into HIV-care, and to sustain them in that care once they have started treatment.

A new research supplement of the Journal of the International AIDS Society, launched this week at the International AIDS Conference addresses this crucial research gap by investigating the relationship between multiple forms of mobility and HIV treatment outcomes.

The twelve papers include articles from each of the four large-scale Universal Test and Treat studies in five African countries. New data are presented on a range of topics including the gender-specific effects of work-related migration and short-term mobility on higher risk sexual behaviour.

There is a strong focus on the effect on retention in HIV treatment for pregnant and postpartum women in the context of their family-related travel, as well as the experience of African migrants in Europe.

Four main themes cut across the articles. First, space and time are important, because mobility affects the time someone has to benefit from an intervention, and where they are affects the services they can access. 

Second, the types of mobility across populations and settings are different and highly gendered, and these should inform HIV prevention and treatment approaches in specific settings.

Third, moving can set in train a series of events – someone may be unable to attend a clinic visit, they miss one then another and that affects their engagement in HIV care and prevention and their health deteriorates -  re-engaging with treatment is hard, particularly in a new place.

Lastly, settling into a new place can be hard and accessing care and support difficult. Such missed opportunities must be addressed through health systems and policy-level actions.

Existing knowledge of mobility patterns can be used to target different ways of providing alternative forms of HIV care, including testing, prevention methods as well as treatment.

These include:

  • Medical Records Systems which can provide a person with multiple points of contact with HIV care and treatment programmes as well as improved technologies such as long-acting ART.
     
  • Longer-acting formulations of biomedical prevention technologies such as Pre-Exposure Prophylaxis (PrEP), and the expansion of the delivery of these technologies beyond clinic settings into communities and key migration destinations and transit hubs.
     
  • Ultimately, for future migrant populations, an effective vaccine. 

Such interventions are urgently needed to enable migrants to maintain their health and that of their sexual partners.  Without these interventions many many people in Africa and elsewhere will continue to miss out – and stopping AIDS will remain a dream.

Publication

Carol S Camlin, Susan Cassels, and Janet Seeley. Bringing population mobility into focus to achieve HIV prevention GoalsJournal of the International AIDS Society. DOI: 10.1002.jia2.25136

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