Last week’s buzzword at the International AIDS Conference is marriage. Not the gay marriage debate currently raging in the United States, but rather the marriage of biomedical advances with behavioral interventions as the next step forward in the fight against HIV/AIDS. Certainly, biomedical advances alone are not enough, as even the most basic issues of uptake, adherence, and diffusion are at sail in a sea of behavioral dependencies. Presenter after presenter is numerous sessions has talked about the need to marry the biomedical with the behavioral without suggesting any sort of framework to make this possible. Optimism is great. Realism is another matter entirely. We seem to have found our soundbite of choice, but have not figured out how or if we can actually engage in the practical steps needed. It’s akin to getting engaged, because you’re tired of hearing people ask when you’re getting married, when you have no intention to actually walk down the aisle. The shining goal of marrying the biomedical to the behavioral is no doubt important, but out in the field, we’ve known it is necessary for a long time. The goal remains, but as British playwright Beverley Nichols once observed, “Marriage is a book of which the first chapter is written in poetry and the remaining chapters in prose”. We’ve written the poetry. How do we now write the prose?
At the conference, I attended a session on PrEP where five questions were posed that as of yet have no answers:
- · Will men-who-have sex-with-men (MSM) want PrEP?
- · How will MSM use PrEP?
- · How will sexual practices change?
- · Where will PrEP delivery systems located?
- · Will PrEP be safe in the real world?
These questions not only highlight the behavioral aspects of these biomedical updates, but also point (although not outwardly acknowledged) towards a need to address structural levels for these interventions. There are three key parts to structural considerations:
(1) Availability (that it exists in quantities respective to the needs of the population).
(2) Accessibility (that individuals can afford, reach and otherwise get what is needed).
(3)Acceptability (that the proposed changes and new products are acceptable and appropriate to the community).
We talk about PrEP as if it is The Second Coming, but what if we build it and no one comes? We have to first consider what it means to be labeled as needing PrEP. What does it mean to the person to actually take this medication? In other words, we need to consider the acceptability. We also need to consider how this will be made accessible? What are the delivery mechanisms that are appropriate and acceptable to the community? Lastly, what are the appropriate amounts needed and that will be made available if we are to go forward and truly have an impact? Will there be new underground markets for these medications, oftentimes referred to in scientific jargon as “diversion,” and which community based organizations recognize for what they are – survival strategies for those who slip through the cracks of the system.
We have the biomedical advances, and we have the behavioral expertise in our profession, although frequently they are not in the same place at the same time. We have reached the juncture where a fully integrated, multi-disciplinary approach, focused on structural and societal components that can aid or hamper the success of our implementations. It’s time to stop talking in broad strokes about marrying the biomedical and behavioral. As Beyonce admonishes us, “If we like it, we need to put a ring on it”.