[learn_more caption=”By Elizabeth Boskey”] Elizabeth Boskey, Ph.D. is a Certified Health Education Specialist and A.A.S.E.C.T. Certified Sexuality Educator as well as an independent scholar, writer, and teacher focusing on sexual health. Although she is best known as the Guide to Sexually Transmitted Diseases at About.com, where she writes a consumer-focused site about sexual health, she has been enjoying writing more in depth content for health professionals at ViroChannel. A researcher herself, Elizabeth has published several peer-reviewed papers on topics in women’s reproductive health and is on the editorial boards of the American Journal of Sex Education and Contemporary Sexuality – the journal of the American Association of Sexuality Educators, Counselors, and Therapists. She has also written or contributed to a number of popular science books including America Debates Genetic DNA Testing, The Truth About Rape, and The Invision Guide to Sexual Health. [/learn_more] Sessions about HIV prevention were highlights of the second full day of programming at the 7th International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention (IAS2013). For example, although trials have to date been largely and sometimes painfully unsuccessful, many scientists are still focused on the development of an HIV vaccine as the ultimate method of stopping the virus. An afternoon symposium reviewed the history of vaccine research and then moved on to discussing potential new vaccination targets and paradigms. It stimulated vigorous debate. Judging from the session on the state of the evidence from various pre-exposure prophylaxis (PrEP) trials, PrEP is also likely to continue to remain controversial – at least in the near future. Despite the fact that a number of proof of concept trials have shown that the technique can be effective, PrEP has been less successful when tested under more realistic conditions. Its real-world efficacy continues to be confounded by issues such as adherence. Therefore, much of the ongoing research is focused on identifying the populations who could benefit most from PrEP and determining what types of treatment they would be most likely, and able, to use correctly. Identifying prevention methods that are not only effective but attractive to the populations they are aimed at is an ongoing problem in HIV research. Discussing these difficulties was the focus of professional development workshops on rethinking effective techniques for prevention in men who have sex with men and working with cross-border migrants. However, it was the session on prevention in injection drug users (IDU) that was particularly interesting, given the work that Malaysia has done to reduce HIV infections in that population. Some of that work was discussed at the conference, when data from a 2010 study of the efficacy of needle and syringe exchange programs (NSEPs) was presented this afternoon. The study found that men who had access to NSEPs were significantly less likely to share needles than men who had no such access. However, syringe and needle sharing was still distressingly common, and the researchers suggested that it may be necessary for NSEPs to provide a larger number of needles and syringes to each participant. Another study presented during the session examined drug users in a very different setting – Vancouver, British Columbia. The researchers performed a randomized controlled trial to discover whether small cash incentives could more effectively engage drug users in HIV counseling and testing. As it turned out, they could. Every single participant in the incentive arm underwent HIV testing, compared to less than a third of the patients in the non-incentive arm. Participants in the incentive group were also significantly more likely to return for their results. This suggests that modest incentives may be very productive for retaining drug users in care, when organizations can afford to provide them. Returning to sexual transmission of HIV, scientists from the Canadian Clinic l’Actuel presented data on their eleven years of experience offering post-exposure prophylaxis (PEP) to individuals after risky sexual encounters. They found that although a majority of patients seeking treatment took the antiviral treatment for four weeks, only half of treated patients completed a full 16 weeks of follow up, as recommended, relatively few came in for PEP more than once. This should allay some concerns about people becoming reliant on PEP instead of exploring more proactive forms of prevention. Finally, a critical bridging session connected treatment access to large-scale HIV prevention issues. The series of talks discussed how even the newest and most promising HIV care advances can only have a limited effect as long as people have trouble accessing counseling, choosing testing, and getting linked into care. This can be seen in research from British Columbia, which found that although increasing numbers of patients were getting tested, diagnosed, and linked to care, there was a great deal of difficulty retaining them there. A significant fraction of patients were lost to follow up before they could begin antiretroviral therapy (ART). Other studies, around the world, also pointed out retention as being key to having a strong effect on not just the health of HIV positive individuals but on HIV incidence within the community. It takes effective treatment to reduce transmission risk, and people can only be treated effectively if they remain in care. How can doctors increase the number of HIV positive patients who are retained in care? Research presented at IAS2013 suggests that it requires a broad range of approaches. It’s not enough just to make care widely available. Economic and social systems also have to change. People need to have money, transportation, and the flexibility to take time off to get to the doctor. They need to be willing to spend that capital as well. To make that leap, countries have to do what they can to not only reduce the stigma associated with HIV testing and care but make the benefits explicitly clear as well. Right now, in many areas around the world, the potential social and financial consequences of being known to carry HIV make the risks of seeking out testing and treatment clear. The advantages, unfortunately, are not nearly as obvious. This is particularly true in the early stages of infection, when the virus is not having obvious effects on a person’s life. When resources are low and stigma is high, it’s hard to make the hope of a longer, healthier life twenty years down the line feel as immediate as the fear of the damage that could be caused by a positive test twenty minutes from now.