Future pathways are not only driven by science, but are equally rooted in communities and implementation needs.

Authors: Jessica Terl ikowski, AIDS Foundation of ChicagoMolly Morgan Jones, RAND EuropeJim Pickett, AIDS Foundation of ChicagoGavin Cochrane, RAND EuropeJennie Corbett, RAND EuropeJoanna Chataway, RAND Europe

Background: Complex chal lenges accompany implementation of ARV-based HIV prevention, including PrEP, treatment, PEP and microbicides. Social, pol it ical, economic and technological factors must be considered — scientif ic data alone is not suff icient. Mapping Pathways partners AIDS Foundation of Chicago and RAND Europe are addressing the U.S. communit ies’ role in research and implementation.

Methods:Three two-day scenario development workshops were conducted in San Francisco, Atlanta and Washington, D.C. in 2013. Stakeholders — including researchers, publ ic health staff, prevention programmers, pol icy experts and advocates — imagined the year 2025 and forecast the potential outcomes of ARV-based implementation strategies . Workshop participants bui lt optimist ic, pessimist ic and mixed-outcome scenarios using the social, pol it ical, economic and technological factors they identif ied as being important. The Mapping Pathways team analyzed the issues and synthesized the scenario outcomes across workshops to create an integrated future scenario as a pathway forward.

Results: Optimistic outcome scenarios were characterized by mobilized communities and strong political will; the use of integrated funding strategies; enhanced educational efforts; a holistic approach to health services; and cohesive local, state and federal policies and activities. Features noted in the pessimistic outcome scenarios included insufficient political will and resistance to changes in the prevention status quo fed by stigma, marginalization and lack of community engagement; funding reductions for community-based organizations (CBOs), advocacy and further research due to ongoing sequestration and other funding challenges; and the partial/total collapse of the Affordable Care Act (ACA).

Central to the mixed outcome scenarios was the idea of fragmentation, with the promise of the ACA only partially realized. Infection rates decrease among better-resourced populations, while marginalized ones continue to lack necessary prevention and care. Other key characteristics included key populations left behind; insufficient personal and organizational resources; poorly targeted communication campaigns; and a focus on treatment expansion with insufficient resources for PrEP and other services for HIV-negative individuals.

Groups titled scenarios to creatively reflect the theoretic futures. For example, a D.C. group named their optimistic scenario “Rodeo Drive Boutique” to express the tailored and specialized care different populations would receive. The same group titled their pessimistic scenario “Thrift Shop” to convey the lack of resources and fragmentation of the health care system. “Department Store” was the title of their mixed outcome scenario because of a generalized approach with lack of specificity and targeting.

Conclusions: The dynamic scientific evidence base must be synthesized and integrated into kinetic political, social, economic and technological

factors that vary by geography, population and infrastructure. This ever-shifting environment provides opportunities and challenges

for the implementation of new ARV-based HIV prevention strategies, as the future is driven by the interplay between science and

communities. Read the United States Workshop Report at mappingpathways.org.

Taking lessons from each outcome, Mapping Pathways broadly concludes:

A more integrated approach to all aspects of HIV prevention is the pathway to effective implementation. The HIV community must leverage its success in developing innovative programs and systems to provide holistic care.

Biomedical and digital health technologies must be directly linked to the social contexts in which they will be implemented.

Participants were energized by new testing and viral load diagnostics, new adherence technologies, and biomedical strategies in early stages of development such as long-acting injectables for PrEP and treatment.However, participants expressed concerns about the marginalization of individuals without access to digital platforms.

Opportunities created by the ACA must be maximized to improve HIV care and prevention service delivery infrastructure and minimize disruptions of current working systems. Achieving this requires:

Development of a more holistic approach to health care.Creation of pathways to health care access previously inaccessible to many key populations.Application of TLC+ (Testing, Linkage to Care, Plus the Offer of Treatment) to those testing positive as well as those testing negative. HIV-negative people in key populations should have their own "cascade of care" that includes HIV prevention in addition to holistic health care services.

These Mapping Pathways activities were funded by an unrestricted educational grant from the Gilead Foundation.

Key findingsAll science is local.

The understanding and utility of the scientific evidence base, coupled with perspectives and views of communities

and stakeholders, are local.

Pathways are locally developed.

ARV-based prevention strategies need to be successful at local levels to have national and global impacts.

What can be done now?Develop cost-benefit and modeling analyses driven by communities/outcomes.

Identify new funding mechanisms to support ARV education and capacity building for CBOs and health departments.

Educate HIV-vulnerable communities (and the providers who serve them) about different ARV-based prevention strategies.

Engage actively to ensure ACA is implemented to meet the needs of people living with and vulnerable to HIV.

Advocate for more and better-integrated implementation and socio-behavioral research.

Engage stakeholders — including CBOs, health departments, governmental institutions, health insurance

providers, medical institutions, pharmaceutical companies, funders, politicians, policy makers, advocates, youth,

media, people living with HIV as well as HIV-negative people in key populations.