Implementation and ethical dimensions of scaling up HIV treatment as prevention (TasP)

A growing body of evidence has demonstrated the potential of utilizing HIV treatment as HIV prevention (TasP) to reduce the transmission of HIV to uninfected individuals, and recent policy commitments from the World Health Organization and UNAIDS recommend the implementation of TasP internationally. However, a number of implementation and ethical challenges exist in relation to the scaling up of TasP (i.e., at a population level), and many of these concerns are particularly significant for TasP programs targeting people who inject drugs (PWID). There is a need for social science research that can inform the development of population-level TasP programs, and PWID-tailored programs and strategies, to address systemic barriers to retention on HIV treatment and the accompanying ethical issues. TasP has been implemented in British Columbia (BC) within the public health system and efforts to improve treatment outcomes are ongoing in BC. The existence of these public health programs provides the ideal setting to explore implementation issues and ethical considerations by examining the 'natural experiment' of scale up, including investigation of PWID's experiences and perspectives regarding TasP, as well as those of various stakeholders. This research will use qualitative research methods to address the study objectives: 1) investigate ethical issues related to health policies supporting the roll out of TasP; 2) examine implementation issues related to scaling up TasP programs and engaging HIV positive PWID; 3) explore the impact of TasP programs upon HIV positive PWID with regard to potential unintended consequences. This work will generate unique data with ability to inform the establishment of TasP programs in other Canadian and international settings, and the development of tailored TasP programs targeting PWID.