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Combination Approaches: An Overview of Combination Prevention
I. Definition of the Prevention Area
In 2009, The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR): Five Year Strategy defined combination prevention as its major approach to HIV prevention, stating that:
"Successful prevention programs require a combination of evidence-based, mutually reinforcing biomedical, behavioral, and structural interventions."
This definition was expanded upon in a 2009 meeting of the Joint United Nations Programme on HIV/AIDS (UNAIDS) Prevention Reference Group and published in the 2010 UNAIDS Discussion Paper on combination prevention, in which combination programming was defined as:
"...rights-based, evidence-informed, and community-owned programmes that use a mix of biomedical, behavioural, and structural interventions, prioritized to meet the current HIV prevention needs of particular individuals and communities, so as to have the greatest sustained impact on reducing new infections."
II. Epidemiological Justification for the Prevention Area
The goal of combination prevention is to reduce the transmission of HIV by implementing a combination of behavioral, biological, and structural interventions that are carefully selected to meet the needs of a population. Also, because individuals’ HIV prevention needs change over a lifetime, combination approaches help ensure that people have access to the types of interventions that best suit their needs at different times. Practitioners and researchers currently believe that combination approaches result in synergies in which the total effect of a set of carefully chosen interventions is greater than the sum of its parts, with a greater impact on reducing the transmission of HIV. This hypothesis, however, remains to be proven.
Prevention programmers have used various models to attempt to identify the drivers of the epidemic, provide a guide on which mix of interventions would have the greatest impact, and give strategic choices on combination prevention approaches.
Others caution against the use of models in making strategic prevention decisions, since models may provide outputs that fail to identify the key behaviors that drive an epidemic and are difficult to fit to local epidemics that are heterogeneous across different locations. Therefore, models are a tool that should always be used in conjunction with other data sources to make programmatic decisions.
The evidence base for combination prevention programming is in its infancy. However, a number of evaluations are currently being conducted to help determine the effectiveness of different combination prevention approaches. The National Institutes of Health are supporting HIV combination prevention studies in Botswana, Estonia, Lesotho, Malawi, Uganda, and in North and South America with a range of populations (e.g., men who have sex with men, people who inject drugs, serodiscordant heterosexual couples, and people of reproductive age). PEPFAR is supporting three studies, over four years, to evaluate combination prevention approaches—one in Zambia and South Africa, another in Botswana, and the last in Tanzania.
III. Core Programmatic Components
In August 2011, PEPFAR issued Guidance for the Prevention of Sexually Transmitted HIV Infections, and recommends a combination approach to prevention that includes three types of mutually reinforcing interventions:
- 1. Biomedical interventions are those that directly influence the biological systems through which the virus infects a new host, such as blocking infection (e.g., male and female condoms), decreasing infectiousness (e.g., ART as prevention), or reducing acquisition/infection risk (e.g., voluntary medical male circumcision).
- 2. Behavioral interventions include a range of sexual behavior change communication programs that use various communication channels (e.g., mass media, community-level, and interpersonal) to disseminate behavioral messages designed to encourage people to reduce behaviors that increase risk of HIV and increase protective behaviors (e.g., risks of having multiple partners and benefits of using a condom correctly and consistently). Behavior interventions also are aimed to increase the acceptability and demand for biomedical interventions.
- 3. Structural interventions address the critical social, legal, political, and environmental enablers that contribute to the spread of HIV. PEPFAR uses five categories to describe structural interventions: legal and policy reform, reducing stigma and discrimination against people living with HIV and marginalized groups, gender inequality and gender-based violence, economic empowerment and other multi-sectoral approaches, and education.
The PEPFAR guidance goes into further detail on which core interventions (i.e., prevention of mother-to-child transmission, voluntary medical male circumcision programs, condom programs, and programs for most-at-risk populations and people living with HIV) should be prioritized and implemented based on UNAIDS’ “Four Knows.” The Four Knows bases selection and scale of interventions on epidemiological evidence, country context, knowledge of other donor programs, and national strategies. Additionally, prevention strategies should be assessed through impact evaluations.
To achieve this, programmers should perform a gap analysis in their countries to determine which key drivers, geographical locations, and range of interventions are lacking and then include those in their prevention portfolio to try and create synergy among them. In order to implement the interventions that would be most effective in the country’s context, the questions to ask when making prevention portfolio decisions are, “How much, when, and where?”
IV. Current Status of Implementation Experience
Although the term “combination prevention” is relatively new, the concept itself is not. Countries experiencing HIV epidemics routinely implement complex packages of prevention interventions; yet the scale, intensity, and quality of these interventions is often insufficient. Furthermore, only a minority of programs include interventions designed to address structural drivers of the epidemic. Complex and successful programs have existed for some time in concentrated epidemics where service packages include biomedical, behavioral, and structural interventions; however, these approaches remain under-implemented and under-evaluated. Often, prevention portfolios are not adequately focused on the populations and the behaviors that actually drive the epidemic, nor are they sufficiently well implemented in the locations where the risk behaviors are most likely to occur. Interventions need to be chosen based on the complexity of behaviors within populations as well as how social and cultural norms influence sexual and health-seeking behaviors. However, current combination prevention programs are building on lessons learned and improving strategies to increase their impact on the epidemic.
A number of countries are implementing combination prevention packages such as South Africa, Botswana, India, Namibia, Uganda, and the Ukraine. Combination prevention is a portfolio approach for a given geographic area—whether at the national, state, district, or community level. It is not an individual implementing a partner-level approach, but involves a number of partners who contribute towards a combination prevention approach. For example, in South Africa, several studies have demonstrated a reduction in HIV incidence mostly due to increased condom use among youth and a slight reduction due to antiretroviral treatment. The decline in incidence also seems to coincide with the increase of prevention interventions in the country such as increased distribution and availability of condoms, school-based HIV life skills programs, and a large mass media serial program that depicted how positive and negative behaviors can affect health outcomes.
HIV Prevention Transformed: The New Prevention Research Agenda
Padian, N. S., McCoy, S. I., Abdool Karim, S. S., et al. The Lancet (2011), Vol. 378 No. 9787, pp. 269–278.
This paper reviews developments over the last three years in HIV prevention since the 2008 Lancet series. The authors searched topics in behavioral, biomedical, and structural interventions, which together make up combination prevention, using Medline and PubMed search engines, HIV conference literature, as well as publications from international (e.g., UNAIDS) and nongovernmental organizations. The paper focuses on the most salient and current issues in the field, such as the state of the search for a vaccine, ART for prevention and its challenges, the scale up of proven prevention interventions (e.g., voluntary medical male circumcision), and an update on behavioral and structural interventions. The paper concludes and discusses the following: that the separation between biomedical and behavioral approaches is counterproductive since both rely on the other, the benefits of having more women-controlled prevention possibilities, implementation challenges to ART as prevention programs, and increasing research in implementation sciences and impact evaluations of proven interventions.
Combination Prevention: A Deeper Understanding of Effective HIV Prevention
Hankins, C. A., & de Zalduondo, B. O. AIDS (2010), Vol. 24 (suppl 4), pp. S70–S80.
This paper provides an overview of what combination prevention programs are and how to design and implement them to match each country’s unique social and epidemiological context. It emphasizes how HIV prevention is vital in keeping the epidemic at bay and has been a mainstay of the response since the beginning. A historical perspective to HIV prevention is provided, and how the field evolved into its current focus on combination prevention programs. UNAIDS “know your epidemic, know your response” is the starting point for planning combination prevention programs. It recommends that prevention programmers “know their epidemic” by asking where the next 1,000 infections will come from instead of focusing on past prevalence rates. “Know your response” focuses on prevention programmers designing strategies based on the current activities being implemented, compared to where the next infections will be coming from, to perform a gap analysis. The results of the gap analysis can help programmers develop a tailored approach unique to the social, cultural, and epidemiological context of a country, region, district, and/or community. The paper states that the evidence base for combination prevention programs is weak and investing in impact research as well as implementation science is vital for the continual refinement and improvement of programs. The paper concludes by stating that focusing on long-term strategies that are tailored to the immediate causes of vulnerability and underlying risk of populations is necessary to curb the rate of the epidemic.
A Decline in New HIV Infections in South Africa: Estimating HIV Incidence from Three National HIV Surveys in 2002, 2005 and 2008
Rehle, T., Hallett, T., Shisana, O., et al. PLoS ONE (2009), Vol. 5 No. 6, e11094. doi:10.1371/journal.pone.0011094.
South Africa conducted three nationally representative household-based surveys in 2002, 2005, and 2008. The study uses the HIV prevalence data from all three surveys to estimate incidence from 2002 to 2005 and from 2005 to 2008. The 2008 survey tested samples to detect the presence of ART drugs in the blood to determine its affect on prevalence due to longer survival. The study also measured behavioral changes in the three surveys among young women between the ages of 15 and 24. It was found that HIV prevalence in 2008 was 16.9%, and that the “excess” (increase in prevalence due to longer survival from ART) prevalence was 1.7%; therefore, HIV prevalence without the affect of ART on survival would be 15.2%. Incidence levels decreased from 2002 to 2005 and 2005 to 2008 for men and women aged 15-49 years (2.0 per 100 person-years at risk verses 1.3 per 100 person-years at risk), but were not statistically significant. The incident decrease was statistically significant for women between the ages of 15 and 24. It went from 5.5 per 100 person-years at risk from 2002 to 2005, to 2.2 per 100 person-years at risk from 2005 to 2008. Because the incident decline was mostly among young women, behavioral trends were analyzed. It was found that significant changes were found in condom use at last sex and being tested for HIV. The changes in incidence and behavior among young women were encouraging, but it should not equate to program complacency. Incident levels still need to be halved in order to meet the goals in the 2011 National Strategic Plan.
Combination HIV Prevention: Tailoring and Coordinating Biomedical, Behavioural and Structural Strategies to Reduce New HIV Infections, A UNAIDS Discussion Paper
Joint United Nations Programme on HIV/AIDS (UNAIDS). (2010).
This discussion paper outlines the advantages of implementing a combination prevention approach by using the synergies of behavioral, biomedical, and structural interventions. While there have been notable declines in prevalence and incidence linked to behavioral changes in the population, greater and more effective prevention programs must be supported to continue and improve upon these trends. The paper provides a definition of combination prevention and outlines the necessary steps in planning and implementing a coherent, evidence-based, and rights-based approach. For planning, the paper highlights issues such as having an inclusive, transparent, and evidence-informed process; identifying modes of transmission, geographic patterns, and populations; as well as developing a national plan for combination prevention. For implementation, understanding and addressing political and capacity barriers and simutaneously working on coordination, quality, and efficiency issues are essential. Lastly, in order to plan and implement effective and evidence-based interventions, investments in monitoring and evaluation must be made. Combination prevention is an attempt to address not just the individual causes of vulnerability but to target the underlying social, cultural, legal, and structural causes of vulnerability as well. Local solutions must be found and responses must be coordinated, synergistic, evidence-based, strategic, and sustained to reach the zero new infections goal found in many national HIV/AIDS strategic plans.
South African National HIV Prevalence, Incidence, Behavior and Communication Survey, 2008, A Turning Tide Among Teenagers?
Shisana, O., Rehle, T., Simbayi, L. C., et al. (2009).
This is a report on the 2008 population-based household survey (two others were conducted in 2002 and 2005). The survey examined the prevalence, incidence, behavioral, and communication differences over time. A multi-stage stratified sample was taken and about 23,000 individuals participated in the survey. A structured questionnaire was utilized to capture demographic information as well as social and behavioral information. Blood samples were drawn to determine HIV prevalence and HIV incidence. Overall, prevalence has remained stable from 2002 to 2008, and is around 11%. However, large differences were found among age groups, gender, and geographic regions. Some positive findings included a decrease in prevalence among young people who were between 15 and 24 years old (10.3% in 2005 compared to 8.6% in 2008) and, using mathematical models, incidence has decreased among young people between 15 and 20 years old. Substantial increases in condom use were observed with people between 15 and 49; 31% reported condom use at last sex in 2002 compared to about 65% in 2008. There was also an increase in youths between 15 and 24 years old being reached with communication messages. Despite these positive trends, women are still infected by HIV more than men, with the highest levels being in the 25 to 29 age group where 1 of every 3 women is infected. Intergenerational sex also increased among young women from 18.5% in 2005 to 27.6% in 2008. Therefore, while South Africa has made numerous advances to combat the epidemic, programs must continue to be strengthened and expanded.
Financing the Response to HIV in Low-Income and Middle-Income Countries
Izazola-Licea, J.A., Wiegelmann, J., Aran, C., et al. Journal of Acquired Immune Deficiency Syndromes (2009), Vol. 52, No. Suppl. 2, pp. S119-S126.
Most countries are not using their funds for HIV treatment and prevention efficiently. According to this study of 50 low- and middle-income countries, funds for prevention constituted 21 percent of all AIDS expenditures. According to UNAIDS, about 45 percent of funding should be invested in prevention. Spending on most-at-risk populations accounted for less than 1 percent in countries with generalized epidemics and 7 percent in countries with concentrated epidemics. The mismatch in the burden of risk and funding was most acute in Latin America, where 60 percent of the people living with HIV are men who have sex with men, but only 0.5 percent of funds were directed toward this group. Among the 17 low-income countries, 87 percent of their funding came from international donors.
Making HIV Prevention Programmes Work
Bertozzi, S.M., Laga, M., Bautista-Arredondo, S., et al. The Lancet (2008), Vol. 372 No. 9641, pp. 831-844.
HIV prevention programs will underperform when any of the following four issues is not appropriately addressed: targeting of risk groups; selection of programs to match the needs of risk groups; delivery and implementation of programs; and funding. Inadequate surveillance or failure to monitor and evaluate interventions can lead to programs that are mismatched for the needs of the region or country. Since quantity is often easier to measure than quality, incentive schemes have favored the former over the latter. This has resulted in situations such as the recent implementation of antiretroviral therapy in which the number of people treated was emphasized over changes in patients’ life expectancy.
Behavioural Strategies to Reduce HIV Transmission: How to Make Them Work Better
Coates, T.J., Richter, L., & Caceres, C. The Lancet (2008), Vol. 372 No. 9641, pp. 669-684.
Behavioral strategies, such as programs to encourage condom use or to reduce or eliminate sex with non-primary partners, can be difficult to sustain and should be combined with other strategies (biomedical and structural) to effect population-level changes. Promoting behavioral change in the absence of structural change can be particularly difficult, for example, when drugs or alcohol are central to a country’s economy. Monitoring and evaluation (M&E) of programs should be integrated into local programs; current M&E projects are often conducted largely in high-income countries with uncertain relevance to lower-income countries. Four key steps to achieving behavioral change are described.
Structural Approaches to HIV Prevention
Gupta, G., Parkhurst, J.O., Ogden, J.A., et al. The Lancet (2008), Vol. 372 No. 9640, pp. 764-775.
Structural factors (economic, social, political, environmental) can affect HIV risk. For example, gender inequality is linked to unprotected sex. That could be due to male control of finances or due to male physical violence, causing some women to submit to unprotected sex out of fear of physical violence or fear of losing financial support. Although the outcome is the same in either case, the necessary interventions differ. Financial problems could be addressed by micro-loans and changes in inheritance laws that treat men and women unequally. Male violence might be addressed by programs exploring concepts of masculinity. Monitoring and evaluation of structural approaches can be difficult since such programs don’t readily lend themselves to experimental design; the authors give recommendations for program assessment.
The History and Challenge of HIV Prevention
Merson, M.H., O’Malley, J., Serwadda, D., & Apisuk, C. The Lancet (2008), Vol. 372 No. 9637, pp. 475-488.
The history of HIV is traced from June 5, 1981, when the disease was first announced by the U.S. Centers for Disease Control and Prevention, to the present. Biomedical, epidemiologic, political, and activist history provides insights into an era of tremendous discovery; obstacles; and social and political ferment. Although the disease was first recognized in men, women now constitute 61 percent of adults living with HIV in sub-Saharan Africa. Projections about the course of the disease were often wrong. The most successful early prevention efforts didn’t come from the medical or public health communities, but from people living with HIV and from combination programs that addressed structural, biomedical, and behavioral issues simultaneously.
Biomedical Interventions to Prevent HIV Infection: Evidence, Challenge, the Way Forward
Padian, N.S., Buvé, A., Balkus, J. et al. The Lancet (2008), Vol. 372 No. 9641, pp. 585-599.
Several biomedical interventions have proven efficacy; the benefits of other medical interventions are less clear. According to a Cochrane review, male condoms are 85 percent effective in preventing transmission of HIV. However, long term compliance, especially with primary partners, tends to wane. Disinhibition – or an increase in risky behaviors associated with a sense of being protected – is a problem with this and several other interventions. Male circumcision is estimated to be 58 percent effective, and has the benefit of being a one-off commitment. However, circumcised men also reported increased numbers of sexual partners. The benefits and limitations of female condoms, cervical barriers, treatment of sexually transmitted infections, vaccines, topical and oral antiretroviral prophylaxis, and microbicides are discussed.
Coming to Terms with Complexity: A Call to Action for HIV Prevention
Piot, P., Bartos, M., Larson, H., et al. The Lancet (2008), Vol. 372 No. 9641, pp. 845–859.
Despite widespread knowledge about the transmission of HIV, approximately 7,000 people are newly infected each day. The impact of combination programs is complex and can cause unexpected consequences. For example, HIV infection in men who have sex with men in Bangkok, Thailand, paradoxically increased in 2005 as sex venues were closed – driving men into illegal settings for sex. There is no single “magic bullet” intervention, and combination prevention approaches are as necessary as combination treatment of HIV. Globally, about 85 percent of HIV transmission is sexual. The promise and limitations of current combination interventions for youth, high-risk groups, and women are discussed.
Reassessing HIV Prevention
Potts, M., Halperin, D.T., Kirby, D., et al. The Lancet (2008), Vol. 372 No. 9641, pp. 845–859.
Nine countries in southern African—where more than 12 percent of adults are infected with HIV—account for two-thirds of infections globally. In these generalized epidemic settings, emphasis has been placed on condom promotion and distribution, voluntary counseling and testing (VCT), and treatment of other sexually transmitted infections (STIs). The authors review the evidence and find that the assumptions driving this choice of HIV prevention strategies are largely unsupported, concluding that the largest donor investments are being made in interventions that will fail to deliver large-scale impact. Greater focus on two promising interventions, male circumcision and reducing multiple sexual partnerships, is suggested.
Expert Think Tank Meeting on HIV Prevention in High-prevalence Countries in Southern Africa Report
Southern African Development Community (2006) Maseru, Lesotho.
Southern Africa is home to 40 percent of all people living with HIV globally. The Southern African Development Community, with support from UNAIDS, USAID, WHO and other organizations, convened a meeting of 38 participants to analyze the drivers of the epidemic and to make recommendations for stepped-up prevention. Key drivers identified included multiple and concurrent partnerships; low levels of circumcision; and sexual violence. Factors underlying the drivers were identified, such as wealth disparities and high population mobility. The report includes recommendations to address the drivers of HIV and their causes; key priorities and processes; and monitoring and utilizing resources.
Evaluation of Large-Scale Combination HIV Prevention Programs: Essential Issues
Paden, N., McCoy, S., Manian, S., et al. Journal of Acquired Immune Deficiency Syndromes (2011), Vol. 58 No. 2, pp. e23-e28.
This commentary provides guidance on how to plan and implement evaluations to determine the impact of combination prevention interventions. The authors note the numerous challenges in conducting evaluations for combination prevention programs, but stress the importance in surpassing these to design a solid study. Challenges that are described include the need to have large population sizes and long time lengths if HIV incidence is the outcome of interest; absence of a naïve control group and ethical considerations with having a control group; and poor outcome surrogates (i.e., measures on self-reported behaviors, sexually transmitted infections, and pregnancy) cannot replace outcomes such as HIV incidence, prevalence, and infections averted. Large-scale evaluations should consider the following: defining the evaluable package, deciding if the evaluation is to study each individual intervention verses the entire package, choosing a “control” or “comparison” group in the study design, finding a reliable assay to measure HIV incidence when one is currently lacking, deciding on various methods in one study, and providing shorter-term outcomes on longer-term goals. In conclusion, a strong evidence base is crucial for combination prevention programs. The HIV community is open to the challenge and is supporting it through current evaluations.
The Future of HIV Prevention
Padian, N.S., Isbell, M.T., Russell, E.S., et al. Journal of Acquired Immune Deficiency Syndromes (August 2012), Vol. 60 Suppl. 2, pp. S22-S26.
According to the authors, prevention strategies have historically been categorized as either behavioral or biomedical. Behavioral interventions have included strategies for condom promotion, partner reduction, and cash transfers to keep young women in school or choose partners close to their own age. Biomedical prevention strategies include the use of antiretrovirals and vaccines (when they become available) to reduce or eliminate infectiousness, and to prevent mother-to-child transmission. The authors note that strategies considered strictly biomedical often include behavioral elements, such as retention in care and adherence to prescribed regimens. They highlight the recent success of using antiretrovirals to prevent new infections and describe some of the challenges that remain in implementing this methodology with population-level effectiveness, including acute and early infections, drug-resistant variants of HIV, and concerns about adherence and long-term use of antiretroviral regimens. The authors encourage further implementation research on how best to increase demand and retention, improve adherence, and prevent behavioral disinhibition. The authors endorse combination prevention, where biomedical, behavioral, and structural interventions are implemented concurrently. They stress the need for assessing large, complex, heterogeneous prevention programs to identify cost-effective, efficient, and effective strategies that improve health outcomes. At the broader systemic level, they endorse the use of implementation science on cost-effectiveness to guide decision makers with limited resources.
HIV Epidemic Appraisals for Assisting in the Design of Effective Prevention Programmes: Shifting the Paradigm Back to Basics
Mishra, S., Sgaier, S. K., Thompson, L. H., et al. PLoS ONE (2012), Vol. 7 No. 3: e32324. doi:10.1371/journal.pone.0032324.
HIV prevention resources are limited, and countries must make strategic decisions on how to allocate funds to result in the highest impact. Two approaches have often been utlized in aiding program planners in making these strategic decisions—the numerical proxy method and the modes of transmission approach. The study examined both approaches in terms of strengths and weaknesses by applying them to diverse epidemics. The study’s authors then took the results of each approach to see how it would affect national and district level HIV/AIDS policies. The study used data from six countries and six districts in India to apply in both approaches. The research team also proposed and tested an alternative qualitative approach to addressing HIV prevention goals called the “transmission dynamics epidemic classification.” Using data for the six countries, it was found that the two methods (numerical proxy and modes of transmission) generated different results that would affect HIV prevention policies. All three methods were applied to the district level epidemic data. When the numerical proxy and modes of transmission approaches were used, similar results were found in terms of them making different conclusions on what populations were the key drivers of the epidemic. When the transmission dynamics epidemic classification was utilized, it found that all of the districts were defined as concentrated epidemics. The study highlights the limitations of the two predominant approaches that are utilized to help program planners strategize their HIV prevention portfolios. To plan in the long-term, strategies should be based on the local dynamics of an epidemic and its trajectory.
Combination HIV Prevention: Significance, Challenges, and Opportunities
Kurth, A. E., Celum, C., Baeten, J. M. et al. Current HIV/AIDS Reports (2011), Vol. 8 No. 1, pp. 62-72.
This discussion paper highlights the advantages of combination prevention programs by focusing on specific populations, behavioral drivers, and geographical areas that are sustaining the HIV epidemic. Evidence-based interventions should be chosen for inclusion in combination prevention approaches, and in 2009 the National Institutes of Health initiated the Methods of Prevention Package Program (MP3) to fund research on combination prevention approaches. A second round of grants was provided for studies that focused on different populations than were represented in the first round, and those started in 2011. The intent of the MP3 program was to better understand the risk patterns at the population level in a particular country, district, or community to enable programmers to design and implement the most effective prevention strategy. The design of combination prevention packages should focus on interventions with shown efficacy in reducing transmission or acquisition. The choice of interventions would depend on the target population, the stage of the epidemic, and behavioral drivers. Interventions that have demonstrated success in reducing transmission or acquisition or have shown promise based on single randomized-controlled trails, preliminary data, observation data, or phase-1 or animal studies include prevention of mother-to-child transmission, voluntary medical male circumcision, male condoms, opioid substitution therapy for people who inject drugs, pre-exposure prophylaxis, and needle exchange. Additional strategies such as microbicides, HIV vaccines, and conditional cash transfers are also possibilities. Structural interventions are key to creating an enabling environment by supporting gender equitable laws, supporting risk-reduction polices, and reducing stigma and discrimination. Combination prevention is the next generation for HIV prevention science.
Namibia’s Prevention Planning Process: Successful Collaboration for a National Combination HIV Prevention Strategy
Clark, S., & Stash, S. AIDSTAR-One (2011)
Namibia’s experience demonstrates the necessity and importance of having an articulated planning approach to design a national combination prevention strategy. This case study describes how Namibia formulated is strategy through a long-term planning and advocacy process. It provides background information on how Namibia decided to invest human resources and finances for the planning process as well as for its technical approach, how the planning process started, and how roles and responsibilities were determined. Successes included increasing national commitment to reorienting the prevention strategy to address the key drivers of the epidemic, performing a situational analysis to determine the epidemiological and contextual factors, initiating and maintaining a participatory process, and having several key documents guide the strategy’s development. Several objectives had not been achieved at the time of the case study’s completion, such as mapping the ongoing prevention programs to increase regional participation and having a budgeted national prevention action plan. The case study outlines what worked well in the planning process as well as the challenges, future programming, and recommendations.
The Avahan-India AIDS Initiative: Promising Approaches to Combination HIV Prevention Programming in Concentrated Epidemics
Rau, B. AIDSTAR-One (2011).
The Avahan-India AIDS Initiative has successfully offered a combination prevention program to many of the regions’ most-at-risk-populations (MARPs) including sex workers, men who have sex with men, transgender individuals, migrant populations, and people who inject drugs. At the start of the program in 2003, it covered six regions and provided the traditional mix of activities to MARPs such as peer educators and outreach workers implementing behavior change programs, condom promotion and distribution, and sexually transmitted infection (STI) treatment. The program also added structural elements to prevent harassment and violence from police, and worked to expand national HIV prevention policies to support behavior change and health seeking behavior. The program evolved into a combination prevention program targeted to MARPs by implementing risk-reduction strategies founded on the latest data and evidence. The combination prevention elements included peer outreach to support behavior change, STI treatment, condom promotion and distribution, distribution of clean needles and syringes, community mobilization, and advocacy to reduce structural barriers. The program was highly reliant on peer educators and they were key in the program’s success and scale-up. The program’s focus on data collection and use was another key achievement. The high reach and effectiveness of the program (e.g., a goal of 80% of MARPs reached with prevention services) has lead to the government agreeing to fully support it financially by 2014.
Prevention of HIV Infection for People Who Inject Drugs: Why Individual, Structural, and Combination Approaches are Needed
Degenhardt L., Mathers, B., Vickerman, P., et al. The Lancet (2010), Vol. 376 No. 9737, pp. 285-301.
This review examines HIV prevention interventions among the population of people who inject drugs (PWID). Articles for inclusion were found through sources such as the Cochrane Library, Evidence-Based Medicine Reviews, and drug and global health interventions that prevented HIV among PWID. For structural interventions, searches were conducted in PubMed, Medline, the Cochrane Review Library, and Embase. Reference lists of selected articles were also reviewed. The paper summarizes current findings on needle and syringe programs, opioid substitution treatment, and antiretroviral treatment for HIV-positive PWID. These programs were found to achieve the greatest positive affect on preventing HIV among PWID. These three interventions were also modeled in various combinations, and degrees of coverage, to explore their effects on HIV incidence. It was concluded that no single intervention addressed all of the risk factors of PWID, which suggests that a combination prevention approach is necessary.
Contact with HIV Prevention Services Highest in Gay and Bisexual Men at Greatest Risk: Cross-Sectional Survey in Scotland
McDaid, L. M., & Hart, G. J. BMC Public Health (2010), Vol. 10, pp. 798.
The paper explored contact of men who have sex with men with HIV prevention interventions and factors that affected that contact. 1,514 men participated in the anonymous 2008 MRC Gay Men’s Survey and provided oral fluid samples. Men were recruited from gay bars and saunas in Glasgow and Edinburgh. The survey questions collected information on demographics, HIV testing history, sexual risk behaviors in the last year, and exposure to HIV prevention activities such as obtaining condoms, picking up sexual health leaflets, and interacting with an outreach worker. It was found that the majority of men had at least one contact with an HIV prevention activity (82.5%), and the predominant activity was obtaining free condoms from a gay venue or over the Internet (73.1%). Other activities included picking up a sexual health leaflet or looking up information on the Internet (51%), talking to an outreach worker (13.5%), and participating in a counseling session (8%). Only 3.6% had exposure to all four activities. Factors that were associated with contact with all four prevention activities included men who frequented the gay establishments most often, received a sexually transmitted infection (STI)/HIV test in the last 12 months, had 10 or more partners in the last year, and had an STI in the last 12 months. It was found that contact with any of the HIV prevention activities was higher among men with more sexual partners and any risky sexual behaviors. The authors conclude that a combination prevention strategy is required to curb the HIV epidemic among men who have sex with men in the United Kingdom.
The Alliance-Ukraine: Promising Approaches to Combi¬nation HIV Prevention Programming in Concentrated Epidemics
Bergmann, H., & Stash, S. AIDSTAR-One (2010).
The International HIV/AIDS Alliance in Ukraine (Alliance-Ukraine) has provided services to most-at-risk-populations (MARPs) since 2004. It is the largest AIDS organization in Ukraine and implements a combination prevention program for people who inject drugs (PWID), sex workers, men who have sex with men, and prisoners. Alliance-Ukraine partners with a number of local nongovernmental organizations and smaller informal groups with growing potential to scale up their activities as well as meet varying regional needs. The program includes a data-driven approach that allows it to change and adapt to local needs, ensures that the affected communities play a central role in the program, provides strong linkages to other governmental and nongovernmental services, and conducts advocacy for supportive policies and regulations. Alliance-Ukraine is able to reach groups of MARPs through innovative and simultaneous approaches including drop-in centers, mobile clinics, partnering with pharmacies, and having a peer-drive response. The program reached an estimated 33% of PWID with harm reduction services and a total of 66% of PWID have had some type of contact with the program since its inception. Challenges remain for the program including the continual work to reduce structural barriers, and coordinating all of the activities of its implementing partners and providing technical support. Recommendations include basing the selection of combination prevention approaches on evidence and the evolving needs of MARPs, and striving to reach all MARPs with quality services. The program has become a technical hub in the region and is offering technical assistance to other countries/programs based on its successful model.
What Mathematical Models Can Tell Us About Prevention Packages
Hallett, T. Imperial College London.
Tim Hallett reviewed how models could aid in the design of HIV prevention portfolios in his presentation during a two-day U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) meeting from November 8 to 9, 2010. The goal of the meeting was to inform the development of a revised PEPFAR HIV prevention guidance document. Hallett’s presentation outlined how models can aid programmers in making strategic choices in their prevention portfolios and provided examples of the limitations of the models.
The U.S. President’s Emergency Plan for AIDS Relief: Five-Year Strategy
The Office of the U.S. Global AIDS Coordinator (2009).
This is the guiding document through 2015 for PEPFAR, the largest international HIV/AIDS program of the United States government. The four separate documents consist of the plan and three annexes: Prevention, Care, and Treatment; Global Context of HIV; and PEPFAR’s Contributions to the Global Health Initiative. A “new direction” cited as a goal is to transition from emergency responses to “sustainable country programs” that are “country-owned and country-driven.” The plan calls for addressing HIV within a broader health and development context; linking HIV to women and children’s health; and expanding programs to relieve hunger.
The U.S. President’s Emergency Plan for AIDS Relief Five-Year Strategy: Annex: PEPFAR and Prevention, Care, and Treatment
The Office of the U.S. Global AIDS Coordinator (2009).
This annex identifies obstacles to successful prevention, care, and treatment programs as well as goals and processes to overcome each obstacle. Special emphasis is placed on combination interventions. A wide range of topics are addressed. These include: blood and injection safety; innovation in prevention; helping governments to support alternatives to prostitution; youth; mobile populations; involvement of people living with HIV; palliative care programs; care of orphans and vulnerable children; targeting treatment; antiretroviral prophylaxis for pregnant women; and expanding efforts to treat people co-infected with tuberculosis and HIV. Links to nine key articles and documents are provided.
Evaluating HIV Prevention Effectiveness: The Perfect as the Enemy of the Good
Laga, M., Rugg, D., Peersman, G., & Ainsworth, M. AIDS (February 2012), e-publication ahead of print.
“Magic bullet thinking” (prioritizing only the well-defined and measurable biomedical interventions) may inhibit understanding of “what works” by leaving out the less measurable social and contextual approaches, as well as the program coverage, uptake, and quality needed for efficacy of all interventions. According to the authors, measuring the impact of combination prevention—the mix of biomedical, behavioral, and structural interventions—remains an elusive goal for the HIV prevention community due to the methodological challenges of applying the “gold standard” of randomized controlled trials (RCTs) for prevention programming. The authors contend that the use of costly randomized designs with the community as unit of intervention (c-RCT) may not produce valid data due to a number of challenges in measuring change in HIV incidence, including a lack of reliable, easy-to-use tools to measure HIV incidence at a population level, the use of unrealistically large sample sizes, and the unreliability of such intermediate indicators as reported behavior change or sexually transmitted infection rates. The authors suggest that plausibility designs—which do not include randomly selected control groups but instead use triangulation of data sources—may provide important data on impact and help explain why a program may have been effective or ineffective. The authors encourage the use of a program impact pathway, which is a clear description of program components and their potential causal pathways, intermediate outputs, and outcomes leading to HIV incidence reduction. They also encourage the use of mixed methods and modeling as an alternative to probability evidence. They acknowledge that there is a clear need to develop incidence assays; until then, they encourage the use of modeling to produce proxy incidence estimates.
Guidance for the Prevention of Sexually Transmitted Infections
U.S. President’s Emergency Plan for AIDS Relief (PEPFAR). (2011).
The August 2011 guidance from the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) on the prevention of sexually transmitted infections aims to support PEPFAR country teams to identify the best combination of HIV prevention strategies, based on country-specific epidemiology. It describes the overarching principles for prevention programs and then summarizes the evidence base and implementation guidelines for specific interventions. Biomedical interventions included in the guidance are male and female condoms, voluntary medical male circumcision, HIV testing and counseling, diagnosis and treatment of sexually transmitted infections, and antiretroviral drug-based prevention. Behavioral interventions that are listed include the different channels of communication (e.g., mass media, community-level, interpersonal) and types of messages (e.g., addressing multiple partners, intergenerational and transactional sex, and alcohol use). Creating the demand for biomedical services is also detailed. Among the structural interventions described are legal and policy reforms, reducing stigma and discrimination against people living with HIV and marginalized groups, gender inequality and gender-based violence, education, and economic empowerment and other multi-sectoral approaches. Comprehensive packages for most-at-risk populations; positive health, dignity and prevention for people living with HIV; and prevention interventions for young people are included as well.
Technical Guidance on Combination HIV Prevention, Men Who Have Sex with Men
U.S. President’s Emergency Plan for AIDS Relief (PEPFAR). (2011).
This guidance was developed in response to the U.S. President’s Emergency Plan for AIDS Relief’s (PEPFAR’s) second five-year strategy, which outlines priorities and plans for countries that implement HIV programs. The guidance is one component in an effort to support comprehensive combination prevention programs. It was found in a review that men who have sex with men (MSM) are 19 times more likely to have HIV compared to the general population. PEPFAR is working to ensure that most-at-risk populations, including MSM, are a prevention priority in epidemics where MSM are shown to be a key driver of transmission. The guidance reviewed the evidence base for HIV prevention programs with MSM, and supports five key elements of a comprehensive response. The elements include community-based outreach; distribution of condoms and condom-compatible lubricants; HIV testing and counseling; active linkages to health care and antiretroviral treatment; targeted information, education, and communication; and sexually transmitted infection prevention, screening, and treatment. Discussion on how to support effective HIV prevention for MSM, and key points on how to optimize prevention programs are described. PEPFAR budgets will support implementation, training, collection, and use of strategic information, research, monitoring and evaluation, and commodity procurement of/for MSM programs. Additional resources are listed at the end of the document to provide PEPFAR country teams with information that may be needed in strategizing their MSM combination prevention portfolios.
Comprehensive HIV Prevention for People Who Inject Drugs, Revised Guidance
U.S. President’s Emergency Plan for AIDS Relief (PEPFAR). (2010).
The guidance was updated in response to the Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis and Malaria Reauthorization Act of 2008 that was signed into law in July of that year. PEPFAR supports three core elements in comprehensive HIV prevention programming targeted to people who inject drugs (PWID). These are: community-based outreach programs, sterile needle and syringe programs, and drug dependence treatment, including medication-assisted treatment with methadone or buprenorphine and/or other effective medications. These elements are globally recognized as best practices with populations of PWID and are endorsed by organizations and agencies such as the World Health Organization, Joint United Nations Programme on HIV/AIDS, and the U.S. Centers for Disease Control and Prevention. It is estimated that there are about 5 million PWID in the 13 countries in which PEPFAR is supporting HIV prevention programs, mostly in Eastern Europe and East and Southern Africa. The sexual partners of PWID are also at risk of acquiring HIV and act as a bridge population to groups that conduct less-risky behaviors, which can fuel the epidemic. Therefore, the evidence base for programs for PWID supports a comprehensive HIV prevention program that includes behavioral, biomedical, and structural interventions as a means to reduce HIV transmission. There are 10 core interventions that PEPFAR adopted from the WHO, UNODC, UNAIDS Technical Guide for countries to set targets for universal access to HIV prevention, treatment and care for injecting drug users. A combination of the ten interventions should be chosen based on the epidemiological, social, legal, and cultural environment of the country and region and implemented with a human rights approach.
Identifying Appropriate Livelihood Options for Adolescent Girls: A Program Design Tool
Caro, D. (2009).
Limited data are available on the effectiveness of economic strengthening interventions among adolescent girls and the impact—if any—on HIV prevention. As such, a series of tools was developed, including this livelihoods tool. It is designed to help program managers conduct more in-depth design, monitoring, and evaluation of activities reducing adolescent girls’ economic vulnerability. The user is guided through a series of diagnostic steps to identify how such girls are at risk of HIV resulting from their lack of control over their immediate environment. Once the program manager identifies constraints and opportunities these youths are living in, they are guided to livelihood interventions that are most appropriate in those situations.
AIDS Indicator Survey (AIS)
MEASURE Demographic and Health Surveys (2009).
The AIS provides survey protocols that meet the reporting requirements of the President’s Emergency Plan For AIDS Relief (PEPFAR), the United Nations General Assembly Special Session on HIV/AIDS (UNGASS), and most other funding agencies. This website provides links to standardized questionnaires, instruction manuals, survey data, and other information that can assist with the effective monitoring of national HIV programs and allow for comparison of data over time and between countries. Webpage tabs provide links to an overview of the AIS; its methodology; and to household and individual questionnaires and manuals that can be downloaded. Guidance on survey instruments, sampling design, data tabulation, and a timeline for implementing the surveys are provided. Other links provide access to survey results and databases that can be queried to provide information on a national basis. Data can be organized by various topics and individual countries.
HIV Triangulation Resource Guide: Synthesis of Results from Multiple Data Sources for Evaluation and Decision-Making
The World Health Organization (2009).
This 12-step guide provides detailed information on how to conduct data triangulation analysis, a dynamic and iterative process, in which each step informs and shapes subsequent and earlier steps as new data become available. Examples of how to conduct the analysis are drawn from experiences with HIV. Case reports and exercise questions and answers provide practical insights into the process of HIV triangulation.
Epidemiological Software and Tools
This UNAIDS website provides the most up-to-date guidance and versions of free software to estimate and project adult HIV prevalence and incidence from surveillance data. Components include:
- Estimation and Projection Package (EPP) software and manuals on generalized and concentrated epidemics
- Workbook Method spreadsheet and manual – useful when there is a lack of HIV prevalence data from consistent sites over time
- Spectrum software suite of tools
- Modes of Transmission spreadsheets (Excel) and manuals
Behavioral Surveillance Surveys: Guidelines for Repeated Behavioral Surveys in Populations at Risk of HIV
Family Health International (2003).
This comprehensive, 358-page collection of surveys allows programs to track risk behavior over time as part of an integrated surveillance system for HIV. These tools are helpful in understanding the behaviors of high-risk and hard-to-reach populations such as sex workers and their clients, men who have sex with men, and injecting drug users.
PEPFAR Announces Largest Study of Combination Prevention
U.S. President’s Emergency Plan for AIDS Relief (PEPFAR). (2011).
This media note provides details on three PEPFAR-supported evaluations on combination prevention in Zambia and South Africa, Botswana, and Tanzania. A total of $45 million dollars over a four-year period was awarded to leading research organizations and universities to conduct the research. Critical research questions on combination prevention programs will be answered through these evaluations. Additional links are provided to the websites for the U.S. President’s Emergency Plan for AIDS Relief, U.S. Agency for International Development, U.S. Centers for Disease Control and Prevention, and National Institutes of Health.
Practical Guidelines for Intensifying HIV Prevention
These guidelines provide a “synthesis of essential prevention measures required for countries to ‘tailor your prevention plans’ in relation to the epidemic scenarios.” Topics include Prevention; Leadership; Know Your Epidemic; Match Your Response to the Epidemic; Prioritizing According to Epidemiological Scenario; Set Ambitious, Realistic, and Measurable Prevention Targets; Tailor Youth Prevention Plans; and Use Strategic Information to Stay on Course. Fifty-four references are provided and links to 21 Tools for HIV Prevention Planning are offered.
View Guidelines (PDF, 387 MB)