Positive Health, Dignity, and Prevention (PHDP)
I. Definition of Positive Health, Dignity, and Prevention
Positive health, dignity, and prevention (PHDP) helps people living with HIV lead a complete and healthy life and reduce the risk of transmission of the virus to others. PHDP is characterized by its systematic delivery of a range of combination, behavioral, and sociocultural services within local communities.
II. Epidemiological Justification for the Prevention Area
As of 2008, an estimated 33 million people worldwide were living with HIV. Advances in HIV treatment have dramatically improved the life expectancy and quality of life of people living with HIV (PLWH). In some settings, expanded access to HIV testing and antiretroviral therapy (ART) has helped to transform HIV into a chronic disease. These advances magnify the urgent need to decrease HIV transmission, including for serodiscordant couples in which one partner is infected with HIV and the other is not. According to a 2008 study in Uganda, 40 percent of the cohabitating PLWH had an HIV-negative spouse. Most of the HIV-infected adults had been sexually active in the last year, and the overwhelming majority reported having unprotected sex with their married or cohabiting partner. Well over half of new HIV infections occurred among serodiscordant marital or cohabiting relationships. As PLWH live longer, it becomes increasingly important to promote safer sex and drug injection practices and to reinforce the role of every individual, HIV-positive or HIV-negative, in preventing the spread of HIV. In order to best use limited resources, prevention efforts should focus on intensive efforts with smaller groups and should be integrated into clinical care for PLWH.
III. Core Programmatic Components
Behavioral interventions for PLWH include individual and community-level education and skills-building programs. The following interventions constitute the minimum package of services for PHDP:
- Condoms (and lubricant) and risk-reduction counseling
- Assessment of partner status and provision of partner testing or referral for partner testing
- Assessment for sexually transmitted infections (STIs) and provision of or referral for STI treatment (if indicated, and partner treatment if indicated)
- Assessment of family planning needs and provision of contraception or safer pregnancy counseling or referral for family planning services
- Assessment of adherence and support or referral for adherence counseling
- Referral or enrollment of PLWH to community-based programs, such as home-based care, support groups, and post-test clubs.
PHDP programs will also include alcohol counseling, psychosocial support services, and integration of prevention messages into routine clinical care. At the community level, programs will focus on HIV stigma reduction, support communication about HIV and sex, disclosure to partners, and access to services. Structural factors will include efforts to reduce and eliminate legal and regulatory barriers to care and support for PLWH. Combination interventions are also critical, such as prevention of unintended pregnancies among HIV-infected women, prevention of mother-to-child transmission, STI assessment and management, and male circumcision. Discordant couples should be identified and provided with appropriate prevention counseling and services. Effective programs for PLWH must ensure meaningful involvement of PLWH in program design, implementation, and evaluation. Prevention programs should be part of a comprehensive set of HIV prevention efforts that target both HIV-negative and HIV-positive individuals. All interventions should be approached with utmost respect and sensitivity, and must be accompanied by efforts to combat stigma against PLWH.
IV. Current Status of Implementation Experience
Although PHDP implementation experience is limited, a number of pilot and qualitative studies support the effectiveness of these interventions. A recent study in Uganda found that individuals who learned they were HIV-positive were three times as likely to use condoms as those who did not know their HIV status, suggesting that testing can aid in reducing HIV transmission. Early studies show that interventions targeted to injecting drug users and to preventing mother-to-child transmission also reduce transmission.
Updated: June 2011
In-depth interviews with 47 HIV-infected men and women in Uganda revealed that participants feel a sense of responsibility for preventing transmission of HIV. They believe that conscious transmission of HIV equals murder and could leave children orphaned. Respondents said their sense of responsibility led them to encourage partner testing and disclosure of the test results; and to be an HIV/AIDS educator to others. Obstacles to safer sex practices included sexual desire; inconsistent condom use; fear of disclosure of one's HIV status; gender-related power dynamics; and social and financial pressures. The authors state that altruism plays an important role in motivating preventive behaviors among HIV-infected persons in Uganda.
Interviews with 7 women and 20 men (no couples) in Uganda who were HIV-positive found that the participants increased condom use, reduced intercourse frequency, and had fewer sexual partners after testing HIV-positive. Interviewees said they were motivated by concerns for personal health and the health of others. Decreased libido also accounted for some of the behavioral changes. Factors contributing to risk taking included gender-power inequities (sometimes manifested by forced sex), pain experienced by women while using condoms, decreased pleasure for men while using condoms, lack of social support, and desire for children. The authors recommend interventions to address domestic violence, partner negotiation, use of lubricants and alternative sexual activities could increase condom use, and/or partner reduction.
This national cross-sectional study examined factors associated with HIV transmission risk among HIV-infected Ugandan adults. Of the approximately 1,092 HIV-infected adults in the study, 79 percent did not know they were infected; three quarters were sexually active; and most reported their last sex act as unprotected. Forty percent of those who were living with HIV and cohabiting had an HIV-negative spouse. Only 21 percent knew that it was possible to have HIV discordance within a couple. Those who knew their HIV status were three times more likely to use a condom at their last sex act than were those who did not know their status.
A pilot intervention in 2004/05 in KwaZulu Natal assessed prevention messages by specially trained counselors who used motivational interview techniques to help people living with HIV to reduce their HIV-transmission risk behavior. Discussions were tailored to a specific patient's HIV risk reduction (or maintenance of safer behavior) needs. Those who received the intervention reported a significant decrease over time in the number of unprotected sexual events, compared to individuals receiving standard counseling. The authors conclude that a counselor-delivered HIV prevention intervention for people living with HIV is feasible and can reduce unprotected sexual behaviors.
Most HIV transmission in sub-Saharan Africa is heterosexually acquired. The degree to which HIV transmission occurs within married or cohabiting relationships is uncertain. Using data from demographic and health surveys in Zambia and Rwanda of married or cohabiting couples or non-cohabiting couples from a voluntary counseling and testing service, the study estimates that 55 to 93 percent of new, heterosexually acquired HIV infections among adults occurred within serodiscordant marital or cohabiting relationships. The authors conclude that since most heterosexual HIV transmission in urban Zambia and Rwanda takes place within marriage or cohabitation, voluntary counseling and testing for couples should be promoted.
The authors of this report argue for a strategic approach to controlling the HIV and AIDS epidemic involving continued expansion and integration of care, treatment, and prevention programs. The paper includes suggestions on how to better utilize opportunities created by the antiretroviral roll-out to achieve more effective prevention, particularly in sub-Saharan Africa.
This systematic review of quantitative studies in developing countries examined psychosocial support services for HIV-infected clients as a behavioral risk reduction intervention. Only one randomized controlled trial had an evaluation component, thereby meeting inclusion criteria for the review. The study, conducted in Tanzania, randomized people living with HIV to receive standard care or standard care with individual counseling by trained staff. Both arms improved equally from baseline with regard to disclosure of HIV-positive status to anyone, condom negotiation, use of condoms, extramarital sex, and sexually transmitted infections. The authors recommend further efficacy evaluations.
Individuals who simultaneously have high viral loads and multiple sex or needle-sharing partners pose a disproportionate risk of transmitting HIV to others compared to individuals with chronic HIV infection and low viral loads. Yet, according to the authors, most prevention programs focus on those with chronic infection. The authors outline a variety of testing strategies to identify people with high viral loads who pose the greatest risk of transmitting HIV. They review programs in North Carolina and Malawi that use testing to identify high-risk transmitters and they review financial feasibility issues in developed and developing nations.
This meta-analysis (a study of studies) identified 12 studies conducted in the United States that tested the efficacy of interventions to reduce HIV risk behaviors. The interventions included efforts to eliminate or reduce risky drug use and/or sexual practices. Interventions that significantly reduced sexual risk behaviors were: (1) based on behavioral theory; (2) designed to change HIV transmission risk behaviors; (3) delivered by health-care providers or counselors; (4) delivered to individuals; (5) delivered in an intensive manner; (6) delivered in settings where people living with HIV receive routine services or medical care; (7) provided skills building, or (8) focused on issues related to mental health, medication adherence, and HIV-risk behavior.
The authors assess the efficacy of behavioral interventions to increase use and acceptability of sexual barrier products, including vaginal chemical barriers, among HIV-positive women in Lusaka, Zambia. Women were divided into group or individual intervention arms. They attended a baseline assessment; three intervention sessions; and follow up assessments at 6 and 12 months. The study reported that all participants increased their acceptance and use of female condoms and vaginal products. Both intervention arms sustained male condom use at 6 and 12 months. The authors conclude that group interventions are likely to be acceptable and cost-effective.
A demonstration project in Bangkok, Thailand, provided screening and treatment of sexually transmitted infections (STIs) for HIV-infected women during a six month period from 2003 to 2004. Just over half of the women were sexually active during the previous three months. STI prevalence varied greatly depending on where women obtained care: 8% of HIV-positive women at infectious disease clinics had STIs, whereas 30% of such women did at the STI clinic. Over one-third of the sexually active women reported not using condoms. However, women receiving antiretroviral treatment had a higher reported use of condoms than women not receiving antiretroviral treatment. The authors report that STI services for HIV-infected people was expanded in Thailand as a result of the findings.
This study examined 393 serodiscordant heterosexual couples to determine the effects of highly active antiretroviral therapy (HAART) on preventing transmission of HIV. The study was conducted in Madrid, Spain, between 1991 and 2003. It found that when the HIV-positive partner had not been treated with antiretroviral therapy over 8 percent of their partners became infected. By contrast, no partner of an individual who received antiretroviral therapy became infected. The authors report that when HAART became widely available, heterosexual transmission of HIV declined by 80 percent.
This paper describes how public access to antiretroviral treatment in South Africa has contributed to improvements in HIV prevention. The report is based on work by Doctors Without Borders/ Médecins Sans Frontières in resource-poor clinics in the Western Cape township of South Africa. In-depth interviews and clinic data were used to gather the information. The authors state that the introduction of mother-to-child-transmission prevention programs in 1999 and three HIV treatment clinics in 2000 were turning points in the region's response to the HIV epidemic. Each of the programs provided incentives for HIV testing; expanded prevention messages and outreach to people most at risk; and contributed to reductions in HIV incidence rates compared to other areas in the province.
This article reviews experiences in integrating family planning services with services for prevention of mother-to-child transmission (PMTCT) of HIV in ten countries in Africa, Asia, and Latin America. Community openness about HIV, fertility norms, and knowledge of PMTCT programs can affect the willingness of women living with HIV to seek family planning services. No differences were observed in use of contraceptives between HIV-positive and HIV-negative women in Kenya and Zambia, but the former were more willing to use condoms. In three countries where HIV prevalence was low and sterilization rates were high, women living with HIV often accepted sterilization. The authors conclude that the rights of HIV-positive women to informed reproductive choice should be respected.
Interviews with 104 HIV-positive men in India examined risk factors associated with HIV transmission. A majority of the men were migrant workers. Over one-third of the men had sex with men. Other risk categories included drug users, truck drivers, sex workers, and, in high prevalence areas, monogamous wives. Fewer than half of men living with HIV disclosed their status to their wives. Disclosure was even lower to health care providers, family members, friends and co-workers. The authors report that stigma and discrimination were the most common barriers to disclosure and they contributed to a reluctance to use condoms; seek counseling and testing; or to obtain care and treatment services.
This paper is an introduction to a set of articles arising from a 2003 meeting in the United States to examine state-of-the-science behavioral risk reduction with HIV-positive persons and to outline immediate research needs. The authors state that although most people who learn they are HIV-seropositive will take steps to reduce risk for themselves and others, safer sex practices are difficult to maintain long term. However, most studies last only 12 months, suggesting a need for longer term studies. Challenges and progress in specific programs are overviewed. The authors comment that while researchers are increasingly consulting with consumer/community members to inform research projects, the quality of consumer-informed research varies widely.
The authors review data from 1990 to 2001 regarding disclosure of HIV status. Rates, barriers, and outcomes of disclosure by people living with HIV are examined through a review of published literature and commentary from researchers and program implementers. Major barriers to discordant-partner disclosure are identified. Policy and programmatic approaches to address those barriers are discussed. Recommendations to enhance disclosure rates and to provide support for women who have (or would like to) disclose their HIV status to their sexual partners are provided.
This authors review 17 studies of rates, barriers, and outcomes of serostatus disclosure and its effects on prevention of mother-to-child transmission in developing countries. Disclosure rates varied greatly. In general, women who attended voluntary counseling and testing (VCT) clinics were more likely to disclose than women who were tested as a part of antenatal care. Fear of discrimination; accusations of infidelity by a partner; and abandonment or violence by a partner were barriers to women's disclosure of their serostatus. The authors recommend broader access to VCT; targeting women most at risk of negative outcomes of disclosure; and greater involvement of communities to reduce the stigma and fear associated with HIV serostatus.
The authors assert that family planning clinics are a "weak platform" for the integration of HIV prevention services in developing nations for several reasons: clients tend to be older married women who are less likely to transmit HIV; the clinics do not serve men; and the addition of HIV prevention services to family planning services strains staff that are already stretched thin and programs that have few resources. The authors suggest that mass media messages can be more effective and can reach a wider audience. They state that existing HIV treatment and prevention programs can be effective platforms to assist with family planning.
This report of a consultation on positive health, dignity, and prevention held in Tunisia in 2009 included participants from around the globe who developed an international consensus on the meaning of positive health, dignity, and prevention (PHDP) with participation by people living with HIV (PLWH) who worked with civil society, government agencies, international development agencies, UNAIDS co-sponsors, and donor agencies. They agreed that PHDP "requires a human rights approach based on legal protections and a policy environment free of stigma and discrimination for PLHIV" and that "programmes must promote holistic health and wellness, including access to HIV treatment." The report concludes with recommendations for networks of PLWH, civil society, and public sector organizations and donors.
This brief from the President's Emergency Program for AIDS Relief (PEPFAR) highlights the importance of involving people living with HIV (PLWH) in program efforts and notes that PLWH are "vital contributors to the success of prevention efforts; important partners in health care delivery; sources of care and support for their communities; and effective advocates who can help build in-country capacity, local ownership, and accountability to promote sustainable efforts."
The President's Emergency Program for AIDS Relief (PEPFAR) expanded from a focus on HIV-negative individuals to include interventions for people living with HIV (PLWH). Prevention efforts with PLWH include efforts to mitigate the spread of HIV to sex partners; injecting drug use partners; and infants born to HIV-infected mothers, as well as efforts to protect the health of infected individuals. The adoption of healthy living and reduction in risk behaviors among PLWH can lead to substantial improvements in the quality of life and a reduction in HIV transmission rates.
This discussion paper was prepared for the LIVING 2008 partnership summit, held in Canada in 2008. The paper calls for leadership by people living with HIV in linking prevention and treatment; working to end stigma and discrimination; and advocacy and policy changes to address social vulnerabilities of people who are living with HIV. The paper outlines a range of programmatic issues and interventions, such as clinical and biomedical issues (including antiretroviral therapy and the risk of re-infection); psychosocial and social determinants of health; community participation; and policy and advocacy.
This short statement from the Summit outlines the issues of living positively, including strong prevention elements. It includes messages and targets for advocacy to advance the issue with policy makers.
To promote health and reduce transmission, this report puts forward a set of "essential" prevention and care services for adults and adolescents living with HIV. Descriptions of each service include country-specific considerations. Recommendations, which include psychosocial support, vaccination, family planning, and hygiene, among others, are scored for the strength of their scientific grounding.
The journal AIDS and Behavior released this special supplemental issue focusing on prevention with people living with HIV. The articles summarize programmatic responses in the United States. While programs highlighted have not undergone outcome evaluation, the peer-reviewed articles summarize the intervention development experience, intervention content, and implementation experiences/lessons learned.
This study examines changes in risky sexual behavior among HIV-infected Ugandan adults following initiation of antiretroviral therapy (ART) and its effects on HIV transmission to stable partners. Other prevention measures were also provided, including voluntary counseling and testing for cohabitating partners and free condoms. Nearly 900 ART-naïve people living with HIV were evaluated at baseline and quarterly following initiation of ART. Six months after initiating ART, risky sexual behavior fell by 70 percent. Over 85 percent of risky sexual acts occurred within married couples. Estimated risk of HIV transmission from cohort members declined by 98 percent. The researchers conclude that ART combined with other risk-reduction measures reduces the risk of HIV transmission. However, they acknowledged that it would be difficult to distinguish whether all, or only some, of the interventions contributed to the reduction.
This advocacy article urges strong emphasis on HIV prevention efforts; the authors point to the enormous human tragedy represented by more than 2.4 million deaths and 3.2 million incident HIV infections in sub-Saharan Africa in 2005. The authors emphasize the inadequacy of current HIV prevention efforts in sub-Saharan Africa and state that despite considerable expansion of antiretroviral therapy (ART) programs, prevention efforts have not kept pace. In low-income countries, investment in prevention may be cost-effective, since future care and treatment costs will be averted. New approaches and new resources might reinvigorate underfinanced HIV prevention efforts and avoid a widening gap between the numbers of individuals needing and receiving ART.
Healthy Relationships, a small-group, skills-based behavioral intervention for men and women living with HIV, is comprised of five sessions delivered over two-and-a-half weeks. Although male and female groups are conducted separately, all sessions are facilitated by one male and one female, one of whom is an HIV-positive peer counselor. The intervention was developed and tested among people living with HIV in Atlanta, Georgia. At six-month follow-ups, participants showed significant reductions in the number of unprotected vaginal/anal sex acts with HIV-negative partners; overall and unprotected vaginal/anal sex acts; and had fewer non-HIV-positive partners than the comparison group. Participants were also more likely to use condoms for vaginal/anal sex and more likely to refuse unsafe sexual practices than comparison group participants.
Partnership for Health (PfH) is a brief (3-5 minute), provider-delivered counseling program for individual men and women living with HIV in California, USA. The program is designed to improve patient-provider communication about safer sex, disclosure of serostatus, and HIV prevention. The model supports clinic staff "buy-in" and training. The intervention study found that patients who had two or more sex partners or at least one casual partner and who received consequences-framed messages were significantly less likely to engage in unprotected anal or vaginal sex. There was no change among those with only one partner or a main partner at baseline.
Choosing Life: Empowerment, Actions, Results (CLEAR) is an intervention comprised of three modules that is delivered individually to youth living with HIV in two major U.S. cities. Modules address physical health and antiretroviral adherence; reduction of risky sexual and substance use behaviors; and condom use and safer sex negotiation skills. Study participants received either in-person intervention, telephone-delivered intervention, or served as waitlist controls. At 15-months, intervention participants reported significantly greater increases in the proportion of protected sex acts with all sex partners and HIV-negative partners than did control participants. Participants who received the in-person intervention reported significantly greater risk reduction behaviors at 15 months compared to participants who received the telephone-delivered intervention.
The Women Involved in Life Learning from Other Women (WiLLOW) intervention is a small group, skill-training for women living with HIV. Rooted in gender and power theory, the four, four-hour sessions delivered over four weeks focus on HIV awareness, safer sex communication skills, and relationship decision-making. The study was conducted among African-American women in Alabama and Georgia, USA. At 6- and 12-month follow-ups, women who participated in WiLLOW reported significantly fewer acts of unprotected vaginal sex and were significantly less likely to report never using condoms than women in the comparison group. Additionally, over 12 months, women in the WiLLOW intervention were significantly less likely to acquire new bacterial sexually transmitted infections than women in the comparison group.
The authors examine the sexual behavior of 963 serodiscordant couples in Lusaka, Zambia, following voluntary HIV counseling and testing (VCT) through self-reports and biomarkers. It was found that condom use was the primary method to reduce HIV transmission to the non-infected partner. Prior to VCT, less than 3 percent of couples reported using condoms. During follow-up in the year after VCT, 80 percent used condoms. Individuals who reported always using condoms, had a 39 to 70 percent decline in sexually transmitted infection rates, including HIV. However, under-reporting of unprotected sex was common. For example, couples who reported to always use a condom still had sperm detected in vaginal smears and pregnancy was common.
This set of recommendations from the United States Centers for the Disease Control and Prevention proposes a role for medical providers in screening HIV-positive patients for sexual and drug-related risk behaviors; engaging them in risk-reduction; notifying and testing partners; and screening for and treating sexually transmitted infections. A table presents the relative risk of a spectrum of sexual behaviors. Patient scenarios are discussed, and tools are offered to guide screening and messaging. Ratings are given for the strength of the evidence underpinning each recommendation.
Home-based care services for people living with HIV (PLWH) can contribute to HIV prevention efforts. Home visitors can: promote safer sex; refer PLWH and partners for services related to HIV, sexually transmitted infections, and preventing mother-to-child transmission. They can also help to decrease stigma and discrimination by supporting community response and acceptance of PLWH. In this evaluation of the Khana Home Care Program for PLWH in Cambodia, nearly half of PLWH said home-care teams increased their comfort in disclosing their HIV status to others and nearly 30 percent of PLWH reported using condoms as a result of their increased knowledge about HIV.
This comprehensive 63-page guide addresses key clinical, structural, legal, and policy issues to serve people living with HIV and strengthen HIV prevention efforts. Specific recommendations are offered around each of the issues, providing actionable points for planning and implementation.
The package includes both a facilitator's and a participant's guide.
The 81-page package on integrating HIV prevention in a care setting includes a facilitator's guide.
This guide offers positive prevention strategies in the areas of individual health education and support. It provides an overview of the controversy regarding the term "positive prevention" and its implications. Guidelines are provided to ensure access to care; improving service delivery; assist with community mobilization; and to enhance advocacy and policy change.
This training module for healthcare providers provides information on how to integrate HIV prevention into clinical settings in resource-constrained settings. Materials include a guide for health managers on integrating HIV prevention in the healthcare setting and a facilitator's manual and PowerPoint presentation on prevention for positives.
WHO's 128-page comprehensive curriculum. See specifically the section discussing "Adult Illness-Chronic HIV Care with ARV Therapy and Prevention."
Prevention Resources for People Living with HIV Web site
This website, created by the PEPFAR Prevention with People Living with HIV Task Force, includes a database of scholarly articles, curricula, and guidelines, policies, frameworks to help program and policy planners design, develop, and deliver effective clinic or community-based HIV prevention programs to ensure that all HIV-positive persons have access to evidence-based, comprehensive HIV prevention services in order to protect their own health and the health of their partner(s) and families.
Ryan White Prevention Project: Patient Exit Interview
This 17-page document features a sample survey tool used by clinicians at government-funded clinics across the U.S. to assess the frequency and variation of prevention services among people living with HIV.
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The Global Network of People Living with HIV (GNP+)
This website offers extensive discussion of issues and current documents under four general categories: empowerment; human rights; positive health, dignity, and prevention; and sexual and reproductive health and rights.