HIV Prevention Knowledge Base
Combination Approaches: An Overview of Combination Prevention
HIV Epidemic Appraisals for Assisting in the Design of Effective Prevention Programmes: Shifting the Paradigm Back to Basics
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
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
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
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
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
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
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
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
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
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
“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.