HIV Prevention Knowledge Base
Combination Approaches: An Overview of Combination Prevention
Guidance for the Prevention of Sexually Transmitted Infections
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
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
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
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)
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
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
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.