From 2001 to 2009, HIV incidence decreased by more than 25 percent in 33 countries around the world, including 22 countries in sub-Saharan Africa. An estimated 6.6 million HIV-infected people in low- and middle-income countries now access antiretroviral treatment (ART)—while this reflects a 16-fold increase in access to ART between 2003 and 2010, another 9 million people continue to go without. 1 And, while the overall number of new HIV infections is decreasing and access to treatment is increasing worldwide, there are two new HIV infections for every one HIV-infected person placed on treatment. 2
In this era of effective ART, treatment as prevention and pre-exposure prophylaxis (PrEP) 3, primary HIV prevention and positive health, dignity, and prevention remain vitally important if we are to turn the tide on the HIV epidemic. Unless we reduce the number of new HIV infections, we will not have a meaningful impact on further reducing the burden of disease caused by HIV. Fortunately, we are at a point in the response where we now have a number of evidence-based interventions: behavioral risk reduction, male and female condoms, voluntary medical male circumcision (VMMC), needle and syringe exchange, knowledge of HIV serostatus, treatment of sexually transmitted infections (STIs), and use of antiretrovirals for both prevention and treatment. How, then, might we employ this evidence to achieve a vision of zero new HIV infections? Current scientific knowledge and thinking suggests a combination approach to HIV programming is most effective. 4 The aegis of a combination approach lies in the fact that, to date, no single HIV prevention intervention offers full protection against HIV. To have the greatest impact on reducing HIV incidence, evidencebased biomedical, behavioral and structural interventions need to be combined in mutually reinforcing intervention packages designed to address the epidemiological and social context of the epidemic within each country. 5
PSI, in collaboration with country governments, donors and partners, is working to deliver an appropriate package of HIV prevention services to address context-specific factors and risk behaviors. In doing so, we employ our deep experience in implementing behavioral and biomedical components of a comprehensive HIV prevention package while working closely with governments and partners to address structural factors. We place strong emphasis on understanding each epidemic to identify the best mix of evidence-based interventions, scale up these interventions in a coordinated and integrated manner in generalized epidemics, and appropriately target populations at highest risk for HIV in mixed and concentrated epidemics. How does combination prevention work in practice?
In eight sub-Saharan African countries with generalized HIV epidemics, PSI is scaling up VMMC services as part of a comprehensive package of services. 6 Adolescent and adult male clients who access static or outreach VMMC services are offered voluntary HIV counseling and testing, screening for sexually transmitted infections (STIs), and are exposed to interpersonal behavior change messages which promote abstinence during the healing period, consistent and correct condom use, and reducing multiple and concurrent sexual partnerships. Where possible so that loss to follow up is minimal and early treatment initiation becomes easier, clients with a positive HIV test result are offered an on-site CD4 cell count, tuberculosis screening, and referral for treatment, care and support services. Female partners of sexually active clients are also reached with risk reduction messages and couples HIV counseling and testing. This model of combination prevention allows for multiple prevention interventions, as well as appropriate referrals and linkages, at a single point of contact.
HIV counseling and testing (HCT) is another example of combination prevention in addition to services integration. In 17 of 26 countries where PSI offers HCT services, we leverage this entry point into care and treatment not only to promote knowledge of clients’ own and his/her partner’s status, but also to offer clients access to family planning services and, for pregnant clients, referrals to antenatal care and prevention of mother-to-child transmission services. PSI promotes dual use of condoms plus one other modern contraceptive method for HIV-infected female clients and discordant couples who don’t intend to become pregnant, while striving to provide balanced and ethical counseling about fertility options. 7 With significantly increased risk of cervical cancer among HIV-infected women compared to HIV-negative women, PSI is also scaling up cervical cancer screening, treatment and referral within existing HIV and family planning and reproductive health services.
In concentrated and mixed epidemics, PSI and its partners are advocating with governments and policy makers to create enabling environments for key populations (also known as most at-risk populations or MARPs), while providing services and products to meet the health needs of these marginalized populations. We work with and through peer educators who understand clients’ needs and link them to friendly services, and also engage local community leaders and key influencers to reduce stigma and discrimination. In Central America, PSI and its regional affiliates, the Pan American Social Marketing Organization (PA SMO), PSI/Mexico and Proyectos en Salud Integral (PSI) Costa Rica, in collaboration and coordination with local Ministries of Health, local non-governmental organizations, and international partners, are working to increase access to HIV prevention services for key populations including men who have sex with men, female sex workers and their clients and partners, transgender persons, mobile populations, and people living with HIV and their partners. These populations are exposed to highly targeted communication interventions and are offered or referred to a core package of HIV services, including HIV counseling and testing, male and female condoms, and diagnosis and treatment of STIs.
Combination approaches offer the opportunity to thoughtfully tailor HIV prevention packages to address specific risk behaviors. A thoughtful and client-centered approach needs to be applied in selecting intervention packages and integrating non-HIV services – such packages shouldn’t overwhelm health personnel and thus health systems. Yet, there is also a need for a stronger evidence base. It is challenging enough to evaluate the impact of a stand-alone intervention; the methodological bar is considerably raised with combination prevention. The public health community will hopefully learn much from research supported under the National Institutes of Health-funded Methods of Prevention Package Program (MP3). While the public health community seeks to understand what works and what doesn’t, a sense of urgency and practicality is needed. It is important to not ignore what we know already works to prevent taking another decade to move from evidence to implementation. Implementing agencies, such as PSI, can contribute to the evidence base by thoughtfully using existing evidence to design our combination prevention approaches, and documenting and sharing what we’re doing.
By Dr. Krishna Jafa, Director, Sexual & Reproductive Health & TB, PSI and Heather Chotvacs, HIV Consultant, Sexual & Reproductive Health & TB, PSI, Washington, D.C.
1. UNAIDS, 2011. AIDS At 30: Nations at the crossroads.
2. UNAIDS, 2010. Report on the global AIDS epidemic.
3. Pre-exposure prophylaxis, or PrEP, is a strategy that uses antiretroviral medications (ARVs) to reduce the risk of HIV infection in HIV negative people (AVAC, 2012. Pre-Exposure Prophylaxis (PReP) Fact Sheet)
4. UNAIDS, 2010. Combination HIV Prevention: Tailoring and Coordinating Biomedical, Behavioural and Structural Strategies to Reduce New HIV Infections. A UNAIDS Discussion Paper.
5. Kurth AE, et al. Combination HIV Prevention: Significance, Challenges, and Opportunities. Curr HIV/ AIDS Rep. 2011 March; 8(1): 62–72.
6. WHO, UNAIDS, 2011. Joint Strategic Action Framework to Accelerate the Scale-Up of Voluntary Medical Male Circumcision for HIV Prevention in Eastern and Southern Africa. 2012–2016.
7. PSI, 2009. Case Study: Integration of Family Planning and HIV Services in Zimbabwe: Hormonal Implants and Dual Protection Messages.