Combination Prevention: A Deeper Understanding of Effective HIV Prevention

Office of the Deputy Executive Director, Programme Branch, Joint United Nations Programme on HIV/AIDS, Geneva, Switzerland.
AIDS (London, England) (Impact Factor: 5.55). 10/2010; 24 Suppl 4(Suppl 4):S70-80. DOI: 10.1097/01.aids.0000390709.04255.fd
Source: PubMed


Evidence-informed and human rights-based combination prevention combines behavioural, biomedical, and structural interventions to address both the immediate risks and underlying causes of vulnerability to HIV infection, and the pathways that link them. Because these are context-specific, no single prescription or standard package will apply universally. Anchored in 'know your epidemic' estimates of where the next 1000 infections will occur and 'know your response' analyses of resource allocation and programming gaps, combination prevention strategies seek to realign programme priorities for maximum effect to reduce epidemic reproductive rates at local, regional, and national levels. Effective prevention means tailoring programmes to local epidemics and ensuring that components are delivered with the intensity, quality, and scale necessary to achieve intended effects. Structural interventions, addressing the social, economic, cultural, and legal constraints that create HIV risk environments and undermine the agency of individuals to protect themselves and others, are also public goods in their own right. Applying the principles of combination prevention systematically and consistently in HIV programme planning, with due attention to context, can increase HIV programme effectiveness. Better outcome and impact measurement using multiple methods and data triangulation can build the evidence base on synergies between the components of combination prevention at individual, group, and societal levels, facilitating iterative knowledge translation within and among programmes.

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Available from: Catherine Hankins, Oct 07, 2015
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    • "Key reported concerns with social desirability are anticipated by select guidelines which outline that site staff should be cognisant of the potential for social desirability bias and recommend the use of neutral advisors and trained counsellors (SAMRC, 2003). Reported complexities also reflect broader concerns with the efficacy of counselling to reduce HIV risk and underscore the search for an expanded array of prevention options that combine biomedical and structural interventions with behavioural interventions (Hankins and de Zalduondo, 2010). "
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    ABSTRACT: Researchers and sponsors are required to assist HIV prevention trial participants to remain HIV-uninfected by ensuring access to prevention services. Ethics guidelines require that these HIV risk-reduction services be state of the art. This and related ethics recommendations have been intensely debated. This descriptive study aimed to identify actual HIV prevention practices for two HIV vaccine trials at five South African sites, to explore whether actual practices meet guideline recommendations and to discuss implications for practices and ethics guidelines. Practices were examined through a review of site documents and interviews with site staff and network representatives, as well as community advisory board and research ethics committee representatives. A thematic analysis of HIV prevention practices, perspectives and perceived challenges was undertaken. Findings indicated that there was a high degree of correspondence between actual practices in South African HIV vaccine trials and guideline recommendations. Key challenges for implementing prevention services were identified as partnerships, provider-promotion of services and participant uptake of services. Practices deviated most from guidelines with regard to the description of prevention plans in informed consent forms. Recommendations are made for both practices and ethics guidelines.
    Public Health Ethics 07/2014; 7(2):195-206. DOI:10.1093/phe/phu010 · 1.18 Impact Factor
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    • "Voluntary medical male circumcision (VMMC) has been demonstrated to reduce risk of HIV acquisition through heterosexual vaginal sex in males by 50–73% [6]–[9], and is an essential part of the ‘HIV prevention toolbox’ of evidence-based behavioural, biomedical and structural interventions [10]–[12]. Targeting VMMC at young males as part of such a combination prevention program in schools before entry into the high risk period could represent a directed and cost-effective means of altering current epidemic trajectories for HIV. An adolescent-targeted strategy could also represent the ‘path of least resistance’ in terms of VMMC scale-up, considering several studies have shown that uptake of VMMC is highest in this age group [13], [14]; indeed, younger men are less likely to be inhibited by barriers to VMMC reported by older men which include concerns about taking time off work and abstaining from sex following the procedure [15]. "
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    ABSTRACT: Epidemiological data from South Africa demonstrate that risk of human immunodeficiency virus (HIV) infection in males increases dramatically after adolescence. Targeting adolescent HIV-negative males may be an efficient and cost-effective means of maximising the established HIV prevention benefits of voluntary medical male circumcision (VMMC) in high HIV prevalence-, low circumcision practice-settings. This study assessed the feasibility of recruiting male high school students for VMMC in such a setting in rural KwaZulu-Natal. Following community and key stakeholder consultations on the acceptability of VMMC recruitment through schools, information and awareness raising sessions were held in 42 high schools in Vulindlela. A three-phase VMMC demand-creation strategy was implemented in partnership with a local non-governmental organization, ZimnadiZonke, that involved: (i) community consultation and engagement; (ii) in-school VMMC awareness sessions and centralized HIV counselling and testing (HCT) service access; and (iii) peer recruitment and decentralized HCT service access. Transport was provided for volunteers to the Centre for the AIDS Programme of Research in South Africa (CAPRISA) clinic where the forceps-guided VMMC procedure was performed on consenting HIV-negative males. HIV infected volunteers were referred to further care either at the CAPRISA clinic or at public sector clinics. Between March 2011 and February 2013, a total of 5165 circumcisions were performed, the majority (71%) in males aged between 15 and 19 years. Demand-creation strategies were associated with an over five-fold increase in VMMC uptake from an average of 58 procedures/month in initial community engagement phases, to an average of 308 procedures/month on initiation of the peer recruitment-decentralized service phase. Post-operative adverse events were rare (1.2%), mostly minor and self-resolving. Optimizing a high volume, adolescent-targeted VMMC program was feasible, acceptable and safe in this setting. Adaptive demand-creation strategies are required to sustain high uptake.
    PLoS ONE 05/2014; 9(5):e96468. DOI:10.1371/journal.pone.0096468 · 3.23 Impact Factor
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    • "Two approaches to intensive HIV control are now being explored by public health researchers. Combination prevention acknowledges that single interventions are unlikely to be sufficient to reverse the epidemic while packages that combine a range of proven interventions are more likely to be effective [2,3]. UTT is a new paradigm whereby population-wide HIV testing is combined with effective linkage to care and immediate onset of ART with the aim of maintaining the health of HIV-infected individuals and steeply reducing HIV transmission [68]. "
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    ABSTRACT: Effective interventions to reduce HIV incidence in sub-Saharan Africa are urgently needed. Mathematical modelling and the HIV Prevention Trials Network (HPTN) 052 trial results suggest that universal HIV testing combined with immediate antiretroviral treatment (ART) should substantially reduce incidence and may eliminate HIV as a public health problem. We describe the rationale and design of a trial to evaluate this hypothesis. A rigorously-designed trial of universal testing and treatment (UTT) interventions is needed because: i) it is unknown whether these interventions can be delivered to scale with adequate uptake; ii) there are many uncertainties in the models such that the population-level impact of these interventions is unknown; and ii) there are potential adverse effects including sexual risk disinhibition, HIV-related stigma, over-burdening of health systems, poor adherence, toxicity, and drug resistance.In the HPTN 071 (PopART) trial, 21 communities in Zambia and South Africa (total population 1.2 m) will be randomly allocated to three arms. Arm A will receive the full PopART combination HIV prevention package including annual home-based HIV testing, promotion of medical male circumcision for HIV-negative men, and offer of immediate ART for those testing HIV-positive; Arm B will receive the full package except that ART initiation will follow current national guidelines; Arm C will receive standard of care. A Population Cohort of 2,500 adults will be randomly selected in each community and followed for 3 years to measure the primary outcome of HIV incidence. Based on model projections, the trial will be well-powered to detect predicted effects on HIV incidence and secondary outcomes. Trial results, combined with modelling and cost data, will provide short-term and long-term estimates of cost-effectiveness of UTT interventions. Importantly, the three-arm design will enable assessment of how much could be achieved by optimal delivery of current policies and the costs and benefits of extending this to UTT.Trial registration: NCT01900977.
    Trials 02/2014; 15(1):57. DOI:10.1186/1745-6215-15-57 · 1.73 Impact Factor
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