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.

    • "Ethnography has been a highly appropriate approach to design and implement culturally appropriate prevention methods, although its use has not been well documented in clinical trials [17, 24–28]. Ethnography, which often includes a range of specific data collection methods, offers methodological strengths that include: [1] long term repeated interaction with participants, allowing the ethnographer to assess and re-assess initial interpretations, improving the validity of findings compared to single interviews or focus groups; [2] the ability to check narrative data through direct observation of actual behavior — or the ability to triangulate between what people say they do and what they actually do; and [3] the engagement of local communities in the construction of culturally appropriate clinical trials [21] [24] [29]. Data collection methods included repeated in-depth interviews with 31 BMSM (3 90-min sessions per participant), 17 60-min key informant interviews , and 11 months of participant observation documented in field notes, maps, and systematic jottings. "
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    ABSTRACT: Although HIV interventions and clinical trials increasingly report the use of mixed methods, studies have not reported on the process through which ethnographic or qualitative findings are incorporated into RCT designs. We conducted a community-based ethnography on social and structural factors that may affect the acceptance of and adherence to oral pre-exposure prophylaxis (PrEP) among Black men who have sex with men (BMSM). We then devised the treatment arm of an adherence clinical trial drawing on findings from the community-based ethnography. This article describes how ethnographic findings informed the RCT and identifies distilled themes and findings that could be included as part of an RCT. The enhanced intervention includes in-person support groups, online support groups, peer navigation, and text message reminders. By describing key process-related facilitators and barriers to conducting meaningful mixed methods research, we provide important insights for the practice of designing clinical trials for 'real-world' community settings.
    No preview · Article · Oct 2015 · Contemporary clinical trials
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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.
    Full-text · Article · Jul 2014 · Public Health Ethics
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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.
    Full-text · Article · May 2014 · PLoS ONE
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