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Meet the needs of populations through combination HIV prevention: Part 2 – a closer look This HIV update will form a chapter of the Alliance’s Good Practice Guide on Community-Based HIV Prevention, due out in June 2011. The chapter gives an overview of combination HIV prevention -- an idea that focuses attention on the overall prevention needs of populations, and the total prevention response from all stakeholders. It also describes the contributions that community-based HIV prevention programmes can make to combination HIV prevention. The chapter also discusses combination HIV prevention that is available now, and changes in the future.

HIV Update No. 10 – part 2 Date:

April 2011


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MEET THE NEEDS OF POPULATIONS THROUGH COMBINATION HIV PREVENTION: PART 2 – A CLOSER LOOK

A closer look at behavioural, biomedical, environmental and structural approaches within combination prevention This section gives some further details about different intervention types. This is still an overview, though. Detailed good practices for each intervention can be found elsewhere.

Behaviour change and community-based HIV prevention Of the different types of prevention interventions, behaviour change has been the primary objective of many community-based efforts. Typical thematic priorities for community-based behavioural interventions •

Education and skills-building related to sex and sexuality, as well as day-to-day gender norms that can be changed to improve sexual health

Increase practical understanding of safer sex, including but not limited to condom use

Support the ability to understand that individuals have various options for HIV prevention. The three basic options for prevention of sexual transmission – abstinence, having sex with one HIVnegative partner, and condom use – each comes with its own advantages and disadvantages for individuals. These can also change at different points in a person’s life

Increasing the ability to deal with real life risk situations. These include skillsbuilding for safer sex, and addressing individual motivations, interpersonal relationships and social norms related to risk and prevention

Promoting sexual health services that are relevant and accessible for the population

Improved attitudes towards people living with HIV – to promote tolerance for its own sake, and also to bolster acceptance of HIV prevention by “normalising” reactions to PLHIV. This can be particularly relevant for populations where HIV rates are relatively high but PLHIV are either stigmatised or socially invisible

Some people have questioned the effectiveness of behaviour change for HIV prevention. They often place a greater priority on biomedical services, or advocate for the potential of structural actions. However, there is a lot of evidence to show that behaviour change interventions play a critical role. It is important to recognise that behavioural interventions on their own are not likely to have a significant impact on large numbers of people at risk. First of all, they cannot meet all the population’s needs, and should be linked up to key sexual health and other services. Structural changes are also usually needed, for instance, to help achieve coverage of priority populations, and for sustainability of prevention efforts.


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At the same time, biomedical and structural approaches alone are also not sufficient, and need to be linked to behavioural interventions to be successful. Successful behaviour change approaches Some of the key points regarding the effectiveness of behavioural interventions have been summarised by the Global HIV Prevention Working Group: 1 •

Where HV infection has been greatly reduced – in places such as Uganda, Thailand, Australia and Brazil – behaviour changes were key.

Behaviour change is complex and challenging to achieve, and there are important gaps in what we know about the most effective approaches.

However, successful behavioural interventions have been researched and documented.

Right now, more effective biomedical interventions are still not available, such as microbicides and PrEP (see below). When these become available, they will still need behaviour change interventions in order to work.

Furthermore, evidence shows successful behaviour change efforts need to: •

have sufficient coverage, intensity and duration, while being tailored to the main drivers of HIV infection in a given epidemic

deal with the specific needs and circumstances of the target population

focus on different determinants of behaviour, notably: knowledge, motivations, interpersonal relationships and social norms

include strong community engagement and political support for prevention efforts

Behavioural interventions can be made a lot more successful by paying attention to a few key factors. These can be addressed in practical ways through better planning, resourcing and implementation of community-based HIV prevention programmes. •

The main approach to behaviour change should be through sexual health promotion rather than through HIV risk awareness

A clear understanding of risky behaviours is important, especially alongside individuals’ perceptions of their own level of risk. However, they are clearly not enough – which is why fear-based HIV awareness has long been discredited. Risk awareness is often accompanied by slogans about abstinence, sexual fidelity and condom use. But this is still not empowering, and it does not address the reasons most people have sex. This is why HIV prevention needs to focus on sexual pleasure and safer sex, and to be linked to other services and resources that will improve people’s sexual health. Behavioural interventions that use a sexual health approach should give people options, and help them develop the skills to take action. This has proved difficult for basic reasons – too few HIV prevention projects tackle social constraints and openly

1

Global HIV Prevention Working Group (2008). Behavior Change and HIV Prevention: st (Re)Considerations for the 21 Century.


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deal with sex as the population experiences it. This is especially true for programmes that try to reach significant numbers of people. •

Reaching people who are at risk, and adequate targeting and tailoring of behaviour change interventions that are aimed at them

Globally, there are too few focused prevention programmes that reach key populations at a scale that is sufficient to have an impact on national or local epidemics. Sex workers and men who have sex with men are relevant to HIV prevention efforts worldwide, in concentrated as well as general HIV epidemics. Other key populations, such as injecting drug users and transgender people, are more geographically specific and relevant to specific countries’ HIV epidemics, but they are also vastly under-served by HIV prevention efforts. As well, in generalised epidemics there is a need to be clear about which priority populations need to be reached within the general population of adults of reproductive age, and to ensure HIV quality prevention activities are delivered to them. Tailoring HIV prevention interventions is also vitally important to deal with issues that are commonly experienced by priority populations, within the context of their sexual lives and their overall sexual health. Adequate targeting and tailoring of interventions are critical to all aspects of combination HIV prevention. However, behaviour change interventions in particular can become meaningless without the right targeting of efforts to people who need them most, and addressing issues that are relevant to the realities and needs of the people we are trying to reach. •

Coverage of priority populations with quality prevention efforts that are renewed and sustained over time

There are complex issues that need to be addressed to achieve impact through behaviour change. It is probably only one of the reasons that many communitybased interventions have been either too simplistic – “wide” programmes that reach larger numbers of people but lack quality – or become long processes – “deep” programmes that address multiple issues but reach small numbers of people. There have been too few examples of programmes focusing on behaviour change that have been of sufficient quality and delivered at scale. In addition, many successful examples of community-based prevention have been time-bound – delivering essential HIV prevention activities to a population, but then moving on. Some people within priority populations will always need “the basics,” particularly people who come of age and start having sex. As well, it seems difficult for prevention programmes to provide follow-up programming, especially to ensure positive behaviour changes do not decline, which has been seen in different settings.


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Prevention efforts based on clear change frameworks that are adequately evaluated

Because a number of different interventions are needed to meet the needs of a population, it is often hard to single out the effects of behaviour change interventions. They should be part of an overall change framework that includes: a programming hypothesis that states how all the interventions will produce changes, and a description of how the overall change can be known. (For an example of a simple change framework, see part 1 of this HIV update.)

Biomedical prevention services There are different understandings of what interventions constitute biomedical HIV prevention. Perhaps it is easiest to understand biomedical interventions as any clinically-based service delivered by a trained provider. Seen this way, biomedical interventions are both population-specific – they meet different needs – and providerspecific – like all health services, their delivery will vary in different contexts. In addition to this, it is important to note that biomedical interventions focused on individuals require accompanying behaviour change interventions, and there are many examples where these are supported by community-based prevention efforts. When behavioural aspects are neglected, the biomedical services can have suboptimal results. Some biomedical services – VCT, PMTCT, male circumcision – need significant quality attention to support behaviour change after the intervention is over. Some biomedical prevention interventions either try to reduce transmission at the level of individuals, or decrease overall transmission in a given population. It is important to understand this difference: •

Examples of proven biomedical prevention methods at individual level include PMTCT for women living with HIV and their babies, and post-exposure prophylaxis (PEP) for people with a very recent possible exposure to HIV

Both of these can involve taking relatively short courses of anti-HIV drugs to prevent new infections. PMTCT also involves other prevention approaches (see table below). •

Biomedical services can also include relatively new HIV interventions that are only partly protective at individual level, and mainly attempt to reduce the overall transmission rates population-wide. Male circumcision is the most notable of these that has been scaled up in recent years.

Male circumcision offers about 60 percent reduction of risk of HIV transmission from women to men – so it is partly protective at the individual level. Women are not directly protected – if their male partner is HIV-positive, the woman’s risk is much the same if he is circumcised or not. But male circumcision aims to reduce overall transmission in settings with high levels of HIV prevalence by reducing the number of men who become HIV-positive. This means there will be a smaller number of men


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passing on HIV to their female partners. That is why male circumcision will be effective at population level, and is recommended where there are high levels of HIV infection and low levels of male circumcision. There are also a number of biomedical interventions in development. At the time this is being written, this includes HIV vaccines and new ART-based protection for individuals, notably pre-exposure prophylaxis (PrEP, or daily pills for HIV-negative people) and microbicides (creams or gels that include anti-AIDS drugs for application in the vagina or rectum). The following table summarises the state of development of the main biomedical HIV prevention interventions that have either been “tried and tested,” or are relatively new, or are not yet available. State of biomedical HIV prevention interventions as of mid-2011 VCT is long-standing. For many people at risk, taking the test for HIV antibody can provoke a lot of anxiety. In practice, VCT reaches many “worried well” who are not at especially high risk but who want to rule out the possibility of being HIV-positive.

Voluntary counselling and testing

VCT does not prevent HIV by itself. It is truly an intervention that should lead to other things, especially treatment for people who get an HIV-positive result. In terms of prevention, VCT can also be a step to follow-up activities, rather than a stand-alone intervention that directly affects risk and prevention on its own. VCT can be particularly important in countries where large numbers of couples include one partner living with HIV and the other partner is HIV-negative. VCT for the couple is promoted in these cases. This is an intervention to help overcome the challenges of disclosing HIV status and to support couples to better protect themselves. Arguably, in most cases there are not sufficient linkages between VCT programmes and quality post-test HIV prevention, including decision-making and practical prevention skills – for both people who test HIV-negative, and people who are informed they are living with HIV.

Prevention of mother-tochild transmission

Since 2001, PMTCT as a prevention approach has included four prongs: 1. Primary prevention of HIV in women of reproductive age 2. Preventing unintended pregnancy in women living with HIV 3. Preventing HIV transmission from mother to child during pregnancy, childbirth or infancy 4. Providing care and support to mothers, their children, and families Prong 3 of PMTCT involves biomedical interventions that can reduce the risk of mother-to-infant transmission from almost 40% to less than 5%. There are still important challenges for scaling up PMTCT. Coverage gaps for prong 3 are often related to the availability of specific elements of care services at different stages: pre-natal, delivery and post-natal. Male partner involvement also plays a role in increasing uptake, and needs to be a stronger focus of regular PMTCT programming.


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Safe male circumcision

Safe male circumcision has been implemented in a number of countries in recent years, and there has been greater uptake among men than many observers expected. It is the biggest recent change to prevention of sexual transmission, alongside PMTCT and the three behavioural options of abstinence, having one HIV-negative partner, and using condoms. It is a population-wide prevention approach, and is only indicated in settings where HIV prevalence is high and rates of male circumcision are low. Experts believe the greatest impact will be in countries where HIV prevalence in the general adult population is more than 15%, HIV is spread mostly through heterosexual transmission, and more than 80% of men are not circumcised. 2 Treatment as prevention is an idea that has some merit – in a given population, overall transmission rates will slow if a greater number of people living with HIV are taking anti-AIDS drugs.

Treatment as prevention

However, as a population-wide intervention it is part of a complicated picture. Treatment rarely reaches people when they are most infectious, because they usually don’t know they are HIV-positive. That is why a prevention method aimed at individuals – by testing viral load among PLHIV, and then advising about infectivity and how to have sex – is not yet available. Also, the “treatment as prevention” idea exists in a global context of a huge shortfall in “treatment as treatment” – the number of people living with HIV who need treatment to save their lives remains very large, and this poses a major challenge to implementing prevention as treatment.

ARV-based prevention for HIV-negative people

These include the following: − Post-exposure prophylaxis (PEP): in some countries this has been available for more than a decade. PEP can be effective if taken quickly after possible exposure to HIV. It involves taking anti-AIDS drugs for several weeks. It works for many people, but some cannot stick with the drugs due to side effects (diarrhoea, nausea, headaches and tiredness). It is also a serious one-time intervention, and clearly not a replacement for safer sex. − Pre-exposure prophylaxis (PrEP): this involves HIV-negative people taking anti-HIV pills regularly. PrEP is under development, with encouraging results for some individuals – greatly reducing risk for people who are able to take the pills all the time. However, so far it has not been effective at a population-wide level; it includes severe side effects; and it is expensive. − Microbicides: these are usually creams or gels that include lower doses of anti-AIDS drugs for application by HIV-negative people in the vagina or rectum. This is also under development. Like PrEP, the theory has been demonstrated – it could work biologically, but as a public health intervention it is not yet available.

AIDS vaccine

As with PrEP and microbicides, there is some evidence that an effective AIDS vaccine could be developed. Unfortunately, however, a longer-term investment is needed for an effective AIDS vaccine to be made available.

It is important to understand specific aspects of different biomedical prevention services – what they are designed to do, who they are most likely to benefit (and who is left out), and whether they offer individual or population-wide protection. To focus 2

WHO and UNAIDS (2007). New Data on Male Circumcision and HIV Prevention: Policy and Programme Implications.


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on current interventions that have the most impact, and to advocate for the right investments in the development of effective HIV prevention, it is also important to understand what biomedical prevention services work now and what might be possible in future.

Environmental and structural interventions – what’s the difference? Environmental and structural interventions try to bring about change beyond the level of individuals who are at risk for HIV infection. The term “structural interventions” should include activities aimed at improving the enabling environment, as well as efforts to improve social, economic and political factors in society. In practice, these interventions are usually described by two different terms. •

Programmes that include an emphasis on improving the enabling environment often focus on issues that are closely related to ensuring the prevention programme’s immediate outcomes.

Structural interventions are often seen as addressing underlying vulnerability factors, such as social norms or economic drivers, which in turn affect the risk of HIV transmission among individuals and specific populations.

Seen this way, we can say that, in most HIV responses, enabling environment actions have been more widely used than structural approaches. Community-based efforts to strengthen the enabling environment can often includes activities such as those shown in the following table:

Community-based efforts to strengthen the enabling environment •

Mobilising communities to respond to HIV

Community work on stigma and discrimination

Increasing the involvement and ownership of key stakeholders and potential allies

Setting up new systems for key prevention commodities – notably condom distribution or social marketing, as well as needle and syringe exchange for injecting drug users

Efforts to change policy or official practices that affect implementation, such as the ability of workers to conduct field outreach with marginalised groups and not be arrested

Managing gatekeepers and authorities that can block prevention activities

Training professionals – e.g. teachers, health care and social service staff – to increase the pool of people delivering targeted or specialist prevention

Advocacy with local stakeholders to improve service delivery and the use of good practice


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These are fairly common and long-standing environmental interventions, and have often been carried out at the local level. On the other hand, interventions that address vulnerability to HIV and structural determinants of AIDS epidemics are not very common. 3 There have been notable examples of innovative field-based structural interventions that have been undertaken. So far, though, examples of field-based structural interventions tend to be small projects with limited reach.

Some reasons for the lack of structural interventions addressing vulnerability •

Structural interventions often work on extremely challenging issues that often exist across entire populations – such as poverty, and the social and economic status of women or sexual minorities. This makes it challenging to develop manageable projects that can be directly linked to HIV prevention outcomes. As well, vulnerability factors are often context-specific, so situations need to be understood and approaches tailored in order to have an impact on underlying vulnerability and on HIV transmission

The effects of anti-vulnerability strategies are often longer term

It can be challenging to demonstrate their direct outcomes

Practical examples of good projects that can be replicated are simply difficult to find

Until now, approaches that address underlying vulnerability have not tended to attract funding

Therefore, it could be argued that most structural interventions addressing underlying vulnerability require further investment for development, especially to provide examples of practical applications and to better demonstrate their outcomes. This will also help to show the need for ongoing programme funding for scaling up structural interventions that contribute to combination HIV prevention.

3

Piot, P., Bartos M., Larson, H., Zewdie, D. and Mane, P (2008). Coming to terms with complexity: a call to action for HIV prevention. Lancet Vol 372, Issue 9641, P:845-859


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GOOD PRACTICE STANDARDS FOR COMMUNITY-BASED HIV PREVENTION This explanation of combination prevention is an integral part of the Alliance’s good programming standards on community-based HIV prevention. These are summarised below.

1. Effective HIV prevention that is rooted in community action

2. Rights-based HIV prevention

3. “Know your epidemic, know your response,” and focus on prevention activities that work

4. Meet the needs of populations through combination HIV prevention

5. A positive approach to sexual health

6. Gendertransformative HIV prevention

8. Ensure access to quality activities, commodities and services

7. Positive health, dignity and prevention for people living with HIV

9. Partnerships and complementary action within the overall AIDS response

For further information please contact: Kevin Orr, Senior Advisor: HIV Prevention e-mail: korr@aidsalliance.org

International HIV/AIDS Alliance (International secretariat) Telephone: +44(0)1273 718900 Fax: +44(0)1273 718901 mail@aidsalliance.org www.aidsalliance.org Registered British charity number: 1038860


HIV Update: Combination HIV prevention (Part 2)