HIV prevention programmes are interventions that aim to halt the transmission of HIV. They are implemented to either protect an individual and their community, or are rolled out as public health policies.
Initially, HIV prevention programmes focused primarily on preventing the sexual transmission of HIV through behaviour change. For a number of years, the ABC approach - "Abstinence, Be faithful, Use a Condom" - was used in response to the growing epidemic in sub-Saharan Africa.
However, by the mid-2000s, it became evident that effective HIV prevention needs to take into account underlying socio-cultural, economic, political, legal and other contextual factors.1 As the complex nature of the global HIV epidemic has become clear, forms of 'combination prevention' have largely replaced ABC-type approaches.
Combination prevention advocates for a holistic approach whereby HIV prevention is not a single intervention (such as condom distribution) but the simultaneous use of complementary behavioural, biomedical and structural prevention strategies.2
Combination prevention programmes consider factors specific to each setting, such as levels of infrastructure, local culture and traditions as well as populations most affected by HIV. They can be implemented at the individual, community and population levels.3
UNAIDS has called for combined approaches to HIV prevention to be scaled-up, to reinvigorate the global response and make a sustained impact on global HIV incidence rates.
UNAIDS defines combination prevention as:
"rights-based, evidence-informed, and community-owned programmes that use a mix of biomedical, behavioural, and structural interventions, prioritised to meet the current HIV prevention needs of particular individuals and communities, so as to have the greatest sustained impact on reducing new infections." 4
'Know your epidemic, know your response'
Developing a clear and evidence-informed picture of a specific HIV epidemic is needed before deciding on a package of HIV prevention interventions.
The ‘know your epidemic, know your response’ approach is the starting point for combination prevention programming, and is comprised of a series of exercises to help categorise an epidemic (such as generalised or concentrated). This involves looking at factors such as modes of HIV transmission, key affected populations and key epidemiological trends (such as the number of new HIV infections among young people).5 6
The planning process that programmers and policy makers are recommended to follow is described below:
- A planning process that is inclusive and based on evidence.
Ensure the participation of all relevant stakeholders, including government officials, cultural leaders, civil society organisations, donors, and most importantly, individuals and communities affected by HIV and AIDS.
- Identify modes of transmission and the most affected populations.
Understand how HIV is spread in an epidemic. Identify the most common modes of transmission, and the most affected populations.
- Identify geographic variations in HIV prevalence.
Identify geographic difference in HIV prevalence, such as urban vs rural areas.
- Know the size of key affected populations.
Ensure that the appropriate tools are available to collect, monitor and evaluate data about key populations.
Identify and understand structural factors that might fuel HIV prevalence.
Analyse social, legal, economic and cultural drivers of HIV prevalence. For example, punitive laws or gender inequalities.
Upon completion of the know your epidemic, know your response planning process, a package of coordinated biomedical, behavioural and structural HIV prevention interventions can be developed and implemented.7
Behavioural interventions seek to reduce the risk of HIV transmission by addressing risky behaviours. A behavioural intervention may aim to reduce the number of sexual partners individuals have; improve treatment adherence among people living with HIV; increase the use of clean needles among people who inject drugs; or increase the consistent and correct use of condoms. To date, these types of interventions have proved the most successful.8
Examples of behavioural interventions include:
- information provision (such as sex education)
- counselling and other forms of psycho-social support
- safe infant feeding guidelines
- stigma and discrimination reduction programmes
- cash transfer programmes.9
Biomedical interventions use a mix of clinical and medical approaches to reduce HIV transmission. One example of a biomedical intervention - male circumcision - is a simple medical procedure that has been shown to reduce the risk of HIV transmission by up to 60% during unprotected heterosexual sex.10
In order to be effective, biomedical interventions are rarely implemented independently and are often used in conjunction with behavioural interventions. For example, when a man is circumcised, he will often be tested for HIV and receive counselling and education about condom use and safer sex.11
Examples of biomedical interventions include:
- male and female condoms
- sex and reproductive health services
- voluntary medical male circumcision
- antiretroviral drugs for the prevention of mother-to-child transmission, pre-exposure prophylaxis, post-exposure prophylaxis and treatment as prevention
- HIV testing and counselling
- testing and treatment of sexually transmitted infections
- needle and syringe programmes
- opioid substitution therapy
- blood screening.12
Structural interventions seek to address underlying factors that make individuals or groups vulnerable to HIV infection. These can be social, economic, political or environmental.
"For many people, the simple fact that 90% of the world's HIV infections occur in developing countries is evidence that social, economic and political structures drive risk behaviours and shape vulnerability." 13
Structural interventions are much more difficult to implement because they attempt to deal with deep-rooted socio-economic issues such as poverty, gender inequality and social marginalisation. They can also be reliant on the cooperation of governments to achieve law or policy reforms.
For example, laws that criminalise same-sex relationships often hinder men who have sex with men from accessing condoms. A woman’s subordinate status can affect her ability to negotiate condom use while a lack of infrastructure such as transport, prevents many people from accessing health clinics. By successfully addressing these structural barriers, individuals are empowered and able to access HIV prevention services.14
Examples of structural interventions include:
- interventions addressing gender, economic and social inequality
- decriminalising sex work, homosexuality, drug use and the use of harm reduction services
- interventions to protect individuals from police harassment and violence
- laws protecting the rights of people living with HIV.15
A public health approach to combination prevention
More recently, some people have advocated for a public health approach to combination prevention. This involves using a combination of biomedical, behavioural and structural strategies to target currently available resources at high prevalence regions or 'hot spots' and high-risk groups.16
For example, a combination of needle and syringe programmes, antiretroviral treatment, HIV testing and opioid substitution therapy in Tallinn, Estonia, was found to reduce HIV prevalence among people who inject drugs from 20.7% to 7.5% between 2005 and 2011.17
Likewise, a study from South Africa has suggested that pre-exposure prophylaxis together with test and treat programmes could reduce HIV transmission among sex workers and their clients by 40% over a 10-year period.18
It is thought that targeting combination prevention initiatives at high-risk groups together with a scale-up in antiretroviral treatment has the potential to reduce HIV prevalence from pandemic levels to low-endemic levels.19
Fast-tracking combination prevention
In order to end the HIV epidemic as a public health threat by 2030, in 2014, UNAIDS launched a Fast-Track strategy to greatly step up the HIV response in low- and middle-income countries.20
The strategy re-emphasises the need for interventions to target key locations and key affected populations.21 It also identifies a number of other ways to increase the effectiveness of combination prevention efforts, a few of which are discussed below.
Increasing political and financial commitment
A UNAIDS modelling exercise suggests that nearly 25% of future HIV investments should go into effective combination prevention initiatives, while the rest should support efforts to achieving the 90-90-90 targets and reducing new infections by 75%.22
Getting the support of political leaders, religious leaders and other influential figures in society can help to raise awareness and influence norms regarding HIV prevention.23
Using new tools and technology
Over the past decade, a number of new HIV prevention tools have emerged that increase the effectiveness of these services. For example, even in low-income countries, mobile phone ownership and internet access have grown considerably and have changed how people interact and receive information.24
Taking advantage of this shift, Young Africa Live enables young people to talk about topics that affect their daily lives including sex, HIV, rape and gender issues, as well as where to get tested for HIV. The platform now has 1.8 million users across South Africa and is expanding to Tanzania and Kenya.25
Achieving full coverage
HIV prevention coverage is currently fragmented. Implementing programmes with sufficient intensity and coverage over a long enough period of time is critical to their success.
Condom programmes show how where high coverage has been achieved, they have had a significant impact. In South Africa, data reveals how condom use increased with an increase in the distribution of condoms leading to a decline in new infections between 2000 and 2008.26
By contrast, condom distribution has not been scaled up enough in many countries despite the low cost.27 Availability also varies greatly between countries as well as within countries with many health facilities experiencing stock-outs. Young people’s access to condoms is also restricted by social norms and the negative attitudes of healthcare workers.28
South Africa’s condom programme utilised social marketing to increase condom use. Specifically, condom brands are designed to be appealing and reflect local cultural values. Condoms are also sold at an affordable price or are distributed for free in impoverished areas.29
- 1. UNAIDS (2010) 'Combination HIV Prevention: Tailoring and Coordinating Biomedical, Behavioural and Structural Strategies to Reduce New HIV Infections'
- 2. UNAIDS (2010) 'Combination HIV Prevention: Tailoring and Coordinating Biomedical, Behavioural and Structural Strategies to Reduce New HIV Infections'
- 3. UNAIDS (2010) 'Combination HIV Prevention: Tailoring and Coordinating Biomedical, Behavioural and Structural Strategies to Reduce New HIV Infections'
- 4. UNAIDS (2010) 'Combination HIV Prevention: Tailoring and Coordinating Biomedical, Behavioural and Structural Strategies to Reduce New HIV Infections'
- 5. UNAIDS (2012, 15 May) '30th Meeting of the UNAIDS Programme Coordinating Board'
- 6. UNAIDS (2007) 'Practical Guidelines for Intensifying HIV Prevention'
- 7. UNAIDS (2010) 'Combination HIV Prevention: Tailoring and Coordinating Biomedical, Behavioural and Structural Strategies to Reduce New HIV Infections'
- 8. Coates, T.J. et al (2008) 'Behavioural strategies to reduce HIV transmission: how to make them work better' The Lancet 372(9639):669-684
- 9. UK Consortium on AIDS and International Development (2013) 'Working Group Briefing Paper: Combination Prevention'
- 10. Auvert, B. et al (2005) 'Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 Trial' PLOS Medicine 2(11):e298
- 11. Padian, N.S. et al (2008) 'Biomedical interventions to prevent HIV infection: evidence, challenges, and way forward' The Lancet 372(9638):585-599
- 12. UK Consortium on AIDS and International Development (2013) 'Working Group Briefing Paper: Combination Prevention'
- 13. Rao, G. et al (2008) 'Structural approaches to HIV prevention' The Lancet 372(9640):764-775
- 14. Rao, G. et al (2008) 'Structural approaches to HIV prevention' The Lancet 372(9640):764-775
- 15. UK Consortium on AIDS and International Development (2013) 'Working Group Briefing Paper: Combination Prevention'
- 16. Jones, A. et al (2014) 'Transformation of HIV from pandemic to low-endemic levels: a public health approach to combination prevention' The Lancet 384(9939)272-279
- 17. Uuskula, A. et al (2014) 'Combined prevention for persons who inject drugs in the HIV epidemic in a transitional country: the case of Tallinn, Estonia' AIDS Care 23:1-7
- 18. Bekker, L.G. et al (2015) 'Combination HIV prevention for female sex workers: what is the evidence?' The Lancet 385(9962):72-87
- 19. Jones, A. et al (2014) 'Transformation of HIV from pandemic to low-endemic levels: a public health approach to combination prevention' The Lancet 384(9939)272-279
- 20. UNAIDS (2014) 'Fast Track Strategy'
- 21. UNAIDS (2015) ‘Fast-Tracking combination prevention’
- 22. UNAIDS (2015) ‘Fast-Tracking combination prevention’
- 23. UNAIDS (2015) ‘Fast-Tracking combination prevention’
- 24. UNAIDS (2015) ‘Fast-Tracking combination prevention’
- 25. Social Tech Guide (2014) 'Young Africa Live'
- 26. Johnson, L.F. et al (2012) ‘The effect of changes in condom usage and antiretroviral treatment coverage on human immunodeficiency virus incidence in South Africa: a model-based analysis’ Journal of the Royal Society Interface 9(72):1544-1554
- 27. United Nations Population Fund (UNFPA) (2011) ‘Comprehensive Condom Programming: A guide for resource mobilization and country programming’
- 28. Sandoy, I.F. et al (2012) ‘Condom availability in high risk places and condom use: a study at district level in Kenya, Tanzania and Zambia’ BMC Public Health 12:1030
- 29. Sweat, M.D. et al (2012) ‘Effects of condom social marketing on condom use in developing countries: a systematic review and meta-analysis, 1990–2010’ Bulletin of the World Health Organization 90:613-622A[/f]
Photo credit: Photo by Kevin Harber/CC BY-NC-ND 2.0