Question

There is an increase in debates around the principles that should guide policy-makers when deciding what resources should be allocated to fighting HIV/AIDS and whether the focus should be preventive or curative remedies. In your opinion, what should the focus be on, and why?

Answer 1

Ans) HIV prevention programmes are interventions that aim to halt the transmission of HIV.

- HIV prevention programmes usually focus on preventing the transmission of HIV through a complementary combination of behavioural, biomedical and structural strategies.
Despite the progress made by prevention programmes across the globe, the decline in new HIV infections among adults has slowed in the past decade, which indicates the need for increased funding and scale up of services.
For maximum impact, HIV prevention programmes need to be targeted at high prevalence regions or 'hot spots', and also meet the needs of high-risk groups.
- Explore this page to find out more about combination prevention, intervention approaches and the future of prevention strategies to meet Fast Track Targets.

- 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.

- In 1990, when HIV had become a global health epidemic, around 1.9 million people became newly infected. In 1996, at the peak of the epidemic, 3.4 million new infections were recorded. Since then, new infections have been slowly declining and fell by 16% between 2010 and 2018 during which around 1.7 million people became HIV positive. What isn’t yet happening is a significant enough decline in enough countries to bring the HIV epidemic to an end.

- In 2014 UNAIDS set ambitious worldwide targets to reduce annual new infections to below 500,000 by 2020 – a 75% reduction from 2010 – and to 200,000 by 2030. Known as the UNAIDS Fast-Track Strategy, achieving such reductions would mean the HIV epidemic was no longer a public health threat.3 However, if current trends continue, the 2020 target will be missed.

- Since 2010, only three countries (Cambodia, Mongolia and Nepal) have reduced new infections among adults by a half or more, and 17 more have reduced new infections by a quarter. But many countries have not made significant progress, and at least 50 have seen new infections increase.

- For this reason, UNAIDS has described HIV prevention as being in crisis.5 In the same year, the International AIDS Society–Lancet Commission warned of a possible resurgence of the HIV epidemic due to the failings in HIV prevention coupled with the largest ever generation of young people moving into adulthood.

- In 2017 UNAIDS devised a road map and 10-point action plan to help countries where efforts to prevent HIV are failing get back on track. The map and plan address the four key issues that are holding back progress: gaps in political leadership, legal and policy barriers, gaps in prevention financing, and a lack of systematic implementation of combination prevention programmes at scale.

Combination prevention:
Effective HIV programmes graphic

- 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.

- 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.9

- 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.

- All combination prevention programmes require a strong community empowerment element and specific efforts to address legal and policy barriers, as well as the strengthening of health and social protection systems, plus actions to address gender inequality, stigma and discrimination.

For example:

Young people in high prevalence countries need more than condoms and behaviour change communications. They also require comprehensive sexuality education and access to effective HIV and sexual and reproductive health services without economic barriers, such as prohibitive costs, or structural barriers, such as parental consent laws.

A combination package for men who have sex with men should include easy access to condoms, lubricant and PrEP, as well as efforts to address homophobia.

A package for people who inject drugs should feature comprehensive harm reduction services, including needle and syringe programmes (NSPs) and opioid substitution therapy (OST). However, few countries have consistently applied a combination HIV prevention approach to programming.

'Know your epidemic, know your response'
Before deciding on a package of HIV prevention interventions for a specific HIV epidemic, a clear and evidence-informed picture of that epidemic is needed.

Known as the ‘know your epidemic, know your response’ approach, this is the starting point for combination prevention programming, and is comprised of a series of exercises to help categorise an epidemic (such as whether it is ‘generalised’ – i.e. within the general population – or ‘concentrated’ within certain groups within the population, often referred to as ‘key affected populations’). 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).

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, people 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 combined package of coordinated biomedical, behavioural and structural HIV prevention interventions can be developed and implemented.

- However, in many countries a lack of aggregated data, poor training, limited resources (including staff time), discriminatory laws, policies and attitudes make it difficult to provide tailored, effective combination prevention activities for the people who could most benefit from them.