HIV prevention is at the core of an effective HIV response. Prevention efforts have played a critical role in the 15% decline in new HIV infections since 2001, as reported by UNAIDS.
We are at something of a tipping point for prevention and the overall HIV response. New developments, growing evidence of what works, and major scientific breakthroughs offer a real possibility of ending AIDS in a generation. However, there have also been worrying signs that the consequences of new technologies are not being properly planned for and the international donor community could be ‘taking its foot off the pedal’ right at the time when it is possible to accelerate progress.
This is particularly pertinent right now as the 19th international AIDS conference approaches, where thousands of scientists, policy makers and communities affected by HIV will meet to shape the future HIV response. Combination prevention will also be a key theme at the next UNAIDS Programme Coordinating Board meeting from 5-7 June. Here governments, UNAIDS co-sponsors, and representatives of non-governmental organisations (NGOs), including associations of people living with HIV, will meet to discuss the issues.
Treatment as prevention
One of the recent developments causing a stir among HIV programmers and policy makers is the evidence from the HIV Prevention Trials Network treatment as prevention trial (HPTN 052). It confirms the prevention benefits of antiretroviral therapy and showed a 96% reduction in risk of sexual HIV transmission among heterosexual couples, in which one partner is living with HIV and is started on treatment immediately.
This has led to WHO passing new guidance on couples HIV testing and counselling including antiretroviral therapy for treatment and prevention in serodiscordant couples. However, the implications for other key populations such as sex workers and homosexual couples are unclear at this stage. Many other questions have also been left unanswered by the HPTN 052 trial, for instance the optimal time to initiate treatment; its benefits in relation to unsafe injecting of drugs; its feasibility, cost and impact in a real world scenario; and the optimal implementation strategies and service delivery models.
The Alliance is currently conducting an organisation-wide consultation and discussion with community networks on treatment as prevention. The preliminary results of this are presented in a new briefing paper that highlights some of the key questions that communities most affected by HIV and organisations supporting them are currently discussing, and outlines the main points to remember for what needs to be in place to make TAP work.
Later this year, we will also publish a Good Practice Guide on HIV prevention, which will include guidance on combination prevention and new technologies. You can download our existing guides here.
No ‘magic bullet’
While the evidence of the HPTN 052 trial is encouraging, it also raises some important questions. For example with many countries struggling to reach universal access targets for HIV treatment, it is unclear how treatment as prevention could work in this context. Also, the existing barriers to an effective HIV response have not vanished, though treatment as prevention may revive the efforts to tackle them and increase equal access, if funding can be secured.
There is no ‘magic bullet’ to prevent HIV. For any new technology or intervention to work it must come as part of a combination prevention approach. The value for money of such an approach is supported by the Investment Framework.
Don’t forget communities
Communities are at the heart of an effective HIV prevention response. They need to become equal partners in planning, implementing and evaluating HIV prevention strategies and programmes, and in prevention research. This requires community and resource mobilisation, community systems strengthening, and strategic partnerships between communities and other sectors.
The Investment Framework describes community mobilisation as a ‘critical enabler’ of an effective response. The World Bank and UK’s Department for International Development conducted an Evaluation of the community response to HIV and AIDS which strongly indicates that community engagement results mostly in positive outcomes. This is also our own experience in supporting community action across the world.
‘HIV starts and ends with communities’ says Anja Teltschik, the Alliance’s senior advisor on HIV prevention, ‘if we are to effectively halt the spread of HIV communities must play an integral part.’
‘We must also remember that different communities and individuals have diverse needs’ she continues, ‘in order to meet these needs, interventions must be implemented at the individual, community, service and structural levels. We must also meet the needs of people living with HIV and key populations who are at higher risk of HIV.’
Combination prevention in action
Examples of effective combination approaches to HIV within communities can be seen in our work in Senegal and Ukraine. Alliance programming and our combination approach to prevention are driven by our Good Practice HIV Programming Standards.
In Senegal well over 60% of people living with HIV are women. The Alliance’s Linking Organisation in Senegal, ANCS, is working hard to reduce new infections among women by continuing to scale up programmes that empower women. This helps women to access and take up prevention services and in turn prevent transmission to their children. For example, 58,800 women were mobilised for prevention of mother to child transmission services by ANCS in 2011. ANCS also works to change behaviours through education, information and counselling on areas such as stigma and discrimination. At the same time, through coalition building, advocacy and education it is working to address the structural drivers of HIV, and empower women living with HIV. For more on keeping mothers healthy see our update: Integrating Maternal, Newborn and Child Health into Community Based HIV Programmes.
In Ukraine a combination approach to addressing the drivers of HIV has seen great results. One of the key population groups at higher risk of HIV in Ukraine is people who inject drugs. Methadone maintenance therapy (MMT) is one of the most effective biomedical interventions to prevent HIV transmission among people who inject drugs. However, MMT could only be effective in Ukraine by also addressing structural and behavioural factors. Alliance Ukraine through advocacy work to remove legal barriers to MMT and reaching people who use drugs through peer support initiatives, has helped individuals get on to MMT and stay on it. You can read the full story of Alliance Ukraine’s successful combination approach in this USAID case study.
Getting prevention right
2015, the ‘end year’ for global targets on HIV is approaching fast. As such, getting the right approach to HIV prevention is crucial, especially in the context of reduced funding. In this environment, value for money is key and the Investment Framework shows that community mobilisation and a combination approach are critical to achieve this.
These issues will be examined in detail at a satellite session the Alliance will run at AIDS 2012.