HIV prevention, treatment and care continuum
In 2015, 36.7 million people were living with HIV, 2 million of whom became HIV positive that year. Thanks to antiretroviral treatment (ART), the number of people dying from AIDS-related illnesses worldwide is decreasing. However, progress made in reducing the number of annual new infections is stagnating, and lifesaving treatment is not available to more than half of the people who need it.
Populations and communities throughout the world have very different access to HV prevention and treatment services. Great disparities still exist between world regions and within countries.
For instance, key and vulnerable populations - such as sex workers, men who have sex with men, people who use drugs, and young women and girls living in Sub Saharan Africa - are normally less able to access prevention services such as condom and lube distribution services, and services offering information about how to protect yourself from HIV, and are therefore more vulnerable to acquiring HIV.
For people from these groups who live with HIV, barriers such as discrimination and marginalisation make them less likely to access HIV treatment, care and support services, leading to dire consequences for their health and their lives.
Ensuring that HIV prevention and treatment services are available to everyone who needs them is critical to see the end of the HIV epidemic.
The Alliance’s approach to HIV prevention and treatment is based on the consolidation of two different but mutually reinforcing strategies: HIV combination prevention and strengthening the HIV continuum of care.
HIV combination prevention
Combination prevention combines three things: biomedical interventions, such as the provision of condoms and clean syringes, pre exposure prophylaxis and voluntary male circumcision; behavioural interventions, which encourage people to adopt safer behaviours; and structural interventions, which aim to engender positive legal and social changes, such as advocating to improve the rights of people living with HIV.
Combination prevention programmes work best when these strands are adapted and prioritised to meet the needs of the people they intend to serve. By enabling communities to lead, plan, implement and monitor their own combination prevention programmes, we are able to meet the needs of specific groups in specific contexts.
This means listening to communities to understand their current realities, what needs to change and what will and won’t work. It means recognising that a context can be different from neighbourhood to neighbourhood, and that the needs of people from a particular key population are not homogenous – that, for example, what people who use drugs need to prevent them from acquiring HIV will differ depending on factors such as their age, their gender identity, their sexuality, their housing situation or whether they sell sex.
Because our programmes are community-led, they will often contain elements that go beyond traditional notions of HIV combination prevention. For example, for a group of female sex workers, combination prevention may involve support with childcare needs. For a group of young men who have sex with men in a country where same sex practices are criminalised, it may mean providing financial support so they can relocate to safer locations after facing violence after being ‘outed’.
Accessing HIV prevention is a universal right, so we listen to and advocate for people who are being left behind by national prevention programmes. Increasingly, as the global HIV response looks to target the geographical areas where HIV prevalence is highest, the Alliance is taking the lead in ensuring people outside these locations, whose lives are still hugely impacted by HIV, are not denied the right to protect themselves from HIV.
The HIV continuum of care
The HIV continuum of care, sometimes known as the treatment cascade, describes the journey that a person living with HIV goes through: from getting tested, being diagnosed, beginning treatment, staying on treatment, and achieving and maintaining viral suppression. If someone is able to become virally suppressed, as long as they are able to remain on effective treatment, they will be able to enjoy long-term good health and their sexual or injecting partners will no longer be at risk of acquiring HIV.
Every person with HIV has the right to make this journey. Our goal is to enable people who are living with, and most affected by, HIV, and who are so often pushed to the back of the queue for treatment and care, to come to the front.
Based on 20 years of working with community-based organisations, we know the obstacles to engaging with care and treatment services people face will be as diverse as they are, so we support communities to take the lead in building programmes that help them navigate their way through the continuum of care and claim their right to health. For example, HIV-related stigma, or stigma and discrimination relating to someone’s identity, may stop some people from getting tested; for others, practical barriers such as living far away from a clinic will make testing out of reach. As a result, many of our programmes deliver counselling and testing services to people where they feel most comfortable, in a youth club or a brothel for instance, and employ skilled peer outreach workers to link those who test positive with the care services they need.
When someone tests positive for HIV, we know that judgemental attitudes of health workers, or the fact that they are criminalised for their identity or behaviours, may stop them from embarking on treatment. To combat this, we support community advocates to work with staff at clinics and hospitals to ensure people living with, and most affected by, HIV are treated with dignity and respect. To help people stay on treatment we may connect them with a peer educator who can offer them adherence tips that suits their lifestyle, or bring treatment to hard-to-reach people through mobile clinics.
- Men’s Sexual Health and Rights Programme (SHARP) was a project that contributed to reducing the spread and impact of HIV among MSM and building healthy MSM communities in Kenya, Tanzania, Uganda and Zimbabwe from December 2012 to November 2015. The key findings from SHARP demonstrate that it is possible to reach, engage, link and provide large numbers of MSM with HIV, health, legal and other services by supporting and working with MSM or LGBT-led community-based organisations.
- Link Up enabled almost 1 million young people in Bangladesh, Burundi, Ethiopia, Myanmar and Uganda to access combination prevention by taking control of their sexual and reproductive health and rights (SRHR). Running between 2013 and 2016, this US $45 million project, which was led by the Alliance and a consortium of partners, demonstrated that young people most affected by HIV can take ownership of their own health and access a broad range of integrated HIV and SRHR services if they are provided with the space and the resources to do so.
- The Pehchan programme, implemented by Alliance India, strengthened and built the capacity of 200 community-based organisations to provide effective, inclusive and sustainable HIV combination prevention services in 17 states in India for more than 450,000 men who have sex with men, transgender people and hijras. The project, which ended in 2016, was a rare example of a community-led combination prevention programme working at a national scale.
- In 2016, the Alliance provided nearly 1.5 million HIV treatment, care and support packages to adults, adolescents and children and reached nearly 1 million people with integrated HIV and sexual and reproductive health and rights services.
- We also provided more than 800,000 defined packages of HIV prevention services to key populations.
- Overall, in 2016, Linking Organisations contributed 10% or more of the national coverage for HIV prevention, care or treatment in 59% of the countries in which the Alliance work.
This brief was produced by the Alliance in partnership with UNAIDS and follows on from the 2015 UNAIDS reference paper, Fast Tracking Combination Prevention. It is intended for advocates from community-led organisations, including networks of people living with HIV, civil society organisations active in the delivery of HIV/AIDS programmes, and groups and people working with and representing populations most affected by HIV.
This case study describes interventions by Alliance Linking Organisation Via Libre in Peru to improve the HIV continuum of care within their clinic. After outlining the typical barriers and challenges faced by people living with HIV when accessing care, the study examines Via Libre’s response and the ways in which barriers were addressed in order to improve patient outcomes.
Discover the key insights from our work with the Men’s Sexual Health and Rights Programme (SHARP) in Kenya, Tanzania, Uganda and Zimbabwe. You can read the London School of Hygiene and Tropical Medicine’s appraisal of SHARP here.
This report documents how communities are advancing the response to HIV through a myriad of ways, including combination prevention and increasing access to treatment and care services.
This community guide was developed in collaboration with the Global Network of People Living with HIV (GNP+) and STOP AIDS NOW! in response to the World Health Organization's Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV.
Increasing access to HIV treatment through a community-supported public private partnership in Myanmar
Case study on innovative ways to increase the number of people in Myanmar on antiretroviral treatment.