PEPFAR Expert Consultation on Unresolved Issues in HIV Prevention Programming in Generalized Epidemics (November 8-9 2010)


November 8-9, 2010

On November 8-9, 2010, PEPFAR convened approximately 75 experts in HIV prevention for a two-day consultation. The purpose of this consultation was to inform development of revised PEPFAR HIV Prevention Guidance. Focusing specifically on interventions whose effectiveness or role in generalized epidemics is not yet clear, the consultation drew upon the knowledge, and perspectives of global experts and key international partners, seeking insights into how best to guide field programs. The consultation asked participants first to review the evidence on HIV prevention interventions, weighing different types of evidence on the efficacy and effectiveness of these approaches. The focus of the meeting then shifted to address the appropriate mix of interventions for generalized epidemics, identifying criteria for prioritization and addressing strategies to maximize synergies within a country’s prevention portfolio.

The consultation included a series of presentations on the evidence base for various HIV prevention strategies, as well as group discussion among attendees. On the second day of the consultation, participants broke into working groups to assemble a prevention portfolio for two theoretical countries. These mock countries were designed to resemble high-prevalence countries in which PEPFAR programs operate; one with an epidemic whose epidemiology mirrored a country in southern Africa and another that mirrored a country in eastern Africa.

Presentations

Caroline Ryan: HIV Prevention in the PEPFAR Context. Dr. Ryan lays the groundwork for the consultation, reviewing some of the achievements in HIV prevention since the beginning of PEPFAR. The talk presents key challenges in research and implementation of prevention programs within PEPFAR, and reviews the scope and purpose of the Consultation. Dr. Ryan also takes a brief look at two interventions – prevention of mother-to-child-transmission and male circumcision – that are not addressed in the Consultation and explains why.

Jane Bertrand: Interventions to Influence Risky Behavior in Adults: Mass Media. Dr. Bertrand reviews the evidence for mass media interventions in HIV prevention. She explains why randomized controls cannot be used to evaluate mass media interventions, then reviews the existing research, including a large, yet-to-be-published meta-analysis.

Nancy Padian, David Holtgrave: Interventions to Influence Risky Behavior: Individual and Group. Dr. Nancy Padian of the University of California at Berkeley and the Office of the U.S. Global AIDS Coordinator, presented provisional findings from an ongoing analysis of published studies of HIV prevention interventions. The exercise sought to identify interventions that warrant further evaluation because they show promising results but with weak evidence. Dr. Holtgrave briefly reviewed the history of research on behavioral interventions, citing important milestones, such as CDC’s RESPECT study, the Institute of Medicine’s endorsement of behavioral strategies, and the CDC Prevention Research Synthesis Project.

Doug Kirby: Interventions to Influence Risky Behavior: Curriculum and Group-Based Interventions (Youth). Dr. Douglas Kirby surveyed the evidence base for youth-focused interventions, drawing in part from recent reports produced by UNESCO and the National Campaign to Prevent Teen and Unplanned Pregnancy.

Judith Wasserheit: Treatment of Sexually Transmitted Infections. Dr. Judith Wasserheit, of the University of Washington, discussed the evidence regarding STI control for HIV prevention and its implications for programs and policy. Evidence shows that other STIs increase both susceptibility to HIV in those uninfected and infectiousness in those living with the disease. After two decades of investigation, numerous questions remain unresolved regarding the relationship between STI control strategies and HIV prevention.

Rachel Baggaley: HIV Testing and Counseling. Dr. Rachel Baggaley of the World Health Organization (WHO) Department of HIV/AIDS reviewed the evidence on the role of HIV testing and counseling (HTC) in HIV prevention.

Carl Dieffenbach, Myron Cohen: Treatment as Prevention. Dr. Carl Dieffenbach, Director of the Division of AIDS at the National Institute for Allergy and Infectious Diseases, highlighted several outstanding research questions that require investigation in order to build the evidence base for ART as HIV prevention. Dr. Myron S. Cohen, of the University of North Carolina, said that while it should be feasible to develop ART as an effective HIV prevention strategy, “the devil is in the details.” Biological plausibility has been firmly established, with at least four studies demonstrating the effectiveness of ART in reducing the risk of transmission among serodiscordant couples. However, Dr. Cohen cautioned, a number of questions remain unanswered.

Tim Hallett, Lori Bollinger: What Models Can Tell Us about Prevention Packages and Cost Effectiveness. Dr. Tim Hallett of Imperial College (London) reviews the opportunities and limitations of modeling in designing an HIV Prevention Portfolio, using some of his own models to illustrate the key issues. Lori Bollinger, of the Futures Institute, demonstrates work done by the Futures Institute to model the potential impact and costs associated with scaling up a package of 19 prevention interventions.

Peter Cherutich, Elioda Tumwesigye: Field Perspectives on Bringing Strong Programs to Scale. Peter Cherutich, of the National AIDS/STD Control Program of Kenya, presents on that countries ground-breaking efforts to scale up Prevention of Mother-to-Child Transmission. Elioda Tumwesigye, Executive Director of Integrated Community Based Initiatives in Uganda, discusses Uganda’s massive door-to-door home-based HIV counseling and testing effort as another model of bringing programs to scale.

Balancing Exercise. In the afternoon of the consultation’s second day, participants were divided into six working groups. Three of the groups were asked to recommend a PEPFAR prevention portfolio for a hypothetical hyper-endemic country, while the other three groups worked to devise a portfolio for a high-prevalence country. Across all groups, many participants noted a new appreciation for the challenges faced by PEPFAR program planners in having to plan real portfolios in the absence of critical data.

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