PEPFAR is working with countries to implement, monitor, and improve comprehensive HIV prevention programs targeted to specific populations in both concentrated and generalized epidemic settings. What follows below is additional detail regarding some of the interventions PEPFAR is at a national and local level. Given that prevention is not a static field, PEPFAR will evaluate implementation of additional activities as the science evolves.
Prevention of Mother-to-Child Transmission (PMTCT)
Mother-to-child transmission is a significant cause of new infections among pediatric populations. Many factors, including lack of access to routine and ongoing antenatal care, have limited progress around PMTCT. In keeping with the Global Health Initiative (GHI) focus on women-centered approaches, PEPFAR is utilizing PMTCT as a mechanism to both prevent transmission of HIV to children and support expanded access to care and related services for pregnant women. Through PMTCT services, women can learn their status, accessing essential care if positive, and receiving information on ways to protect themselves if negative.
PEPFAR is increasing investments in PMTCT to support countries in expanding access to screening and coverage. It is working to ensure that every partner country with a generalized epidemic has both 80% coverage of testing for pregnant women at the national level, and 85% coverage of antiretroviral drug prophylaxis and treatment, as indicated, of women found to be HIV-infected. PEPFAR is also working to expand access to PMTCT to at-risk populations in countries with concentrated epidemics. To help the children of these mothers, PEPFAR supports antiretroviral prophylaxis regimens and essential medical care for HIV-exposed infants. These expanded PMTCT efforts strengthen overall maternal and child health care.
Male Circumcision (MC)
UNAIDS and the World Health Organization (WHO) have issued normative guidance stating that male circumcision should be recognized as an additional important intervention to reduce the risk of heterosexually acquired HIV infection in men. PEPFAR supports MC as a component of a comprehensive HIV prevention program in sub-Saharan Africa, and is working to scale up quality MC programs as feasible and appropriate to the country context. In its next phase, PEPFAR is transitioning to a two-pronged MC assistance approach. This approach would simultaneously support the immediate demand for MC and allow governments to develop policies and the necessary infrastructure for more sustained service delivery.
The comprehensive MC interventions supported by PEPFAR include not only the MC surgery, but risk reduction counseling, sexually transmitted infection treatment, and HIV testing and counseling.
Health, Dignity and Prevention Programs for PLWHA
A strong body of literature supports the effectiveness of prevention interventions for PLWHA in a variety of settings. PEPFAR’s prevention strategy for PLWHA and their partners includes both behavioral and biomedical interventions in clinic and community-based settings. Examples of these behavioral interventions include correct and consistent use of condoms, disclosure of status to partners, partner and family testing, reduction in number of sexual partners, reduction of alcohol use, and adherence to HIV medications which decrease viral load. Examples of these biomedical interventions include management of STIs in PLWHA and their sex partners and services to reduce maternal-to-child-transmission of HIV. PEPFAR is working with partner governments to integrate these interventions as part of the standard package of care at care and treatment sites. Civil society organizations and community-based groups providing these services will be linked to this larger clinical network.
Behavior Change Communication (BCC)
Throughout sub-Saharan Africa, key drivers of the epidemic include: multiple and concurrent sexual partnerships (MCP); intergenerational and transactional sex; low rates of male circumcision and of correct and consistent condom use; high rates of STIs; and high levels of alcohol use. PEPFAR supports a diverse range of culturally- and age-appropriate and comprehensive behavior change programming targeted to the country context.
Behavior change programming should include:
Testing and Counseling
Each testing and counseling encounter is an important opportunity to reinforce and share prevention messaging. Expanding testing and counseling diminishes the stigma associated with knowing one’s status. Individuals who test HIV-positive and who are exposed to strong behavior change interventions can reduce their risk of onward transmission. Individuals who test negative can receive counseling and information to help protect themselves and remain HIV-free. PEPFAR is working to link testing and counseling with clinical and community interventions, and improve referrals to care, treatment, prevention, and necessary supportive services. It is also working with governments to implement public health interventions that allow past contacts of PLWHAs to get tested and receive necessary prevention and treatment services. For those that are HIV-negative but are participating in high-risk behaviors, PEPFAR will work to implement modified case management with sustained prevention interventions. Finally, PEPFAR is working with countries to expand the use of rapid test kits, in order to enable more widespread use of testing outside of health facilities.
Safe Blood and Injection Safety
Medical injections and blood draws are among the most common health care procedures worldwide. In developing countries, the risk of contracting HIV from a blood transfusion is magnified by weak health care infrastructures and inadequate supplies of safe blood. Women and children are at greatest risk, due to the frequent use of blood transfusions to treat complications during pregnancy, childhood anemia associated with malaria, and various trauma incidents. To date, PEPFAR has engaged in significant support for blood safety programs. It is supporting infrastructure and lab development, technical assistance and training, and universal testing of blood units for HIV and other transfusion-transmissible infections.
Safe medical injection practices protect not only patients, but also local community members and health care workers who are routinely exposed to needles and other medical sharps. PEPFAR is supporting countries to develop safe injection policies, purchase safe injection equipment and supplies, and expand safe disposal among health care workers and community members. In addition to promotion of universal precautions, PEPFAR will work to reduce demand for unnecessary injections and promote appropriate use of transfusions.
Innovation in Prevention
Over the next five years, research may demonstrate the efficacy of additional prevention interventions such as microbicides, pre-exposure prophylaxis, and vaccines. PEPFAR will remain involved in and supportive of partner country and international efforts to identify and implement successful prevention interventions.
Microbicides, an invisible, women-controlled prevention method, will be a great asset to prevention interventions when available. PEPFAR supports efforts to find a safe, effective microbicide that can be easily used in low-resource settings. It will continue to assist partner countries in preparations for eventual microbicide introduction, regulation, manufacturing, and distribution.
There is currently a great deal of research under way involving the preventive impacts of treatment, including studies regarding the protective effect of pre-exposure prophylaxis with antiretrovirals. If efficacy is shown, demonstration projects will be essential to determining the feasibility of this approach, resource requirements, and the potential for scale-up.
Research on vaccines continues to propel hopes that an HIV vaccine can be an important part of HIV prevention strategies in the future. Even a partially efficacious vaccine could have tremendous impact in HIV prevention when coupled with other interventions. It is important for PEPFAR to continue to have links to vaccine research, as well as efforts to determine where effective vaccines can have the greatest public health impact.
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