The United States President's Emergency Plan for AIDS Relief

Prevention


In Malawi, the PEPFAR-supported Lions Drama Group uses theatrical performances to educate audiences about HIV prevention and encourage behavior change. Thlupego Chisiza, founder of the Lions Group, knows his group's performances are creating impact. After performing in southern Malawi, a local businesswoman confided in him that seeing her life experience acted out in her community prompted her to take action and start actively encouraging young people to employ safe sexual practices. Photo by Malawi PEPFAR Team

Prevention

Key Points:

  • A major short-term priority for PEPFAR's prevention programs is to support countries in mapping and documenting current and emerging prevention needs.
  • PEPFAR's prevention programs will focus on scaling up high-impact, evidence-based, combination prevention approaches.
  • Mutually reinforcing prevention interventions must be targeted to address needs of subpopulations in which new infections are concentrated.
  • PEPFAR is supporting and evaluating promising and innovative practices to determine the effectiveness and impact of such interventions at both the country and global level.
  • Linking treatment and care programs to prevention messaging allows PEPFAR to maximize its impact in all areas, particularly in reaching partners and families of people living with HIV/AIDS (PLWHA).
  • Structural factors, such as existing economic, social, legal and cultural conditions contribute to increased risk for HIV infection. PEPFAR's prevention activities are addressing and evaluating the response to these factors.
  • PEPFAR's prevention efforts will contribute to the global evidence base around prevention.
  • PEPFAR is utilizing prevention of mother-to-child transmission (PMTCT) as a mechanism to both prevent transmission of HIV to children and support expanded access to care and related services for pregnant women.

Prevention remains the paramount challenge of the HIV epidemic, and preventing new infections represents the only long-term, sustainable way to turn the tide against HIV/AIDS. For any given population, the public health response must strike a balance between prevention opportunities and treatment needs. A successful prevention program requires a combination of mutually reinforcing interventions tailored to the needs of different target populations.

According to the Joint United Nations Programme on HIV/AIDS (UNAIDS), there were approximately 2.7 million new HIV infections in 2008, and 33.4 million people living with HIV.1 New infections still far outpace the world's ability to add people to treatment. For every two people put on antiretroviral drugs (ARVs), another five become newly infected.2 In recent years, several low-prevalence countries have had some success in containing their epidemics, concentrated in most-at-risk populations (MARPs). However, only a few high-prevalence countries have significantly reduced HIV prevalence. Increased attention is critical for hyperendemic countries, while simultaneously continuing to respond to countries with both concentrated and generalized epidemics.

Challenges to Successful Prevention Programs

Challenges in carrying out successful prevention programs encompass multiple factors, such as:

Lack of country-level and locally-specific data
PEPFAR's prevention response is based upon HIV demographic and epidemiologic data. In many countries, there is a need for additional or updated data necessary to track the most recent new infections - primarily new infections over the past year. These data allow for outreach to the populations in which these infections are occurring. Without such ongoing surveillance, countries are unable to match timely investments to existing and evolving needs.

Existence of multiple epidemics and need for multiple targeted interventions
There is not a single HIV epidemic within any given country. Rather, multiple epidemics exist within diverse populations and social networks, including concentrated epidemics within larger generalized epidemics. Identifying and targeting interventions to match the needs of multiple populations is difficult, especially when such epidemics involve groups that are often marginalized and discriminated against. Stigmatized populations are frequently hidden and hard to reach with services. Effectively addressing a country's HIV epidemic must involve mutually-reinforcing interventions targeted to populations based upon epidemiological and demographic data. Specific populations, such as youth, women, transient populations, men who have sex with men (MSM), sex workers, and injecting drug users (IDUs), require programming tailored to their situation within the country context, rather than broad-based, national-level, generalized prevention messaging.

Need for expanded evaluation, operations research and metrics
There are a number of evidence-based interventions used by PEPFAR and other HIV prevention programs. Several programs targeting most-at-risk populations have been proven to be effective. Certain interventions utilized in generalized epidemics, such as prevention of mother-to-child transmission and male circumcision (MC) also have a strong evidence base. More operations research regarding prevention is needed, particularly around general population prevention programs in high-prevalence countries. Although many small pilot programs involving behavior change interventions have proven effective, there is a need to demonstrate continued efficacy following scale-up of these pilots. At the global level, there is a need for additional research to better measure the impact of prevention programs and refine estimates of infections averted.

Stigma and discrimination
The majority of HIV infections occur through sexual contact. In addition to sexual transmission, a significant number of infections occur due to sharing of needles, often in the context of injecting drug use. Stigma and discrimination create barriers to accessing key populations with critical prevention interventions. Denial about the epidemic can also contribute to perceptions of low risk and reduce demand for services. Finally, cultural and social norms may lead to policies that reinforce stigma and discrimination.

Structural conditions
Existing economic, social, legal and cultural conditions often increase the risk of HIV transmission for individuals. For example, if a community treats sexual violence as a cultural norm, rather than a criminal act, those impacted by this violence may be unable to protect themselves from HIV or receive necessary care following the assault. Prevention must take into account the factors existing outside the health sector that impact risk and vulnerability to HIV. There is also a need for increased research and evaluation into the impact of structurally-based prevention interventions.

Inability to capitalize on all opportunities for prevention
Multiple opportunities to advance prevention messaging are present in individual interactions with the healthcare system. There are also opportunities to reach existing audiences through social networks, schools, or mass media. With multiple demands on health, education, and social welfare systems, it is difficult to effectively utilize every opportunity to engage in prevention messaging.

Lack of unified messaging
In order for prevention messages to be effective, population-specific messages delivered by mass media, community mobilization activities, and interpersonal communication activities must be coordinated and mutually reinforcing. Otherwise, mixed messages and inconsistent information can dilute the impact of prevention programs.
Over the next phase, PEPFAR's prevention response will be guided by the following concepts:
  • Supporting countries in reassessing their prevention response through mapping the epidemic, identifying the populations most impacted by new infections, and updating prevention strategies based upon these data;
  • Assisting countries in implementing a combination of behavioral, biomedical, and structural interventions;
  • Implementing, scaling up, and measuring the impact of proven and promising interventions, tools, and methodologies;
  • Working with countries to target and reach most- at-risk populations, no matter how stigmatized or marginalized these populations may be;
  • Expanding the evidence base around prevention, through monitoring, evaluation, and operations research of prevention programming; and
  • Contributing to international efforts to develop harmonized indicators and new surveillance methodologies.

Identifying Greatest Need: Mapping the Epidemic

A major short-term priority for PEPFAR's prevention programs is to support countries in mapping and documenting current and emerging prevention needs. This process includes surveillance, surveys and program mapping, and data analysis to craft and revise overall strategies to address the drivers of the epidemic. Through this mapping, PEPFAR can help governments develop and expand epidemiologically-driven responses, thus improving efforts to reduce overall HIV incidence.

For example, in Kenya, PEPFAR and the Ministry of Health conducted a revised Kenya AIDS Indicator Survey (KAIS). This survey was a tool designed to provide up-to-date information on HIV and other sexually transmitted infections (STIs). Following the data collection and analysis, PEPFAR and the Kenyan Government supported a series of HIV Prevention Summits. These Summits used findings from the KAIS that led to the development of a National HIV Prevention Strategy. With this National Prevention Strategy, PEPFAR has been able to ensure alignment with national priorities, improve coordination with other donors in accordance with a country plan, and increase efficiencies in the program. Over the next few years, PEPFAR will work to support the Kenyan government in implementing and assessing the impact of its prevention programming.

Combination Prevention

By combining quality biomedical, behavioral and structural interventions - known as "combination prevention" - countries can work over time in given geographic areas to craft a comprehensive prevention response. Components of combination prevention include:

  • Biomedical interventions, such as prevention of mother-to-child transmission, use medical approaches to block infection, decrease infectiousness, or reduce infection risk. The treatment or intervention often acts as the platform for a larger prevention message. For example, PEPFAR's male circumcision package not only provides the actual circumcision procedure, but includes a package of prevention interventions, including risk reduction counseling and outreach to the sexual partner of the man being circumcised.
  • Behavioral interventions include a range of approaches that address key behavioral outcomes - including delay of sexual debut, partner reduction, mutual monogamy, and correct and consistent use of condoms. Approaches are geared to motivate positive behavioral change in individuals, couples, families, peer groups or networks, institutions, and communities. These science-based, culturally- and age-appropriate interventions promote sustained behavior change through different, mutually-reinforcing program components. For example, mass media, community mobilization and interpersonal communication efforts are used in concert to encourage individuals, families, and communities to adopt and maintain healthy behaviors and norms.
  • Structural interventions acknowledge that an individual's behaviors are in part governed by social, cultural, political, and economic norms. These interventions aim to change the larger societal, political, and economic contexts which can contribute to vulnerability and risk. For example, gender-based violence (GBV) has been linked to increased risk for HIV. Structural interventions targeting this risk include legal and policy changes that criminalize gender-based violence and result in increased awareness, reporting, and enforcement of penalties for those who engage in gender-based violence.

Priority Interventions

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.3 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:

  • Mutually reinforcing activities, including a mix of mass media, community mobilization, small-group and individual interventions that reflect best practice in BCC; and
  • Prevention messages that address key epidemic drivers, are based on formative research, and are coordinated and delivered across both community and clinical settings.

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.
Evan - a former sex worker - is now educating peers about safer sexual practices and raising HIV/AIDS awareness through the PEPFAR-supported 'Keep the Light On' project. The project is aimed increasing peer education of sex workers in Guyana to provide HIV/ AIDS education to their peers and to teach them safer sexual practices. Photo by Guyana PEPFAR Team

Strategic Populations

PEPFAR’s prevention strategies must be responsive to the drivers of the epidemic and address the needs of most-at risk populations in both generalized and concentrated epidemics. Prevention messaging needs to educate populations about the way the virus is transmitted. Successful prevention interventions help individuals to acknowledge and identify risk factors in their lives and actions they can take to protect themselves. The following describes ways in which PEPFAR will support countries in implementing prevention programs for specific populations:

Vulnerable women and girls

Nearly 60% of HIV infections in sub-Saharan Africa occur among women.4 PEPFAR is working through
its gender strategy to address the needs of women and girls, many of whom are vulnerable due to structural conditions that limit their ability to access or utilize prevention programming. It is especially important for PEPFAR and countries to address the needs of girls and young women in relationships with older men, as these types of relationship are often common in hyperendemic areas. More detailed information about PEPFAR’s work with women, girls, and gender activities can be found in additional annex documents available at www.pepfar.gov/strategy/.

Men who have sex with men (MSM)

Reaching MSM in both generalized and concentrated epidemic settings poses significant challenges. In several of the countries in which PEPFAR works, homosexual activity is defined as a criminal act, and may result in detention or arrest for those suspected of engaging in MSM activity. Governments are often reluctant to engage in outreach to these communities. Cultural mores and stigma may make MSM reluctant to disclose possible risks in a clinical setting. In addition, transgender populations face significant stigma and barriers to receiving appropriate health services. In order to address the health needs of these populations, PEPFAR is working with countries to engage in the following:

Identifying the need in the MSM community

Rates of HIV infection among MSM are often much higher than the general population. A major prevention priority for PEPFAR is helping governments to engage in the research necessary to map their epidemic and identify increased risk existing among subpopulations including MSM. This data-driven base makes it easier for public health programs to target prevention efforts.

Removing Stigma and Discrimination

PEPFAR will work to ensure that its prevention, care, and treatment programs are free from stigma and discrimination directed toward clients.

Supporting MSM access to prevention, care, and treatment

PEPFAR supports country government policies that ensure that MSM have equal access to health care, HIV/ AIDS information and supportive services, and do not face arrest or detention for seeking these services.

Persons in Prostitution

Individuals who engage in or procure transactional sex, even on an occasional basis, are at higher risk for HIV. The intersection of trafficking in persons and prostitution further complicates efforts to provide needed HIV services. Prostitution is associated with psychological and physical risks, and PEPFAR is working with countries to help persons in prostitution get the prevention, care, and treatment services that they need. PEPFAR supports countries in the following activities:

Engaging in targeted prevention, care, and treatment outreach

PEPFAR is supporting efforts to provide basic HIV prevention, care, and treatment services to persons in prostitution. In many countries, cultural norms contribute to stigmatization of sex workers, limiting their ability to seek or obtain care. PEPFAR is working with governments to ensure that access to health care and social services is not denied because an individual is a sex worker.
A Walvis Bay Corridor Group member hands a Namibian truck driver a copy of the NamibiAlive II CD. The CDs, which were produced by two Peace Corps Volunteers to raise awareness about HIV/AIDS, are given to truck drivers in an effort to educate and prevent the spread of HIV/AIDS among industry employees. Photo by Namibia PEPFAR Team

Helping governments to support alternatives to prostitution

From a public health perspective, it is important not only to reduce the overall risk to individuals who are engaged in transactional sex, but to prevent people from turning to transactional sex in an economic crisis. PEPFAR is working with governments to support programs that increase educational and economic opportunity for sex workers, and that keep at-risk youth in schools or vocational training. It is also important to ensure that prevention programs and personnel recognize the risks associated with occasional transactional sex.

Working to reduce demand

Through its gender programming, PEPFAR is working with countries to change behavioral
expectations that promote transactional sex as “masculine” behavior. It also works to ensure that men who procure sex take measures to protect themselves and all their sexual partners.

Injecting drug users

Comprehensive prevention packages for IDUs not only reduce immediate risks of transmission, but enable this population to receive care to treat and end their addiction. In multilateral fora, the Obama administration has supported a package of prevention to injecting drug users that mirrors the prevention package supported by the UNAIDS/United Nations Office on Drugs and Crime (UNODC)/WHO Technical Guide on harm reduction programs in relation to HIV.5 The Technical Guide recommends that programs directed toward IDUs should include a comprehensive package of nine activities. PEPFAR is currently working with agencies across the U.S. Government (USG) to determine the best way forward in supporting this comprehensive package.

Youth

The categorization of “youth” is often misleading, as youth not only encompass multiple age ranges, but also face various types of risk. PEPFAR’s programming for youth is medically accurate, age-appropriate, and targeted to needs based upon behavior. Behavioral interventions include delaying age of sexual debut, discouraging MCP or intergenerational sex, and providing information about consistent and correct use of condoms. PEPFAR will work with countries to strengthen school-based programs. HIV prevention messages that address the needs of both girls and boys will be integrated into life skills curricula. PEPFAR will also encourage governments to involve youth as part of the civil society response to the epidemic, so that policies targeting adolescents and young adults are realistic and responsive.

While much of the focus on youth involves BCC, it is important to recognize the diversity of situations faced by the youth PEPFAR serves. Youth exist among most-at-risk populations. Given the rates of child marriage in some PEPFAR countries, there are a significant number of girls and young women in marriages who need information about how to protect themselves from HIV infection. Confounding these prevention interventions are the gender inequities that may limit the power of young women in these relationships. Youth who are out of school present particular risks, as do orphans and vulnerable children (OVC). These populations may need prevention messaging that is packaged along with vocational or other social support programming to address their economic needs. PEPFAR is working with countries to ensure that youth programming – including OVC programming – is responsive to the needs of out-of school youth.

Mobile populations

Truck drivers, migrant workers, and the military all pose significant challenges for HIV prevention efforts. The transient natures of these populations often limit exposure to prevention messaging, and also may increase opportunities to engage in high-risk behavior. Involuntarily mobile populations, such as internally displaced persons or other refugees, can be at high risk for HIV, particularly due to increased risk of sexual assault. Given the fact that these populations are moving across borders, governments may be less aware of their needs. There is difficulty cataloging and documenting need among these rapidly changing communities. The cross-border nature of these populations and their related epidemics exemplifies the need for cross-border and regional programming for these vulnerable populations. PEPFAR is working with governments, regional institutions, and multilateral organizations to provide outreach to these populations and ensure that comprehensive services are accessible to them.

Incarcerated populations

Prevention work with incarcerated individuals affords an opportunity to diminish risk of transmission within and outside the correctional facility. Governments often do not place an emphasis on the ways in which a revolving door of prison populations can amplify risk in the general population. PEPFAR is supporting governments to minimize transmission within correctional facilities, educate and involve law enforcement in prevention activities, and ensure that adequate HIV prevention, care, and treatment services are available within prison settings.

Health Care Workers

To date, PEPFAR has supported post-exposure prophylaxis (PEP) treatment for health workers who suffer needle-stick injuries. PEPFAR is continuing to work with countries in developing a health care infrastructure that follows internationally-accepted infection control protocols. PEPFAR supports implementation of universal precautions, and increased availability of basic medical supplies to limit the risks faced by these workers.

Moving Forward with Prevention

Years 1-2 –

  • Support countries in efforts to collect data and map drivers of the multiple epidemics in a country.
  • Assist countries to develop and implement short- and long-term combination prevention strategies linked to epidemiologic and demographic data.
  • Scale up existing high-impact interventions, maximizing linkages to care, treatment and broader health services.
  • Identify evidence-based best practices, engaging in piloting of promising interventions, and increase operations research for prevention programming.
  • Begin impact evaluation of prevention programs and establish baselines for evaluations of new activities.
  • Work with countries to target and reach most-at-risk populations, no matter how stigmatized or marginalized these populations may be.

Years 3-5 –

  • Scale up innovative programs based on operations research, basic program evaluations and other prevention research from years 1-2.
  • Engage in targeted remapping as necessary to ensure that prevention investments meet need

Stigma and Discrimination

Using public health principles as a foundation, PEPFAR supports HIV prevention, care, and treatment activities as a mechanism to advance the rights of people who are marginalized, stigmatized, discriminated against, and denied access to essential care. Advances in expanding access to quality services in low-resources settings have highlighted the discrimination that still exists.

It is difficult to quantify the impact of stigma and discrimination.

 Kindergartener Binh Luom relaxes at home after school with his older brother and his mother. Thanks to the PEPFAR-supported Hanoi Legal Clinic, Binh and other HIV-positive children in Vietnam are able to attend school. Photo by Vietnam PEPFAR Team
There are no statistics to document the number of people denied access to care because of their HIV status, gender, or sexual orientation, or the number of people who choose not to go to a clinic because they face judgmental workers. However, anecdotal evidence exists. Stigma results in individuals not adhering to treatment because doing so will mean explaining to others exactly why they are taking medication. Fear of disclosure means that children stop receiving HIV services because their mothers can no longer pass off frequent clinic visits as routine pediatric monitoring. Such stories demonstrate why it is imperative for PEPFAR and its partner countries to provide impartial, science-based information, education, care and support services.

In order for PEPFAR to support countries in reducing stigma and discrimination, it will focus on the following activities over its next phase:

Emphasizing support for marginalized populations as an essential part of country engagement
As PEPFAR moves towards increased country ownership, discussions with government are addressing the need for health and social service structures that are responsive to all people living with and at-risk for HIV. Doing so will require policies that address the drivers of the epidemic in country and provide equitable access to quality services for marginalized populations. By demonstrating the public health benefits that result when prevention, care, and treatment are provided to otherwise stigmatized communities, PEPFAR is emphasizing the importance of a comprehensive, inclusive response.

Elimination of “double stigma”
PEPFAR trainings, guidance, programming, and engagement with countries will be geared to help with the identification and targeting of “double stigma.” This term refers to the stigma faced by people who are both HIV-positive and part of a marginalized population – for example, HIV-positive MSM, or HIV-positive IDUs. Quality care and treatment programs must be fully accessible to all subpopulations within the HIV-positive population. PEPFAR will work with the health care workers it supports to address the issues around adherence and retention in care that arise when people who are HIV-positive are unable to disclose their status in unsupportive communities.

Continued support for greater involvement of PLWHA
Since the early years of the epidemic, a major component of the HIV movement has been meaningful involvement of persons living with HIV. As PEPFAR increases engagement with countries, it will emphasize this principle as one that should be incorporated in planning, prioritization and implementation of national HIV programs. Greater involvement of intended recipients of services enables programs to be culturally appropriate and configured for optimal effectiveness. PEPFAR and its country teams will also improve their efforts to involve PLWHA and their input in all aspects of its work.

Continued support for greater involvement of persons from most-at-risk populations
PEPFAR will work to increase engagement with persons from most-at-risk or targeted populations in the planning and implementation of national HIV programs. Representatives from key populations should be included in all aspects of their programming.


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