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.
Over the next phase, PEPFAR's prevention response will be guided by the following concepts:
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.
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:
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.
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.
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.
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.
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.
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.