ART as an HIV Prevention Strategy


  1. Definition of the Prevention Area

    Antiretroviral (ARV) drugs, used to improve the health of people living with HIV, have also been shown to reduce HIV transmission to HIV-negative people. By reducing viral load in the HIV-positive partner, ARV drugs have been shown to lower the risk of HIV transmission to the uninfected partner. Similarly, some recent studies of pre-exposure prophylaxis have suggested that ARV drugs may reduce transmission, even when taken by HIV-negative persons at risk for HIV infection. The topic of pre-exposure prophylaxis is covered in another Prevention Knowledge Base.

  2. Summary of the Evidence

    HIV circulates at high levels in blood, semen, vaginal fluids, and breast milk in HIV-positive people who are not taking ARV drugs. Effective ARV therapy (ART) lowers HIV levels in these fluids, often below the limit of detection of standard viral load assays. Antiretroviral drugs reduce HIV levels in pregnant and breastfeeding women enough to significantly lower the risk of mother-to-child transmission. Multiple observational studies have provided evidence that a lower viral load—and ART to lower one’s viral load—decrease the chance of HIV transmission. These data informed the development of several clinical trials to determine ARVs’ effect on HIV transmission at individual and population levels. One published trial, HIV Prevention Trials Network (HPTN) 052, reported the HIV transmission rates between serodiscordant partners randomized to have the HIV-positive partner start ART immediately or wait until his/her CD4 count fell below 250 cells/mm3. In this trial, authors reported a 96 percent reduction in the risk of HIV transmission that could be genetically traced to the index partner (approximately 18 percent of new infections came from outside the partnership; see Eshelman et al. 2011) among those who started treatment immediately. The effect was so strong that the trial’s data safety and monitoring board recommended that all couples in the study be offered early treatment initiation.

  3. Core Programmatic Components

    The expanded use of ART in persons living with HIV as a tool to reduce HIV incidence among uninfected individuals has exciting potential, because ARV drugs also have the benefit of reducing morbidity and mortality in persons diagnosed with HIV. However, despite the encouraging results reported by HPTN 052, additional research and debate on policy and community implications are needed to identify the best approaches to implementation. To truly maximize the prevention benefit from HIV treatment, programs must ensure that:

    1. People are tested for HIV and linked to care and treatment programs
    2. HIV-diagnosed individuals agree to start ART
    3. ARV drugs are available and affordable
    4. Patients started on ART are retained in care and remain adherent to treatment
    5. Patients on ART do not engage in more risky behavior as a result of starting treatment.

    While there have been impressive strides in expanding access to HIV treatment worldwide, improving the tolerability and acceptability of ARV drugs, and supporting ongoing patient retention and adherence, a number of issues must be considered as additional data from ongoing trials become available:

    • Who are the most appropriate target populations? Who should be prioritized if resources are limited?
    • What are the best ways to educate health workers and target populations on the benefits of HIV treatment?
    • As demand increases, how will we ensure uninterrupted stocks of ARV drugs?
    • What messages should we convey to improve uptake of testing, linkage to care, and lifelong adherence to ART?
  4. Current Status of Implementation Experience

    Since their inception, HIV treatment programs have been contributing to HIV prevention. However, many treatment programs still prioritize treating people who have the lowest CD4 counts. As HIV viral load—and risk of transmission—is highest during acute infection and with lower CD4 counts, this is one strategy to maximize the prevention benefit of ART with limited resources. The additional prevention benefit from expanding ART to people living with HIV in discordant relationships and at higher CD4 counts is currently under study. Treatment-as-prevention programs are being evaluated in several ongoing trials around the world—most notably in Botswana, Malawi, Mozambique, South Africa, Tanzania, Uganda, the United States, and Zambia—either separately or as part of combination prevention packages. HPTN 065 in the United States is exploring the strategy in two cities: New York, NY (specifically, the Bronx), and Washington, DC. The HPTN 052 study trial sites in Brazil, India, Malawi, Thailand, the United States, and Zimbabwe are continuing to offer all study couples early initiation of treatment and will follow them until the planned end date of 2015.

UPDATED 8/2015

What We Know

Prevention of HIV-1 Infection with Early Antiretroviral Therapy

Cohen, M. S., Chen, Y. Q., McCauley, M., et al. New England Journal of Medicine (2011),365(11): 493–505.

This article reported expanded demographic and clinical information from the HIV Prevention Trials Network 052 trial, whose interim findings revealed a 96 percent reduction in the risk of HIV transmission among participants who had a CD4 count between 350 and 550 cells per cubic millimeter (cells/mm³) and received antiretroviral therapy (ART) upon entering the trial. Over half of the participating serodiscordant couples (54 percent, or 954 couples) were from Africa, 531 from Asia, and 278 from the Americas; 50 percent of the infected partners were men. Enrollees were randomized to receive ART immediately upon testing positive or to delay therapy until their CD4 counts dropped below 250 cells/mm³ or they acquired an AIDS-related illness. Of the total of 39 HIV transmission events, 35 occurred among participants in the delayed arm. A total of 61 percent of the 28 “linked” events occurred among individuals whose partner had a CD4 count greater than 350 cells/mm³, and 64 percent of HIV transmissions were from female to male partners. Individuals in the immediate treatment arm experienced a 41 percent lower risk of a clinical event than those in the delayed arm. According to the authors, the most likely mechanism in preventing HIV-1 transmission was sustained suppression of HIV-1 in genital secretions—the result of ART.

Adherence to Early Antiretroviral Therapy: Results from HPTN 052, a Phase III, Multinational Randomized Trial of ART to Prevent HIV-1 Sexual Transmission in Serodiscordant Couples

Safren, S.A., Mayer, K.H., Ou, S.S., et al. Journal of Acquired Immune Deficiency Syndrome (2015), 69(2): 234–40, doi: 10.1097/QAI.0000000000000593.

This article evaluated predictors of adherence to antiretroviral medication among 886 HIV-1-positive subjects who were offered early antiretroviral treatment (ART) as HIV prevention in the HPTN 052 trial. Participants received couples and adherence counseling. Adherence to medication was measured using an interviewer-administered adherence questionnaire and pill counts. Psychological variables were collected at every quarterly visit. Adherence percentage was determined by dividing the total number of pills taken by the total number of pills that should have been taken since ART initiation. Based on pill count, 82 percent and 83 percent of participants, respectively, were adherent (defined as ≥ 95 percent level) in the first month and one year after ART initiation. The most common reasons for non-adherence at year one were omission (45 percent), diversions (21 percent), travel (23 percent), and pill shortage (14 percent). A higher mental score measured by a quality life questionnaire was significantly associated with better adherence. Self-reported adherence score and pill count adherence ≥ 95 percent were significantly associated with viral suppression. The authors concluded that treatment adherence is optimized when evidence-based couple counseling is an integral part of ART provided the counseling explains benefits to the sexual partner and offers information on viral suppression.

Antiretroviral Therapy for Prevention of HIV Transmission in HIV-Discordant Couples

Anglemyer, A., Rutherford, G. W., Horvath, T., et al. Cochrane Database Systematic Reviews (2013), Vol. 4, CD009153. doi: 10.1002/14651858.CD009153.pub3.

The review explored the efficacy of using antiretroviral therapy (ART) as a prevention strategy for reducing HIV transmission in discordant couples when the HIV-positive partner was taking ART. All randomized controlled trials, case-control, and cohort studies were included. Ten studies were included in the review: one randomized controlled trial and nine observational studies. The randomized controlled trial comparing immediate versus delayed treatment of serodiscordant couples showed a reduced risk of HIV transmission from infected to uninfected partners. In eight of the nine cohort studies, similar results were observed. Only one observational study showed an increased risk which was not statistically significant. Data from the randomized trial (HPTN 052) showed a greater risk reduction among infected partners with CD4 count between 350 and 550 cells/µL.The studies in the review confirmed the benefit of treating the HIV-positive person in discordant couples with ART to reduce HIV transmission to the uninfected partner. The authors noted that implementation challenges remain, as do unanswered research questions such as the durability of protection, toxicity, and transmission of ART-resistant strains to partners.

Systematic Review of HIV Transmission between Heterosexual Serodiscordant Couples where the HIV-Positive Partner is Fully Suppressed on Antiretroviral Therapy

Loutfy, M.R., Wu, W., Letchumanan, M., et al. PLOS One (2013) 8(2): e55747, doi: 10.1371.

This paper described a systematic review to assess the risk of heterosexual transmission between serodiscordant couples when the HIV-positive partner has undetectable viral load level under combination antiretroviral treatment (ART). Only three cohort studies from a review of 20,252 citations included viral load suppression data at the time of HIV transmission among 991 heterosexual couples from Brazil, Spain, and Uganda, for a total of 2,064 person-years of follow-up (PYF). Two cohort studies and a randomized controlled clinical trial (the HPTN 052 study) were included for secondary analysis. These studies reported unconfirmed viral load at the time of HIV transmission among 6,070 couples from various African countries, Brazil, India, Thailand, and USA, for a total of 8,170 PYF. The pooled HIV transmission rate from the three studies with confirmed viral suppression at the time of HIV transmission was 0 per 100 PYF. The pooled transmission for all six studies, regardless of confirmation of viral suppression at time of transmission, was 0.14 per 100 PFY. The authors concluded that despite the lack of data on same-sex couples and type of sexual intercourse, unprotected sexual intercourse is a viable option for heterosexual serodiscordant couples in monogamous relationships if the HIV-infected partner has undetectable viral load under combination ART.

ARVs as HIV Prevention: A Tough Road to Wide Impact

Shelton, J.D. Science (2011), 334: 1645–1646.

This two-page article heralded the potential use of antiretrovirals (ARVs) as an HIV prevention measure in a combination approach. The author cautioned against wide-scale implementation of ARVs as an HIV prevention method until challenges and research questions are addressed. The challenges include identifying individuals most in need, missing individuals in the acute phase of disease, increasing adherence, reducing drug resistance and toxicity, and limiting risk compensation. Current ARV programs have difficulty meeting the current needs of populations, and the expansion of ARV as a prevention approach may place excessive stress on existing programs. The author concluded that ARV programs should prioritize people who are positive but untreated, HIV-positive pregnant mothers, and those at higher risk of acquisition and transmission of HIV, such as sex workers and people who inject drugs. There are limited funds for HIV programs; therefore, an incremental and balanced prevention approach should be implemented.

Treatment as Prevention – Where Next?

Hull, M., Lange, J., Montaner, J.S. Current HIV/AIDS Reports (2014),11(4): 496–504, doi: 10.1007/s11904-014-0237-5.

This paper outlined findings justifying the use of antiretroviral therapy (ART) for the prevention of onward HIV transmission and the proposed Joint United Nations Programme on HIV/AIDS (UNAIDS) post-2015 Millennium Development Goal 90-90-90 Antiretroviral Therapy Target. This target proposes that by 2020, 90 percent of all people living with HIV will be aware of their HIV status; 90 percent of all people with diagnosed HIV infection will be treated with sustained ART; and 90 percent of all people on ART will have durable viral suppression. Realizing this goal will result in virological suppression for 73 percent of all people living with HIV worldwide. The paper also described the evidence needed to justify causality for ART use and prevention of onward HIV transmission. The authors used the British Columbia ART Program to propose the use of the HIV cascade of care as a framework of evaluation of all HIV care programs and the ongoing need to monitor and ensure availability of commodities like testing kits, antiretroviral drugs, and laboratory supplies, along with adequate health care staff. The authors concluded that given the primary benefits of ART and lower HIV transmission associated with a strong cascade of care, efforts must be directed to expanding treatment programs worldwide to meet UNAIDS Development Goal Targets.

Community Viral Load as a Measure for Assessment of HIV Treatment as Prevention

Miller, W.C., Powers, K.A., Smith, M.K., et al. Lancet Infectious Diseases, (2013),13(5): 459–64, doi: 10.1016/S1473-3099(12)70314-6.

The paper discussed the limitations and potential biases of the concept of community viral load, which has been proposed as a measurement for monitoring HIV treatment uptake and quantifying its effects on transmission. The authors argued that data available to measure community viral load and its link to HIV incidence are inadequate. The community viral load is subject to selection bias and is more likely to miss those with acute and early infection, the authors said. Further, it is a suboptimum measure of the potential for HIV transmission in a community, because it is a composite measure and thus does not depict the combination of factors that define the risk of transmission. Lastly, although associations between community viral load and new HIV infections might be explained by reduced infectiousness of individuals under antiretroviral treatment, these links are also affected by factors at the individual and population levels (e.g., combination prevention for injecting drug users). The authors recommended alternative measures, such as population-based sampling with a viral load greater than a pre-specified cutoff, or a viral load of more than 400 or 1,000 copies per ml. They suggested future studies to address the strengths and weaknesses of community viral load and other proposed measures for the monitoring of antiretroviral therapy in HIV prevention.

Antiretroviral Therapy in Prevention of HIV and TB: Update on Current Research Efforts

Granich, R., Gupta, S., Suthar, A. B., et al. Current HIV Research (2011),9(6): 446–469.

The paper reviewed literature on antiretroviral therapy (ART) as prevention for HIV and tuberculosis (TB) to provide information for policy development and future planning initiatives. The search included all research articles and studies that evaluated how ART was used in programs to reduce HIV and TB morbidity, mortality, risk behaviors, and HIV incidence and transmission. A total of 50 studies were included, covering 52 different countries in North America (20), Africa (22), Asia (4), Europe (1), and multiple country sites (3). Twenty-four studies were randomized controlled trials. A number of research studies are being conducted and planned in this area, with wide variations in methodology, interventions, and geographical location across the studies. The review found strong support for ART as a prevention method. However, the authors said that many questions remain, such as when to begin ART, the overall impact of ART on HIV and TB prevention at the population level, and how to improve ART coverage.

Modeling the Impact on the HIV Epidemic of Treating Discordant Couples with Antiretrovirals to Prevent Transmission

El-Sadr, W. M., Coburn, B. J., and Blower, S. AIDS (2011),25(18): 2295–2299.

The authors applied mathematical modeling to the results of the HIV Prevention Trials Network 052 study to predict the effect of treating discordant couples with antiretroviral therapy (ART) to prevent HIV transmission and reduce overall incidence levels. They also explored the number of infections prevented in relation to ART coverage. Country-level data on HIV prevalence, population size, and discordancy rates from Ghana, Lesotho, Malawi, and Rwanda were used in the model. Analysis showed that reductions in annual incidence rates were highest in Lesotho, moderate in Malawi, and low in Rwanda and Ghana; while the annual number of infections averted was highest in Malawi, high in Ghana, and low in Lesotho and Rwanda. The model showed that ART use by discordant couples was most effective in reducing annual incidence rates and averting HIV infections in Malawi. The annual number of infections prevented was low in Lesotho and Rwanda, but reductions in annual incidence rates were higher in Lesotho than Rwanda. Overall, treatment had a greater effect in reducing annual incidence rates in populations with a higher proportion of stable partnerships. The model illustrated the complexity of gauging which country would be most able to reduce annual infection and incidence rates based on expanding ART coverage.

HIV Treatment as Prevention: Contradictory Perspectives from Dynamic Mathematical Models

Wu, J., Norris, J.L., Jia, Y., et al. Scientific World Journal (2014), doi: 10.1155/2014/760734, E-publication.

This article used mathematical models to examine the complex effects of antiretroviral therapy (ART) on HIV transmission based on the dynamics of such variables as risk behaviors, drug resistance, initiation and uptake of ART, and the role of these variables in different settings. The authors argued that the preventive effectiveness of ART varies with changes in treatment parameters such as initiation time, adherence, drug resistance, coverage, and efficacy of treatment. HIV testing and risk behaviors also affect prevention of new infections. The authors said that conclusions on whether a disease will be eliminated or eradicated should be based on real and practical input parameters. They concluded that HIV antiretroviral drugs as treatment cannot eliminate HIV epidemics, even given achievements under real field conditions. Combination prevention methods are still warranted in high-endemic resource-limited settings, the authors added; and there are still some challenges to using HIV treatment as prevention.

Putting it Into Practice

HIV-1 Treatment as Prevention: The Good, the Bad, and the Challenges

Smith, K., Powers, K.A., Kashuba, A.D., et al. Current Opinion in HIV and AIDS (2011),6(4): 315–325.

The authors analyzed current findings on the impact of antiretroviral therapy (ART) on HIV prevention, and discussed the benefits and implementation challenges of deploying ART as a preventive strategy. ART as a prevention method will be key to future programs, the authors said; but more needs to be understood before a universal roll-out. For example, more research is needed on how ART affects male and female genital tracts and rectal mucosal tissue. HIV-1 replication continues in these areas despite viral suppression in the blood, which affects transmission. Drug resistance is another concern if more individuals are initiated on ART. Observational studies in serodiscordant couples, community-level ecological studies, and mathematical modeling demonstrate solid findings in favor of ART as a prevention method, but limitations still need to be addressed. As programs are implemented, managers will need answers to questions about how to increase HIV and CD4 testing to identify those most in need, and how to provide optimal treatment during the early stages of HIV.

Retention in HIV Care between Testing and Treatment in Sub-Saharan Africa: A Systematic Review

Rosen, S., and Fox, M.P. PLOS Medicine (2011),8(7), doi: 0.1371/journal.pmed.1001056

This systematic review examined attrition rates in the continuum of care between the time when individuals test positive for HIV and the time when they are linked to care and treatment services. People living with HIV (PLHIV) are lost at various points along this continuum, and understanding the reasons behind this loss is vital to improving health outcomes among PLHIV. In their review, which focused on sub-Saharan Africa, the authors defined three stages delineating the time from: (1) HIV testing to obtaining CD4 count results; (2) designation as enrollment to pre-ART care until eligible to ART; and (3) designation as ART-eligible to initiating ART. Of the 28 articles included in the review, 20 studied only one stage, six addressed two stages, and two addressed all three stages. Median patient retention in stage 1 was 59 percent (35 to 88 percent); in stage 2, 46 percent (31 to 95 percent), and in stage 3, 68 percent (14 to 86 percent). Thus, there are great challenges in following healthy PLHIV to ensure initiation to treatment services that could span a long period of time. A limitation to the review was the wide variation in how studies defined and measured entry points to care and treatment. The authors recommended that researchers standardize language to allow the public health community to generalize across studies.

Treatment to Prevent HIV Transmission in Serodiscordant Couples in Henan, China, 2006 to 2012

Smith, M.K., Westreich, D., Liu, H., et al. Clinical Infectious Diseases (2015), 61(1): 111–119, doi: 10.1093/cid/civ200, E-publication.

This report assessed how well antiretroviral therapy (ART) works under the Chinese health care system, in which HIV-positive patients are often managed by non-physician clinicians. From 2006 to 2012, 4,916 HIV-serodiscordant couples were enrolled in an open cohort to measure time to HIV seroconversion in the initially uninfected partner. All HIV-positive index partners were treatment-naïve at baseline. The overall incidence rate (IR) was 0.59 cases per 100 person-years (PY); and of 157 seroconversions, 84 happened after the index partner began ART (IR = 0.43/100 PY) and 73 before treatment (IR = 5.87/100 PY). Stratified analyses showed that ART conferred a modest protective effect in the early phase from 2006 to 2008, when second-line ART was not available (hazard rate or HR = 0.68) and a greater effect in the later period from 2009 to 2012 (HR = 0.33). Transmission was lower for index partners initiating ART at higher CD4 counts (HR = 0.41[≥ 250 cells/mm3], versus 0.98 at CD4 counts below 250 cells.mm3). The authors concluded that the benefits of ART will depend on the availability of well-tolerated antiretroviral drugs, a strong health care infrastructure, and good adherence to medication.

Is Expanded HIV Treatment Preventing New Infections? Impact of Antiretroviral Therapy on Sexual Risk Behaviors in the Developing World

Venkatesh, K. K., Flanigan, T. P., and Mayer, K. H. AIDS (2011), 25(16): 1939–1949.

The review explored the link between antiretroviral therapy (ART) initiation and risky sexual behaviors. Eight cross-sectional and nine observational cohort studies were included in the review, all of which were conducted in developing countries. All but one of the studies found a decrease in sexual risk-taking after ART initiation. The authors noted that the majority of patients on ART decreased their reported risky sexual behaviors after treatment, but a sizable minority still engaged in risky behaviors. The patients who engaged in risky behaviors had common characteristics, including the type of partner (causal, spouse, seroconcordant), desire for children, psychosocial factors (depression, drug use), and membership in higher-risk populations (men who have sex with men, injecting drug users); and these factors need to be addressed through behavior change programs within the treatment setting. A limitation in these studies was that patients on treatment had access to resources that encourage healthier sexual behavior, such as risk-reduction counseling, support groups, and ongoing care. Other patients may not have access to such resources. Using ART as a prevention method is a viable option, but the limitations and challenges of this approach should not be ignored.

Antiretroviral Therapy Refusal among Newly Diagnosed HIV-Infected Adults

Katz, I.T., Essien, T., Marina, E.T., et al. AIDS (2011), 25(17): 2177–2181.

South Africa’s treatment goal in the national strategic plan is to provide antiretroviral therapy (ART) to at least 80 percent of treatment-eligible clients. To reach this goal, it is necessary to understand the challenges of expanding treatment to those who are eligible, including those who refuse treatment. The authors examined data on adults who tested positive for HIV at the Perinatal HIV Research Unit in Soweto and were eligible for treatment based on CD4 counts. There were 7,287 clients who presented for voluntary counseling and testing, of whom 2,562 clients (35 percent) tested positive. Of those who tested positive, 743 (29 percent) were eligible to start treatment, but 148 (20 percent) refused. Multiple logistic regressions showed that those who refused were more likely to be single and to have active tuberculosis, compared to those who accepted treatment. Social workers recorded the reasons for refusal; the most common reason was “feeling healthy” followed by inability to disclose status, drug side effects, inability to adhere to drugs, cultural beliefs, and stigma. Increasing voluntary counseling and testing and drug availability, and reducing cost of drugs, are not the only factors in expanding treatment, the authors concluded. Promoting ART as a life-saving and safe method will be necessary to encourage all eligible individuals to accept treatment.

Triple Antiretroviral compared with Zidovudine and Single-dose Nevirapine Prophylaxis during Pregnancy and Breastfeeding for Prevention of Mother-to-Child Transmission of HIV-1 (Kesho Bora study): A Randomized Controlled Trial

Kesho Bora Study Group. Lancet Infectious Diseases (2011), 11(3): 171–180.

This paper reported results from a multicenter randomized controlled trial that assessed HIV -free infant survival at 6 weeks and 12 months among HIV-positive pregnant mothers randomized to either triple antiretroviral (ARV) prophylaxis or zidovudine and single-dose nevirapine. All infants received a single dose of nevirapine at birth and, beginning December 2006, zidovudine for one week after birth. From 2005 to 2008, 824 HIV-positive women were randomized and gave birth to 805 singleton or first live-born infants. The overall rate of HIV transmission at six weeks was 3.3 percent in the triple ARV group and 5 percent in the zidovudine and single-dose nevirapine group. The transmission rate at 12 months was also lower in the triple ARV group (5.4 percent) than in the zidovudine and single-dose nevirapine (9.5 percent). In breastfed infants, the rate of transmission at 12 months was significantly lower (5.6 percent) in the triple ARV group as compared to the zidovudine and single dose nevirapine group (10.7 percent). The authors concluded that triple antiretroviral prophylaxis during pregnancy and postpartum breastfeeding is safe and reduces HIV transmission from mother to child. This finding aligns with current World Health Organization guidelines, which recommend antiretroviral treatment to pregnant and breastfeeding women living with HIV to prevent mother-to-child transmission.

Economics of Antiretroviral Treatment vs. Circumcision for HIV Prevention

Bärnighausen, T., Bloom, D.E., and Humair, S. Proceedings of the National Academy of Science of the United States of America (2012),109(52): 21271–6, doi: 10.1073/pnas.1209017110.

The authors used modeling to assess whether treatment as prevention (TasP) is a "game changer" in the HIV field, or if similar outcomes are obtainable at comparable cost by increasing coverage of medical male circumcision (MMC) and antiretroviral therapy (ART) at CD4 count <350 cells/mm3. They modeled behavioral and biological variables in the South African context between 2009 and 2020. TasP was the most expensive of the three interventions, followed by increases in ART coverage and then by increases in MMC coverage. The cost per infection averted was U.S. $8,375 for TasP, $6,790 for ART, and $1,096 for MMC; the cost per death averted was $7,739 for TasP, $5,604 for ART, and $5,198 for MMC. The models also showed that the most cost-effective prevention scenario for both infections and deaths averted was 50 percent ART and 60 percent MMC coverage. Considering infections averted alone, the most cost-effective scenario was 50 percent ART and 80 percent MMC coverage. These results suggested that the priority should be to increase intervention coverage first of MMC, followed by ART and lastly TasP. The authors concluded that higher priority should be given to MMC scale-up, and that TasP is an effective HIV prevention intervention but not a game changer, and could be delayed during intensive scale-up of MMC and ART.

Tools and Curricula

Guidance for the Prevention of Sexually Transmitted Infections

U.S. President’s Emergency Plan for AIDS Relief (2011).

The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) guidance provides PEPFAR country teams with the latest scientific data on prevention programs to increase the impact of their country portfolios. Prevention programs should be tailored to the country's epidemiological and social context, and should optimize existing programs implemented by other partners to help fill gaps. The guidance highlights the importance of knowing the country’s epidemic, context, response, and costs; and ensuring that HIV prevention is part of a comprehensive national response. It also outlines current evidence and program activities that PEPFAR funds will support. The section on antiretrovirals for prevention discusses post-exposure prophylaxis, treatment as prevention, and pre-exposure prophylaxis. The evidence section outlines the findings from past observational studies that demonstrated reduced HIV transmission between serodiscordant partners; these studies were confirmed by findings from the randomized controlled trail, HIV Prevention Trial Network 052, in July 2011. PEPFAR recommends that country programs identify discordant couples as soon as possible to link them to prevention, care, and treatment services. Programs should consider early treatment for people living with HIV whose CD4 count is 350 cells/μL or lower and who are in discordant couples.

Additional Resources

Debate Six: Treatment as Prevention

World Bank and U.S. Agency for International Development (2012).

This report outlined the sixth in the Emerging Issues in Today’s HIV Response debate series sponsored by the World Bank and the U.S. Agency for International Development. In November 2011, a panel of four renowned public health experts—two each assigned to argue for and against—addressed this proposition: countries should spend a majority of what is likely to be a flat or even declining HIV prevention budget on treatment as prevention (TasP). The topic was inspired by the findings of the recent HIV Prevention Trial Network (HPTN) 052 clinical trial of serodiscordant couples, showing that early treatment reduces the risk of HIV transmission to an uninfected partner by at least 96 percent. The two panelists favoring the proposition said that given the overwhelming evidence for the effectiveness of TasP, ethical principles require its rapid implementation as part of comprehensive HIV prevention and care programming. The opposing panelists countered that despite HPTN 052’s powerful results, a blanket recommendation to launch TasP is premature, because there are still too many unanswered questions about its long-term effects in different populations. They also argued that each country’s response to HIV should be driven not by a single programming imperative but by the specific characteristics and prevention needs of the local epidemic. More than 800 people worldwide registered to attend the debate either in person in Washington, via the Internet, or by video conferencing.