An Overview of Combination Prevention

Introduction

  1. Definition of the Prevention Area

    In 2009, The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR): Five Year Strategy defined combination prevention as its major approach to HIV prevention, stating that:

    "Successful prevention programs require a combination of evidence-based, mutually reinforcing biomedical, behavioral, and structural interventions."

    This definition was expanded upon in a 2009 meeting of the Joint United Nations Programme on HIV/AIDS (UNAIDS) Prevention Reference Group and published in the 2010 UNAIDS Discussion Paper on combination prevention, in which combination programming was defined as:

    "...rights-based, evidence-informed, and community-owned programmes that use a mix of biomedical, behavioural, and structural interventions, prioritized to meet the current HIV prevention needs of particular individuals and communities, so as to have the greatest sustained impact on reducing new infections."

  2. Epidemiological Justification for the Prevention Area

    The goal of combination prevention is to reduce the transmission of HIV by implementing a combination of behavioral, biological, and structural interventions that are carefully selected to meet the needs of a population. Also, because individuals’ HIV prevention needs change over a lifetime, combination approaches help ensure that people have access to the types of interventions that best suit their needs at different times. Practitioners and researchers currently believe that combination approaches result in synergies in which the total effect of a set of carefully chosen interventions is greater than the sum of its parts, with a greater impact on reducing the transmission of HIV. This hypothesis, however, remains to be proven.

    Prevention programmers have used various models to attempt to identify the drivers of the epidemic, provide a guide on which mix of interventions would have the greatest impact, and give strategic choices on combination prevention approaches.

    Others caution against the use of models in making strategic prevention decisions, since models may provide outputs that fail to identify the key behaviors that drive an epidemic, and are difficult to fit to local epidemics that are heterogeneous across different locations. Therefore, models are a tool that should always be used in conjunction with other data sources to make programmatic decisions.

  3. Core Programmatic Components

    In August 2011, PEPFAR issued Guidance for the Prevention of Sexually Transmitted HIV Infections, and recommends a combination approach to prevention that includes three types of mutually reinforcing interventions:

    1. Biomedical interventions are those that directly influence the biological systems through which the virus infects a new host: for example, by blocking infection (e.g., male and female condoms), decreasing infectiousness (e.g., antiretroviral therapy as prevention), or reducing acquisition/infection risk (e.g., voluntary medical male circumcision).
    2. Behavioral interventions include a range of sexual behavior change communication programs that use various communication channels (e.g., mass media, community-level, and interpersonal) to disseminate behavioral messages designed to encourage people to reduce behaviors that increase risk of HIV and increase protective behaviors (e.g., risks of having multiple partners and benefits of using a condom correctly and consistently). Behavioral interventions also are aimed at increasing the acceptability of and demand for biomedical interventions.
    3. Structural interventions address the critical social, legal, political, and environmental enablers that contribute to the spread of HIV. PEPFAR describes structural interventions in terms of five categories addressing: legal and policy reform; stigma and discrimination against people living with HIV and marginalized groups; gender inequality and gender-based violence; economic empowerment and other multi-sectoral approaches; and education.

    The PEPFAR guidance goes into further detail on which core interventions (i.e., programs for prevention of mother-to-child transmission, voluntary medical male circumcision, condom promotion, and key populations and people living with HIV) should be prioritized and implemented based on UNAIDS’ “Four Knows,” (based on the principle "know your epidemic, know your response." The Four Knows bases selection and scale of interventions on epidemiological evidence, country context, knowledge of other donor programs, and national strategies. Additionally, prevention strategies should be assessed through impact evaluations.

    To achieve this, programmers should perform a gap analysis in their countries to determine which key drivers, geographical locations, and range of interventions are lacking; and then include those in their prevention portfolio to try and create synergy among them. To implement the interventions that would be most effective in the country’s context, the questions to ask when making prevention portfolio decisions are, “How much, when, and where?”

  4. Current Status of Implementation Experience

    Although the term “combination prevention” is relatively new, the concept itself is not. Countries experiencing HIV epidemics routinely implement complex packages of prevention interventions; yet the scale, intensity, and quality of these interventions is often insufficient. Furthermore, only a minority of programs include interventions designed to address structural drivers of the epidemic. Complex and successful programs have existed for some time in concentrated epidemics where service packages include biomedical, behavioral, and structural interventions; however, these approaches remain under-implemented and under-evaluated. Often, prevention portfolios are not adequately focused on the populations and behaviors that actually drive the epidemic, nor are they sufficiently well implemented in the locations where the risk behaviors are most likely to occur. Interventions need to be chosen based on the complexity of behaviors within populations, as well as how social and cultural norms influence sexual and health-seeking behaviors. However, current combination prevention programs are building on lessons learned and improving strategies to increase their impact on the epidemic.

    A number of countries are implementing combination prevention packages, including Botswana, India, Namibia, South Africa, and Uganda. Combination prevention is a portfolio approach for a given geographic area—whether at the national, state, district, or community level. It is not an individual implementing a partner-level approach, but involves a number of partners who contribute towards a combination prevention approach. Modeling can be used as a tool to identify the most cost-effective package of prevention interventions for different populations and in different settings.

UPDATED 10/2016

What We Know

Economics of Antiretroviral Treatment vs. Circumcision for HIV Prevention

Bärnighausen, T., Bloom, D., and Humair, S. Proceedings of the National Academy of Sciences (December 2012), 109(52): 21271–21276.

This article reported on a model developed and applied in South Africa to compare the health effects and costs of scaling up treatment as prevention (TasP), expanded antiretroviral therapy (ART), and medical male circumcision (MMC) to prevent new HIV infections and avert deaths. The researchers defined TasP (initiating ART at CD4 cell count >350/μL) and ART (initiating ART at CD4 <350/μL) according to the World Health Organization definitions, and included optimistic assumptions about the programmatic effectiveness of TasP. The model showed that high ART coverage plus high MMC coverage provided roughly the same reduction in new HIV infections as TasP and cost some USD$5 billion less from 2009 to 2020. MMC was more cost-effective than ART in averting new infections, and similar in cost per death averted. TasP was significantly less cost-effective than either MMC or ART. In this model, which included recurrent costs but not start-up costs, the most cost-effective approach for reducing HIV mortality was to scale up MMC and ART together. The authors concluded that although TasP has been heralded as a “game changer,” continuing to scale up MMC and ART could have the same impact at significantly lower cost.

Investigating Combination HIV Prevention: Isolated Interventions or Complex System

Brown, G., Reeders, D., Dowsett, G.W., et al. Journal of the International AIDS Society (December 2014), 18: 20499, doi: 10.7448/IAS.18.1.20499. 

The authors of this commentary drew on a scoping study of 496 published articles on combination prevention to identify gaps and inform future research to meet the ambitious 90-90-90 targets set in 2014 by the Joint United Nations Programme on HIV/AIDS (UNAIDS). They defined combination prevention as evidence-informed, simultaneous use of behavioral, biomedical, and structural HIV prevention strategies that are both synergistic and adaptable. The scoping study found that HIV prevention evaluation centered on three main themes: individual behavior change; isolated interventions; and limited implementation experience that allowed for adaptation. The authors noted that research on HIV prevention interventions generally looked at one intervention at a time, with little attention to the context, and that simply adding interventions missed opportunities to assess synergies that may accompany more strategic packaging. They said that gaps remained in evidence to inform strategic configuring of combination prevention; and urged recognition of combination prevention as a complex system whose interactions can amplify or multiply effects. Systems science approaches could offer analytic tools to assess these dynamics. The authors noted that partnerships are also vital to addressing the political and policy challenges of understanding these complex dynamics and using the evidence generated. Realizing the synergies needed to meet UNAIDS' bold agenda will require investment in systems approaches, partnerships, and openness to applying evidence to inform programs. 

Combination Prevention: A Deeper Understanding of Effective HIV Prevention

Hankins, C. A., & de Zalduondo, B. O. AIDS (2010), Vol. 24 (suppl 4), pp. S70–S80.

This paper provided an overview of combination prevention programs and described how to design and implement them to match each country’s unique social and epidemiological context. The authors underscored HIV prevention as a mainstay in the HIV response, and vital to keeping the epidemic at bay. They gave a historical perspective of HIV prevention and described how the field evolved into its current focus on combination prevention programs. Planning combination prevention programs begins with the “know your epidemic, know your response” motto devised by the Joint United Nations Programme on HIV/AIDS. Knowing your epidemic entails asking where the next 1,000 infections will come from instead of focusing on past prevalence rates. Knowing your response focuses on designing strategies by comparing predicted new infections to the current activities being implemented, to perform a gap analysis. The results of the gap analysis can help programmers develop a tailored approach appropriate for the social, cultural, and epidemiological context of a country, region, district, and/or community. The authors added that the evidence base for combination prevention programs is weak; investing in impact research and implementation science is vital to continue to refine and improve programs. They concluded by stating that long-term strategies, tailored to the immediate causes of vulnerability and underlying risk of populations, are necessary to curb the rate of the epidemic's growth.

Combination Implementation for HIV Prevention: Moving from Clinical Trial Evidence to Population-Level Effects

Chang, L.W., Serwadda, D., Quinn, T.C. et al. The Lancet Infectious Diseases (January 2013), 13(1): 65–76, doi: 10.1016/S1473-3099(12)70273-6. 

The authors of this review article argued that in addition to combination prevention, “combination implementation” is needed to realize substantial reduction in HIV incidence. They defined combination implementation as practical, specific use of evidence-informed approaches to support high, ongoing uptake and quality of HIV prevention interventions. The review outlined how cross-cutting strategies like task shifting, structural interventions, and demand creation can work with a range of specific interventions, including HIV testing and counseling, behavior change and condom promotion, linkage and retention in care, and voluntary medical male circumcision, among others. The article included a brief section examining the implications for key populations. The authors acknowledged that there is limited evidence on many of the individual interventions and strategies, and on the impact of implementing them in combination. However, they maintained that there is sufficient evidence to guide early interventions, and argued for rigorous implementation science and operational research to assess the impact and inform future combination prevention activities. They recommended using mixed methods for such assessments, and monitoring for potential synergistic or antagonistic effects; and cautioned that programs would need to be flexible to adapt to the findings of the assessments. They also noted that evaluation, implementation, and scale-up of combination prevention will require substantial investment. 

Combination HIV Prevention: Tailoring and Coordinating Biomedical, Behavioural and Structural Strategies to Reduce New HIV Infections, A UNAIDS Discussion Paper

Joint United Nations Programme on HIV/AIDS (UNAIDS). (2010).

This discussion paper outlines the advantages of implementing a combination prevention approach by using the synergies of behavioral, biomedical, and structural interventions. While there have been notable declines in HIV prevalence and incidence linked to behavioral changes in the population, improving these trends will require support for larger and more effective prevention programs. The paper defines combination prevention and outlines necessary steps for planning and implementing a coherent, evidence-informed, and rights-based approach. For planning, the paper highlights using an inclusive, transparent, evidence-informed process; identifying modes of transmission, geographic patterns, and populations; and developing a national plan for combination prevention. Implementation requires understanding and addressing political and capacity barriers and simutaneously working on coordination, quality, and efficiency.Finally, effective implementation requires investments in monitoring and evaluation. Combination prevention is an attempt to address not just the individual causes of vulnerability, but also the underlying social, cultural, legal, and structural causes. This approach requires identification of local solutions and development of coordinated, synergistic, and evidence-based responses; these must be both strategic and sustainable if they are to reach the goal of zero new infections found in many national HIV strategic plans.

Measuring the Potential Impact of Combination HIV Prevention in Sub-Saharan Africa

Khademi, A., Anand, S., and Potts, D., Medicine (September 2015), 94(37): e1453, doi: 10.1097/MD.0000000000001453.

The authors of this article reported on an HIV transmission model developed to assess the impacts of universal access to treatment, combined with scale-up of HIV education. The authors defined universal access to treatment as coverage of at least 80 percent of the population needing treatment, and considered HIV education inclusive of adherence to partner reduction and condom use. The analysis reported in this article focused on South Africa and examined the impact of two interventions on prevalence, incidence, and HIV-related deaths over 15 years. Findings showed that implementing the interventions in combination had a significantly larger impact (74% decrease in incidence over 15 years) than the sum of the impacts of implementing the two interventions individually (43% for universal access to treatment and 8% for scale-up of HIV education). Based on this model, the authors concluded that comprehensive combination HIV prevention could have a larger effect than disparate separate prevention interventions.  They recommended that policymakers planning combination prevention programs in sub-Saharan Africa prioritize achieving rapid universal access to treatment and improving condom use.

Putting it Into Practice

HIV Epidemic Appraisals for Assisting in the Design of Effective Prevention Programmes: Shifting the Paradigm Back to Basics

Mishra, S., Sgaier, S. K., Thompson, L. H., et al. PLOS ONE (March 2012),7(3): e32324, doi:10.1371/journal.pone.0032324. 

Program planners seeking to make strategic decisions on allocating scarce HIV prevention resources have traditionally used one of two approaches—numerical proxy and modes of transmission. The authors of this study examined the strengths and weaknesses of both approaches by applying them to diverse epidemics in six countries and six districts in India; and then assessing how the results of each approach would affect national- and district-level HIV policies. At the district level, they also tested an alternative qualitative approach called the “transmission dynamics epidemic classification.” The two traditional methods (numerical proxy and modes of transmission) generated different results that would affect HIV prevention policies at the country level. Similarly, at the district level, the two traditional approaches came to different conclusions on what populations were the key drivers of the epidemic. However, the transmission dynamics epidemic classification method found that all of the districts were defined as concentrated epidemics. These findings, the authors said, highlighted the limitations of the two predominant approaches that program planners use to develop their HIV prevention portfolios. Long-term strategies should be based on the local dynamics of an epidemic and its trajectory.

A Situational Analysis Methodology to Inform Comprehensive HIV Prevention and Treatment Programming, Applied in Rural South Africa

Treves-Kagan, S., Naidoo, E., Gilvydis, J.M., et al. Global Public Health (September 2015), 28: 1–19. 

This article reported on a community-based situational analysis conducted to inform design and implementation of a large, comprehensive HIV prevention program in rural North West Province, South Africa. The authors described the approach and its implementation to inform others wishing to use this approach in the future. They also assessed whether the method provided data that could be used to shape HIV programming, and whether it succeeded in engaging the community. The method entailed building community partnerships, conducting background research and field work, analyzing data, sharing results with the community, and incorporating findings into the program. The research team collected mainly qualitative data through 192 in-depth interviews, 17 focus groups, and 20 assessments. Research included questions about community characteristics, accessibility of HIV and tuberculosis prevention and treatment, stigma, sexual partnerships, and comprehensive assessments of services and programs. The methodology successfully and rapidly generated relevant, actionable, high-quality data from diverse stakeholders, although some key populations were challenging to reach. Partnerships with implementing partners, government agencies, and community stakeholders all contributed to building a strong foundation for ongoing collaboration. Balancing requirements of funders with community needs and research funding was challenging, underscoring the realities of donor-driven programming. The authors concluded that this approach can effectively engage stakeholders and guide the development of combination HIV prevention and care programming.

Evaluation of Large-Scale Combination HIV Prevention Programs: Essential Issues

Padian, N., McCoy, S., Manian, S., et al. Journal of Acquired Immune Deficiency Syndromes (October 2011), 58(2): e23–e28.

This commentary provided guidance on how to plan and implement evaluations to determine the impact of large combination prevention interventions. The authors stressed the need to meet numerous challenges in conducting evaluations for such interventions. These challenges included the need to have large population sizes and long-term follow-up if HIV incidence is the outcome of interest; absence of a naïve control group and ethical considerations with having a control group; and poor surrogate measures (for example, data on self-reported behaviors, sexually transmitted infections, and pregnancy cannot replace outcomes such as HIV incidence, prevalence, and infections averted). Large-scale evaluations should consider the following: defining the evaluable package; deciding if the evaluation is to study each individual intervention verses the entire package; choosing a “control” or “comparison” group in the study design; finding a reliable assay to measure HIV incidence when such an assay is currently lacking; deciding on various methods in one study; and providing shorter-term outcomes on longer-term goals. The authors concluded that a strong evidence base is crucial for combination prevention programs. The HIV community is open to the challenge, and is supporting it through current evaluations.

Community Mobilisation and Empowerment Interventions as Part of HIV Prevention for Female Sex Workers in Southern India: A Cost-Effectiveness Analysis

Vassall, A., Chandrashekar, S., Pickles, M., et al. PLOS One (October 2014), 9(10): e110562, doi: 10.1371/journal.pone.0110562, eCollection 2014.

This study assessed the cost-effectiveness of adding community mobilization (CM) and empowerment interventions to a core HIV prevention package for female sex workers (FSWs) to address broader societal, contextual, and structural factors that influence risk behavior. The study was conducted in two districts of Karnataka state, Bellary and Begaum, within an ongoing behavior change program for FSWs in India. The CM elements added included involving FSWs in program management and services, reducing violence, and addressing legal policies and police practices. A two-stage process estimated the incremental impact of CM and empowerment on HIV infections averted. The authors estimated that around one-third of the program's impact in these communities (31% in Bellary and 39% in Begaum) could be attributed to the CM elements. The incremental cost per disability-adjusted life year (USD$14.12 in Bellary and $13.48 in Begaum) was far lower than the World Health Organization threshold; when savings from antiretroviral therapy were included, the investments were cost-saving. The authors acknowledged that some of this cost-effectiveness may be attributable to the overall cost-effectiveness of HIV prevention interventions in India. However, they concluded that CM and empowerment are highly cost-effective, even cost-saving investments, and recommended that such interventions be considered as core components of HIV prevention for FSWs.

Prevention of HIV Infection for People Who Inject Drugs: Why Individual, Structural, and Combination Approaches are Needed

Degenhardt, L., Mathers, B., Vickerman, P., et al. The Lancet (July 2010), 376(9737): 285–301.

This review examined HIV prevention interventions among people who inject drugs (PWID). The authors searched sources such as the Cochrane Library, Evidence-Based Medicine Reviews, and drug and global health interventions to prevent HIV among PWID. For structural interventions, they searched PubMed, Medline, the Cochrane Review Library, and Embase. They also reviewed the reference lists of selected articles. The paper summarized current findings on needle and syringe programs, opioid substitution treatment, and antiretroviral treatment for HIV-positive PWID. These programs were found to achieve the greatest positive effect on preventing HIV among PWID. These three interventions were also modeled in various combinations and degrees of coverage, to explore their effects on HIV incidence. The authors concluded that no single intervention addressed all of the risk factors of PWID, which suggests that a combination prevention approach is necessary. 

Combination HIV Prevention Interventions: The Potential of Integrated Behavioral and Biomedical Approaches

Brown, J.L., Sales, J.M., DiClemente, R.J. Current HIV/AIDS Reports (December 2014), 11(4): 363–75, doi: 10.1007/s11904-014-0228-6.

This article considered combination HIV prevention approaches that bring together effective behavioral and biomedical strategies. The authors drew on a literature review to summarize efficacy and acceptability data for three biomedical HIV prevention approaches: microbicides, oral pre-exposure prophylaxis, and HIV vaccination. They also identified challenges with assessing acceptability, and reviewed factors associated with differential acceptability and uptake of the methods. Trials of microbicides and vaccines have shown limited or no efficacy in reducing the risk of HIV acquisition, the authors noted; and few randomized controlled trials or implementation science studies have assessed combination prevention. They offered suggestions for optimizing combination prevention for individuals and populations, and described the challenges of combining behavioral and biomedical approaches. They concluded that effective approaches for implementing and evaluating combination HIV prevention approaches are urgently needed.

Effectiveness of an Integrated Intimate Partner Violence and HIV Prevention Intervention in Rakai, Uganda: Analysis of an Intervention in an Existing Cluster Randomised Cohort

Wagman, J.A., Gray, R.H., Campbell, J.C. et al. Lancet Global Health (January 2015), 3(1): e-22–33, doi: 10.1016/S2214-109X(14)70344–4.

This article reported on a cluster-randomized trial assessing the effect of providing a combination of intimate partner violence (IPV) and HIV services on IPV incidence; shared risk factors for IPV and HIV; and individual incidence of HIV within an existing HIV surveillance community cohort in rural Uganda. The IPV intervention (Safe Homes and Respect for Everyone or SHARE) comprised community mobilization and IPV services; these were added to ongoing HIV prevention and treatment services. Primary endpoints were reported experience and perpetration of past-year IPV (emotional, physical and sexual); and laboratory-diagnosed HIV incidence. Data were collected at baseline and two follow-up intervals in four intervention regions and seven control regions. SHARE was associated with significant reductions in reported past-year physical and sexual IPV, and a decrease in HIV incidence at second follow-up. No changes were seen in perpetration of violence reported by men or reported alcohol use at sex, number of sex partners, or condom use. SHARE was the first study of behavioral interventions to show significant decreases in both IPV and HIV incidence. The authors suggested that these findings could inform other HIV programs' efforts to address IPV and HIV, and that SHARE could be considered standard of care for other HIV programs in sub-Saharan Africa.

Maximising the Effect of Combination HIV Prevention Through Prioritisation of the People and Places in Greatest Need: A Modelling Study

Anderson, S.J., Cherutich, P., Nilonzo, N., et al. The Lancet (July 2014), 384(9939):249–56, doi: 10.1016/S0140-6736(14)61053-9.

Noting the wide variation in HIV risk among communities within countries, this article reported on a mathematical model to assess whether focusing interventions on high-risk settings and populations could increase the impact of HIV prevention investments. Using Kenya as a case study, the model reflected the HIV epidemic’s evolution across time and settings, including demographic, behavioral, and programmatic variations. The authors modeled several HIV prevention interventions (male circumcision, behavior change communication, early antiretroviral therapy, and pre-exposure prophylaxis) for different populations based on location or specific risk behaviors. Using a set national budget, they then compared the effect of a program strategy that provided the same interventions throughout the country with a focused strategy that provided specific packages of interventions and resources based on epidemiological data. The uniform combination prevention approach could reduce the number of HIV infections by 40 percent over 15 years. A focused strategy could increase this effect by 14 percent using the same resources. Depending on the program costs and level of investment, the focused approach could add a substantial number of HIV cases averted. The authors concluded that prioritizing people and settings at high risk of HIV, and tailoring programs to meet their specific needs, could result in significant improvements in the efficiency and impact of resources for HIV prevention.

Tools and Curricula

Guidance for the Prevention of Sexually Transmitted Infections

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

The August 2011 guidance aims to help PEPFAR country teams to identify the best combination of HIV prevention strategies, based on country-specific epidemiology. It describes the overarching principles for prevention programs, and then summarizes the evidence base and implementation guidelines for specific interventions. Biomedical interventions included in the guidance are male and female condoms, voluntary medical male circumcision, HIV testing and counseling, diagnosis and treatment of sexually transmitted infections, and antiretroviral drug-based prevention. Behavioral interventions include the different channels of communication (e.g., mass media, community-level, interpersonal) and types of messages (e.g., addressing multiple partners, intergenerational and transactional sex, and alcohol use). The document also details creating demand for biomedical services. The structural interventions described address legal and policy reforms; stigma and discrimination against people living with HIV and marginalized groups; gender inequality and gender-based violence; education; and economic empowerment and other multisectoral approaches. The guidance also includes comprehensive packages for: key populations; positive health, dignity and prevention for people living with HIV; and prevention interventions for young people.

Technical Guidance on Combination HIV Prevention, Men Who Have Sex with Men

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

This guidance was developed in response to PEPFAR’s second five-year strategy, which outlines priorities and plans for countries that implement HIV programs. The guidance is one component of an effort to support comprehensive combination prevention programs. It was found in a review that men who have sex with men (MSM) are 19 times more likely to have HIV compared to the general population. PEPFAR is working to ensure that key populations, including MSM, are a prevention priority in epidemics where MSM are shown to be key drivers of transmission. The guidance reviews the evidence base for HIV prevention programs with MSM, and supports five key elements of a comprehensive response: community-based outreach; distribution of condoms and condom-compatible lubricants; HIV testing and counseling; active linkages to health care and antiretroviral treatment; targeted information, education, and communication; and prevention, screening, and treatment for sexually transmitted infections. The document describes how to support effective HIV prevention for MSM, and offers key points on how to optimize prevention programs. PEPFAR budgets will support implementation, training, collection, and use of strategic information, research, monitoring and evaluation, and commodity procurement of/for MSM programs. Additional resources are listed at the end of the document to provide PEPFAR country teams with information that may be useful for strategizing their MSM combination prevention portfolios.

Comprehensive HIV Prevention for People Who Inject Drugs, Revised Guidance

U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) (2010).

This guidance was updated in response to the Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis and Malaria Reauthorization Act of 2008, signed into law in July of that year. PEPFAR supports three core elements in comprehensive HIV prevention programming for people who inject drugs (PWID): community-based outreach programs, sterile needle and syringe programs, and drug dependence treatment, including medication-assisted treatment with methadone or buprenorphine and/or other effective medications. These elements are globally recognized as best practices with populations of PWID, and are endorsed by diverse international organizations. An estimated 5 million PWID live in the 13 countries where PEPFAR supports HIV prevention programs, mostly in Eastern Europe and East and Southern Africa. The sexual partners of PWID are also at risk of acquiring HIV, and act as a bridge population to groups that conduct less-risky behaviors, which can fuel the epidemic. Therefore, the evidence base for programs for PWID supports a comprehensive HIV prevention program that includes behavioral, biomedical, and structural interventions as a means to reduce HIV transmission. The guidance includes 10 core interventions. PEPFAR recommends choosing a combination of these 10 interventions, based on the epidemiological, social, legal, and cultural environment of the country and region, and implemented with a human rights approach.

Fast-Tracking Combination Prevention: Towards Reducing New HIV Infections to Fewer Than 500 000 by 2020

Joint United Nations Programme on AIDS (UNAIDS) (2015). 

This paper lays out the rationale and specific actions for fast-tracking combination HIV prevention to meet the UNAIDS target of reducing new HIV infections to fewer than 500,000 by 2020. Each section synthesizes and presents key epidemiological, clinical trial, and programmatic data; and uses examples and graphics to illustrate key points. The paper focuses on HIV prevention in adolescents and adults, and is broken down into six sections: commitment, focus, synergies, innovation, scale, and accountability. National commitments to HIV prevention need to be renewed through a focus on specific targets and resources, including program packages for policymakers to consider. Efforts should focus on key locations, priority populations, and high-impact programs and interventions. Synergies can be found in HIV prevention packages tailored to specific user groups and settings; the document provides examples for high-prevalence settings in southern Africa for men who have sex with men, young women and their male partners, people who inject drugs, and sex workers. It describes innovations in prevention tools, delivery approaches, and integration, including medical male circumcision, pre-exposure prophylaxis, digital social media, and cash transfers. Using examples, the paper underscores the importance of delivering products and programs at scale and with the intensity needed for impact. It concludes with an accountability framework that can be used to ensure that each program does its part and has the appropriate resources to do so.