Definition of the Prevention Area
Positive health, dignity, and prevention (PHDP) helps people living with HIV lead a complete and healthy life and reduce the risk of transmission of the virus to others. PHDP is characterized by its systematic delivery of a range of combination, behavioral, and sociocultural services within local communities.
Epidemiological Justification for the Prevention Area
As of 2008, an estimated 33 million people worldwide were living with HIV. Advances in HIV treatment have dramatically improved the life expectancy and quality of life of people living with HIV (PLWH). In some settings, expanded access to HIV testing and antiretroviral therapy (ART) has helped to transform HIV into a chronic disease. These advances magnify the urgent need to decrease HIV transmission, including for serodiscordant couples in which one partner is infected with HIV and the other is not. According to a 2008 study in Uganda, 40 percent of the cohabitating PLWH had an HIV-negative spouse. Most of the HIV-infected adults had been sexually active in the last year, and the overwhelming majority reported having unprotected sex with their married or cohabiting partner. Well over half of new HIV infections occurred among serodiscordant marital or cohabiting relationships. As PLWH live longer, it becomes increasingly important to promote safer sex and drug injection practices and to reinforce the role of every individual, HIV-positive or HIV-negative, in preventing the spread of HIV. In order to best use limited resources, prevention efforts should focus on intensive efforts with smaller groups and should be integrated into clinical care for PLWH.
Core Programmatic Components
Behavioral interventions for PLWH include individual and community-level education and skills-building programs. The following interventions constitute the minimum package of services for PHDP:
- Condoms (and lubricant) and risk-reduction counseling
- Assessment of partner status and provision of partner testing or referral for partner testing
- Assessment for sexually transmitted infections (STIs) and provision of or referral for STI treatment (if indicated, and partner treatment if indicated)
- Assessment of family planning needs and provision of contraception or safer pregnancy counseling or referral for family planning services
- Assessment of adherence and support or referral for adherence counseling
- Referral or enrollment of PLWH to community-based programs, such as home-based care, support groups, and post-test clubs.
PHDP programs will also include alcohol counseling, psychosocial support services, and integration of prevention messages into routine clinical care. At the community level, programs will focus on HIV stigma reduction, support communication about HIV and sex, disclosure to partners, and access to services. Structural factors will include efforts to reduce and eliminate legal and regulatory barriers to care and support for PLWH. Combination interventions are also critical, such as prevention of unintended pregnancies among HIV-infected women, prevention of mother-to-child transmission, STI assessment and management, and male circumcision. Discordant couples should be identified and provided with appropriate prevention counseling and services. Effective programs for PLWH must ensure meaningful involvement of PLWH in program design, implementation, and evaluation. Prevention programs should be part of a comprehensive set of HIV prevention efforts that target both HIV-negative and HIV-positive individuals. All interventions should be approached with utmost respect and sensitivity, and must be accompanied by efforts to combat stigma against PLWH.
Current Status of Implementation Experience
Although PHDP implementation experience is limited, a number of pilot and qualitative studies support the effectiveness of these interventions. A recent study in Uganda found that individuals who learned they were HIV-positive were three times as likely to use condoms as those who did not know their HIV status, suggesting that testing can aid in reducing HIV transmission. Early studies show that interventions targeted to injecting drug users and to preventing mother-to-child transmission also reduce transmission.