HIV Prevention Transformed: The New Prevention Research Agenda

From the Lancet,  Volume 378, Issue 9787, Pages 269 - 278, July 16 2011, this review analyses trends in the rapidly changing landscape of HIV prevention and is intended to chart a new path for HIV prevention research that focuses on the implementation of effective and efficient combination prevention strategies. It reviews developments in HIV prevention from the past 3 years (ending July 2011), with particular emphasis on gaps in knowledge and a focus on prevention issues: discovery in the continued search for vaccines and a cure; challenges related to antiretroviral-based prevention; implementation challenges that preclude scale-up of prevention strategies known to be effective -specifically, HIV testing, voluntary medical male circumcision (VMMC), and prevention of mother-to-child transmission (PMTCT); and progress on and challenges for structural and behavioural interventions.

The research includes the following communication-related observations [Footnotes removed by editor]:

• Antiretroviral prophylaxis and testing - "This approach, whereby HIV testing is central to the prevention-treatment continuum, moves away from general risk reduction messages for all audiences (eg, condom use, sexually transmitted infection [STI] treatment) towards specifically tailored approaches for individuals based on their serostatus and prevention needs.... Research is focused on streamlining the content of the testing process, particularly in response to the diminishing support for pre-test counselling, by moving assessments of individual risk and plans for risk reduction to post-test sessions.... Much of the substantial scale-up in HIV testing6 has been attributable to worldwide recognition of the value of expanding testing from client-initiated testing (eg, voluntary counselling and testing) to routine testing, which could normalise and destigmatise HIV testing... The most crucial questions for HIV testing centre on identification of the best strategies to increase demand for and provision of testing services, in both individuals and couples.... Although onsite rapid testing and provider-initiated testing can overcome some of these obstacles, approaches to mitigate fear and the threat of violence (particularly for women) are being investigated. Similarly, models of service delivery to optimise uptake of testing and linkage to care and treatment, while protecting patient rights and confidentiality, are an active part of operations research. Home-based, door-to-door testing is a promising model, as are structural interventions, such as economic incentives, which can play an important enabling part. In this way, both supply-side and demand-side barriers as well as inefficiencies can be addressed to improve access to and delivery of this key entry point to HIV prevention services."

• Prevention of mother-to-child transmission - The World Health Organisation (WHO)'s “four-pronged strategy for PMTCT recommends: (1) primary HIV prevention in women of childbearing age; (2) prevention of unintended pregnancies in women with HIV infection; (3) prevention of HIV transmission from women with HIV to their infants via use of antiretroviral drugs; and (4) provision of treatment, care, and support to women with HIV and to their families.... Understanding women's fertility intentions and the expansion of family planning services to HIV-infected non-pregnant and pregnant women is important to address the second prong of WHO's PMTCT strategy.... In addition, stimulation of demand and strengthening of delivery of services are a major focus of research attention, with particular emphasis on prevention of leakage [loss of involvement of mother - infant pairs] at every step in the cascade.....“

• Male circumcision – "....Efforts will benefit from implementation research, such as how best to create demand, increase levels of HIV testing, and maximise adherence to the 6-week period of sexual abstinence after surgery.... Although there are examples of rapid and intensive scale-up, the same has not happened in some high-burden regions and countries. In many countries, policy makers have been slow to support VMMC.  This reluctance may stem from perceptions that support is biased towards particular religious groups, that its advocation will lead to widespread behavioural disinhibition, and that rollout will strain already overburdened health systems...."

• Structural interventions - "Legislative reforms, reducing stigma and discrimination, and enhancing social capital are important structural interventions for a range of populations, including sex workers, men who have sex with men, and injecting drug users.  A systematic review showed that policy-level support and empowerment strategies for sex workers can improve acceptability, adherence, and coverage of HIV-prevention programmes.  Similarly, modelling suggests that approaches designed to mitigate the harmful effects of drug use, such as needle and syringe exchange programmes, medication assisted treatment for substance misuse, and other interventions, could substantially curtail epidemics related to injecting-drug users, particularly when implemented alongside non-discriminatory laws and rights-based interventions....Further research should explore key elements of economic interventions such as microfinance (leading to independence and more choice and control over sexual partners and behaviours), including the additional benefits of training or community mobilisation...Finally, the importance of structural interventions that address cultural norms, gender and economic inequalities, migrant labour, and other factors underlying individual behaviour (eg, concurrent partnerships) is a substantial area of exploration...."

• Behavioural interventions – "....In the generalised epidemics of southern Africa, much attention has focused on overlapping or concurrent partnerships; albeit with controversy.   Although there is no disagreement that multiple concurrent partnerships contribute to risk for HIV transmission, and thus should be subject to HIV prevention programming responses,  the normative hold of concurrency makes such partnerships difficult to address directly. Regional media campaigns in South Africa suggest some preliminary effects on some risk behaviours, but no effects (as yet) for multiple partnerships...Difficulties in measurement of HIV incidence, together with the well documented problems in self-report of sexual behaviour, mean that the ‘gold standard’ of evidence for behavioural interventions is unlikely to be reached soon.  However, large-scale behavioural change is clearly central to reduction of incidence, and behavioural interventions are crucial in amplification and facilitation of other prevention approaches, including driving demand for HIV services such as HIV testing, VMMC, PMTCT, and treatment. Assessment of the effect that these programmes have on service uptake might be useful both alone and as a proxy for effect on HIV incidence. Key questions for implementation of behavioural interventions concern the challenge of bringing community-based programmes to scale while maintaining quality and a better appreciation of the balance between local adaptability and fidelity...."