PEPFAR - an overview of HIV prevention research from the 2006 Implementers Meeting

Integrating prevention and treatment

“One of the important parts of the Emergency Plan from day one – President Bush said that we must have integrated prevention, treatment and care – you can’t have one without the other, they are synergistic,” said Dr. Mark Dybul, acting US Global AIDS Coordinator. “Prevention is improved by treatment and treatment is better with prevention and care is a part of all of it. We have said from day one that the three must be integrated and have emphasised all three equally.”

Reasons for the focus on prevention are clear. “Permanent sustainability needs much more effective prevention,” said Dr. Alex Coutinho of TASO. “If you go back to your house and find that you forgot to turn off the tap, and the house is flooded, what do you do first? Do you mop the floor or do you turn off the tap? You turn off the tap.”

At the same time, the scale-up of antiretroviral treatment has strengthened prevention efforts. “Treatment is a very important entry point to scaling up further prevention,” said Dr. Coutinho. He said that offering treatment should help fight stigma, and provide people with an incentive to get tested, leading to more effective prevention.

TASO and the CDC in Uganda provided examples of leveraging treatment to support prevention by targeting partners and family members of people receiving home-based care for HIV testing and counselling and by promoting safer sexual behaviour in people on antiretroviral treatment (ART). As in industrialised countries, effective ART also contributes to a reduction in transmissions to HIV-negative partners in addition to the reduction in MTCT.

While PEPFAR has been subjected to a great deal of (sometimes histrionic) criticism because of its ring-fencing of some of its funding to Abstinence and Being Faithful-only HIV prevention programmes, the complete picture of PEPFAR-supported prevention work is far more complex.

About a fifth of the presentations at the PEPFAR 2006 Implementers meeting focused primarily upon prevention. In some cases, the demographics of HIV are changing (or are not quite what people expect) so the presentations covered both investigations of the risks associated with, and strategies or interventions to prevent, medical and bloodborne transmission, injection drug use, mother to child transmission (MTCT) as well as the sexual transmission of HIV. Finally, improving access to HIV testing and counselling has been woven into all of PEPFAR’s activities.

“We have a range of interventions that if applied correctly and within an enabling environment will substantially reduce the number of new infections,” said Dr. Thomas Kenyon, Country Director for the US Centers for Disease Control (CDC) in Namibia during a rapporteur session at the closure of the meeting.

Medical and bloodborne transmission

Unsafe injections and unsafe blood transfusions are still a significant source of HIV transmission in sub-Saharan Africa. One study at the Implementers Meeting reported that three PEPFAR focus countries lack systems to ensure that medical facilities have a reliable supply of safe blood and other supplies — and that without safe supplies the risk of transfusing unsafe blood increases, particularly in countries where there is a high HIV prevalence.

Other presentations reported that following the introduction of training and quality assurance programmes in Zambia, Namibia, Uganda and Ethiopia, there were improvements in several indicators of injection safety including reductions in the prevalence of (often unnecessary) injections, reductions in the frequency of needle recapping, and increased use of safety boxes for needle disposal. But studies suggest that it may be even more important to spread these practices to the private sector (both for-profit and non-governmental organisations) where unsafe injection practices are even more common than in the public sector.

Injection drug use

There were several presentations on data indicating that injection drug use is increasing in sub-Saharan Africa. Reaching out to this often hidden population (often avoiding the law and stigma) can prove challenging however. Currently, PEPFAR is sponsoring programmes which are using community based outreach workers with mixed success.

The demographics of sexual transmission

Recently gathered demographic data may suggest how better to target prevention funding in the future. Dr. Vinod Mishra described the methods used in the Demographic and Health Surveys and AIDS Indicator Surveys to collect data on HIV prevalence in a number of countries with a generalised HIV/AIDS epidemic and reviewed the risk factors associated with the patterns of transmission in selected countries.

The surveys were conducted from 2001-2005 in Mali, Zambia, the Dominican Republic, Kenya, Ghana, Burkina Faso, Tanzania, Cameroon, Senegal, Guinea, Uganda, Lesotho and Malawi. Adult men and women were tested for HIV and their results were linked anonymously to their risk factors and characteristics including age, sex, urban/rural residence, education, marital status, household income, geographic regions, and HIV risk factors (condom use, number of sexual partners, high risk sex, use of alcohol and sexually transmitted disease).

Even though there were substantial differences in HIV prevalence from country to country and large regional differences within each country, several consistent patterns were observed in HIV prevalence according to the characteristics and risk factors of the participants. For example, HIV infection rates were considerably higher in urban areas, in women than in men (especially among younger women), in wealthier households (relatively), and among people who were widowed/divorced or separated. Sexual risk factors associated with a greater risk of HIV infection included being in polygamous unions or having multiple sex partners, and having sexually transmitted infections.

While these data are intriguing, and many of these patterns have been confirmed by other researchers, there may be dangers from trying to over-generalise and over-simplify some of these data — particularly when it comes to the observations related to wealth and poverty (see related article).

PMTCT

According to the UN Global Report on AIDS, half of the new infections are in children or people under the age of 25 years. “MTCT is the most significant cause of HIV infection to children under the age of 15” said Dr. Mary Pat Kieffer of USAID in East Africa. “700,000 HIV positive infants were born in 2005, 630,000 of those were in sub-Saharan Africa.”

PEPFAR funding has led to a rapid expansion of programmes for PMTCT. However, these programmes are doing more that simply using single-dose nevirapine for PMTCT. For example, increasingly, they are providing ART to mothers who qualify for treatment. Many PMTCT programmes are reaching out to the father as well.

The feminisation of AIDS

However, the observation of the high risk of HIV among young women was also a key finding of the 2006 UN Global Report. Termed the “feminisation” of the HIV epidemic, women now represent more than half of the persons with HIV across the globe. The proportion of adults with HIV that are women is even higher in sub-Saharan Africa where, according to the Report “three women are HIV-infected for every two men. Among young people (15 – 24 years), that ratio widens considerably, to three young women for every young man.”

Creating an enabling environment for behaviour change

Thus in order for prevention programmes to be truly effective, they need to address the special vulnerability of women. “Gender inequities are a huge obstacle towards creating an enabling environment,” Dr. Kenyon reaffirmed later in the meeting. Projects are needed to empower young women with the skills to negotiate how to protect themselves. At the same time, programmes targeted towards males are needed to discourage intergenerational sex, multiple partnerships and to encourage fidelity to their partner, as well as to use condoms if they do have risky sex (see related article).

Balancing monitoring and evaluation with action

To translate lessons learned from prevention efforts that appear to be working, PEPFAR Implementers will need to prospectively monitor and evaluate the effects of each prevention project in their country. Careful monitoring and evaluation is necessary to capture the nuances of why one ABC programme works (as in Kenya) when others appear to be frustrated (as in South Africa). In addition to the annual Implementer’s meetings, PEPFAR needs to make sure that lessons learned are quickly passed along as best practices that can be adapted to each country setting.— whether on the PEPFAR website or via other publications (many of the presentations from the Implementers meeting will become available in full online on August 13th).

At the close of the meeting, Dr Kenyon pointed out several areas that PEPFAR partners should focus on:

• Activities that achieve fidelity and partner reduction
• Stimulating dialogue on how to address HIV-related cultural and gender norms
• Interventions that promote abstinence in young people should be accompanied by interventions to achieve “B” (be faithful) in adults
• Target young girls and older men with interventions to address trans-generational sex
• Prevention for positives
• The relationship of alcohol and HIV (several studies show that alcohol abuse increases the risk of HIV, but few interventions have been suggested to address it).

Dr. Kenyon stressed the need to balance programme evaluation with the urgency to act:

“The group hopes that the prevention sessions covered during this meeting will stimulate PEPFAR country teams and their partners to take a step back and re-examine where they are with respect to the implementation and evaluation of prevention activities. But we won’t reach the target of 7 million infections averted with pilot projects alone, we also need to be examining what is working or what seems to be working in our countries and take it to scale. High quality evaluations are indeed encouraged, but we need to balance the need to act with the need to evaluate.”