Implementation of HIV prevention interventions that work

Implementation of HIV prevention interventions that work

Dr Olive Shisana

5th SAHARA conference1 December 2009

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In this presentationIn this presentation

• Introduction

• HIV prevention interventions that work

• Challenges with implementation of interventions that work

• Way forward

• Conclusion

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IntroductionIntroduction

• It is essential to identify HIV prevention interventions that work

• Prevention efforts should be based on the best available epidemiological and social science evidence

• The challenges that prevent the implementation of HIV prevention interventions need to be identified and dealt with.

• In order to deal effectively with the epidemic, we require approaches that are relevant, feasible and context-specific.

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Quality of evidence and level of effectiveness or efficacy

Quality of evidence and level of effectiveness or efficacy

0-24%

25-40%

40-64%

65% +

% Effectiveness or efficacy (in RCT)Quality of evidence

Strong evidence

Moderateevidence

No evidence

Weak evidence

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Summary of Biomedical HIV prevention interventions that work

Summary of Biomedical HIV prevention interventions that work

80-95% [Natural experiment]

94-97% [Natural experiment]

92-98% [RCTs]

60-80% [RCTs]

65% [3 RCTs]

Male Condoms

Female Condoms

PMTCT [Dual & triple therapy]

HAART

Male Circumcision

31.2% [1 RCT]

30% [1 RCT]

No efficacy [RCT]

Failed [RCTs] and negative

results [10 RCTs]

RV 144 Thai Vaccine trial

HPTN 035 (PRO 2000)

HIV Vaccine Trials Network(HVTN)

Early-generation microbicides &

topical microbicides

40% [1 RCT]STI treatment

% Effectiveness or efficacyBiomedical InterventionsQuality of evidence

Strong evidence

Moderateevidence

Weak or No evidence

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Summary: Behavioural and structural interventions that work

Summary: Behavioural and structural interventions that work

68% reduction in high risk sexual

behaviors [1 comm RCT]

HCT for PLWHA

7/13 reported sex [Systematic Review]

No impact of C&T on behavior of untested

No effect on HIV incidence [comm RCT]

No conclusive evidence

Abstinence-only interv’s

HCT on untested

Microfinance (IMAGE)

Concurrency

None

% Effectiveness or efficacyInterventionsQuality of

evidence

Strong evidence

Moderateevidence

Weak or No evidence

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HIV prevention interventions with Strong evidence

HIV prevention interventions with Strong evidence

• Male circumcision (MC)

• Highly Active Antiretroviral Therapy (HAART)

• Prevention of mother to child transmission (PMTCT)

• Condoms (Male and Female)

• HCT for people living with HIV (PLHIV)

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HIV prevention interventions with Moderate evidence

HIV prevention interventions with Moderate evidence

• Treatment of Sexually Transmitted Infections (STI)

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HIV prevention interventions with Weak or No evidence

HIV prevention interventions with Weak or No evidence

• Microbicides and cervical barriers

• HIV vaccine

• Abstinence-only interventions

• HIV Counselling and Testing (HCT) on untested people

• Microfinance (IMAGE study in Limpopo)

• Concurrency

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Systems challenges in implementing interventions that

work

Systems challenges in implementing interventions that

work

• Inadequate financing of services

• Misallocation of resources for health and HIV prevention

• Capacity limitations to implement interventions,

• Service fragmentation and verticalization

• Stigma and discrimination

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Socio-economic challenges in implementing interventions that

work

Socio-economic challenges in implementing interventions that

work

• Social and cultural factors,

• Economic factors such as the current poor economic climate.

• Political factors,

• Legal factors

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Way forwardWay forward

No “Magic Bullet” for HIV

“It is critical to note that there is no “magic bullet” for

HIV prevention. None of the new prevention methods

currently being tested is likely to be 100 percent

effective, and all will need to be used in combination

with existing prevention approaches if they are to

reduce the global burden of HIV/AIDS.”

Source: Global HIV Prevention Working Group (2008)

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Combination prevention or Highly Active HIV Prevention is the way to go!

Combination prevention or Highly Active HIV Prevention is the way to go!

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ConclusionConclusion

• Combining HIV prevention measures and delivering them on a wider scale is crucial to reversing the HIV epidemic

• Prevention strategies will never work if they are not implemented completely, with appropriate resources and benchmarks, and with a view toward sustainability.

• We require serious commitment and leadership to implement combination prevention interventions which include context-specific, evidence-based interventions.

• Important gaps and limitations remain in our knowledge about what works in HIV prevention. Accelerating HIV prevention requires that these limitations be acknowledged and addressed.