A New Paradigm for Optimizing HIV Intervention Synergy

Moving the Bar to the Right Place: Positioning Interventions in HIV Prevention

Uganda’s rising HIV epidemic is a cause of concern. HIV prevalence has increased from 6.4 to 7.3 % in a space of 6 years (2005–2011), and the number of new HIV infections in adults and children is estimated to have increased from 130,000 in 2010 to 145,000 in 2011 based on results from mathematical models. In order to reverse this trend, Uganda has adopted a national combination HIV prevention approach that involves implementation of biomedical, behavioral, and structural interventions at a scale, quality, and intensity necessary to impact the epidemic. This chapter discusses Uganda’s progress in implementing biomedical HIV prevention interventions, including HIV counseling and testing (HCT), voluntary medical male circumcision (VMMC), antiretroviral therapy (ART), and prevention of mother-to-child transmission (PMTCT) of HIV. Modeling studies suggest that the coverage of these interventions should reach 80–90 % of the adult population if Uganda is to reverse the current epidemic trends by 2015. Reports from the Ugandan Ministry of Health suggest that the coverage of HCT, PMTCT and ART services has increased over the past 5 years. For instance, the percentage of health facilities (HFs) offering HCT has increased from 37 % in 2009/10 to 38 % in 2011/12. The percentage of HFs offering PMTCT services has also increased from 23 % in 2009/10 to 36% in 2011/12. By the end of 2012, approx. 24 % of 4,493 HFs in Uganda were actively offering ART. Despite this level of coverage, only 26 % of Ugandan men are circumcised, 73 % of eligible HIV-positive patients receive antiretrovirals (ARVs), 87.4 % of all HIV-positive pregnant women identified at antenatal clinics, during labor and delivery, and during the post-natal period receive prophylactic ART to reduce the risk of mother-to-child transmission of HIV (constituting approx. 52 % of all expected HIV-positive pregnant women in Uganda), while 34 % of women and 55 % of men are not aware of their HIV status. Several challenges still inhibit national scale-up of these interventions, including the slow progress in translation of research into policy, lack of adequate resources to put everybody who is eligible for ART on treatment, and the fact that the majority of Ugandans present late for HIV diagnosis, and therefore enter late (with lower CD4 cell counts) into HIV care.

Evidence-informed and human rights-based combination prevention combines behavioural, biomedical, and structural interventions to address both the immediate risks and underlying causes of vulnerability to HIV infection, and the pathways that link them. Because these are context-specific, no single prescription or standard package will apply universally. Anchored in 'know your epidemic' estimates of where the next 1000 infections will occur and 'know your response' analyses of resource allocation and programming gaps, combination prevention strategies seek to realign programme priorities for maximum effect to reduce epidemic reproductive rates at local, regional, and national levels. Effective prevention means tailoring programmes to local epidemics and ensuring that components are delivered with the intensity, quality, and scale necessary to achieve intended effects. Structural interventions, addressing the social, economic, cultural, and legal constraints that create HIV risk environments and undermine the agency of individuals to protect themselves and others, are also public goods in their own right. Applying the principles of combination prevention systematically and consistently in HIV programme planning, with due attention to context, can increase HIV programme effectiveness. Better outcome and impact measurement using multiple methods and data triangulation can build the evidence base on synergies between the components of combination prevention at individual, group, and societal levels, facilitating iterative knowledge translation within and among programmes.

A wide range of HIV prevention strategies have been evaluated or are in late-stage clinical trials. These include male circumcision, microbicides, diagnosis and treatment of sexually transmitted diseases, barriers, pre-exposure and post-exposure sexual prophylaxis with antiretroviral drugs, and behavioral interventions. While condoms are widely available and highly effective if used consistently and correctly, they have not been the answer to the problem, with UNAIDS reporting that 2.7 million new HIV infections occur each year. Current behavioural prevention interventions have been associated with a decline in HIV prevalence in some settings but have yet to demonstrate a generalizable impact. Biomedical interventions, such as male circumcision, substitution therapy for injection drug users, management of sexually transmitted diseases, antiretroviral therapy, female barrier methods and topical microbicides offer promise, with many under investigation in clinical trials. However, no single biomedical or behavioral intervention is likely to be effective and the focus of research is switching to the investigation of combinations of strategies. This review examines proven biomedical methods of reducing HIV transmission, such as male circumcision, efforts which have failed (e.g. first generation microbicides) and strategies for the future, including pre-exposure prophylaxis and next generation microbicides. Behavioural interventions are the keys to any successful efforts to reduce HIV transmission. While such interventions may provide (short-term) changes in individual behavior, new strategies seek to effect behavioural change at a population level.

HIV/AIDS was in 2006 the leading cause of death worldwide for people aged 15 to 49 years. The pandemic is having a dramatic impact on child mortality, with 380,000 children who died of AIDS-related diseases [1]. The same year, it was estimated that 2.3 million children under the age of 15 years were living with the virus, mainly as a result of mother-to-child transmission of HIV (MTCT) [1]. More than 90% of these children were living in sub-Saharan Africa. The number of children orphaned after their parent(s) died from AIDS is also rising dramatically, reaching 15.2 million children worldwide in 2005. More than five million children are currently living with HIV-related chronically ill family members and will become orphans unless appropriate care and treatment is provided [2]. Considerable progress has been achieved in industrialised countries towards the prevention of new paediatric HIV infections, the provision of adequate treatment to HIV-infected children, and the support to vulnerable children and orphans affected by HIV/AIDS. But for many children, especially in low-incomes countries (LINCs), adequate prevention, care and treatment still remains inaccessible. The aim of this article is to review the state of knowledge in the field of paediatric HIV/AIDS, to describe the research undertaken over the past decade, and to assess the level of implementation of research results, focusing mainly on the experience of African countries.

Lessons Learned From Dissemination of Evidence-Based Interventions for HIV Prevention.

The first behavioral interventions designed to stem the spread of HIV were tested over 25 years ago, within just a few years of the first reported cases of AIDS. Interventions grounded in sound theories of behavior change have since been demonstrated effective at reducing high-risk injection and sexual practices in nearly every population with known risks for HIV/AIDS. Brief risk reduction counseling, small group skills building workshops, syringe exchange programs, enhanced HIV counseling and testing, interventions aimed at people living with HIV/AIDS, condom social marketing programs, peer influence models and other behavioral HIV prevention approaches have all shown efficacy in carefully controlled clinical and community trials. Meta-analyses repeatedly show that these interventions produce consistent positive behavioral outcomes and several have significantly reduced recurrent sexually transmitted infections. Unfortunately, behavioral interventions have also demanded considerable commitment to implement and resources to sustain. Despite their effectiveness, HIV risk reduction interventions have not provided the quick fix to the AIDS problem that so many policy and decision makers have sought for the past 20 years. In contrast to behavioral interventions, biomedical approaches to HIV prevention offer the promise of immunity, permanent reductions in susceptibility, and diminished infectiousness. By far, the most successful biomedical intervention for HIV prevention remains the use of antiretroviral medications for preventing mother-to-child transmission of HIV. Comprehensive mother-to-child transmission prevention programs have witnessed declines in HIV infected infants to levels approaching zero. For example, in New York there were nearly 100 HIV infected infants in 1997 whereas there were less than 10 in 2006. The number of HIV infected babies has similarly plummeted in Botswana where all pregnant women are tested and treated, whereas neighboring South Africa has been slow to implement mother-to-child prevention of HIV transmission and the country remains burdened by these avoidable and tragic infections. Several important clinical trials that are testing new biomedical HIV prevention interventions were launched in the early part of this decade and their results are now becoming available. Most encouraging has been the definitive findings from three randomized clinical trials of male circumcision for HIV risk reduction (Auvert et al. 2005; Bailey et al. 2007; Gray et al. 2007). These compelling studies all showed as much as a 60% reduction in HIV transmission among men who underwent circumcision, a magnitude of protection that cannot even be expected from most vaccine models. Male circumcision faces implementation challenges due to obvious cultural and religious meanings attached to circumcision, issues that individual communities have to sort out. But the effectiveness of male circumcision for preventing female-to-male HIV transmission is indisputable. The results of several other eagerly awaited biomedical prevention technologies have unfortunately been more disappointing. Based on a clear and convincing model of cervical susceptibility to HIV transmission, Nancy Padian conducted a critical study of the diaphragm for HIV prevention. The findings did not demonstrate added benefit from diaphragm use over and above supplying women with condoms and risk reduction counseling (Padian et al. 2007). In the past year we have also seen two promising vaginal microbicides, cellulose sulfate and Carraguard, fail to demonstrate efficacy. What was another innovative approach to preventing HIV transmission was use of antiviral medication to suppress Herpes Simplex Virus (HSV) S. C. Kalichman (&) University of Connecticut, Storrs, CT, USA e-mail: seth.k@uconn.edu

Scientific evidence supports the synergy between biomedical and behavioral interventions aimed at preventing the transmission of HIV as a strategy to eradicate AIDS. To characterize comparatively the benefits from biomedical and behavioral interventions to prevent HIV transmission. Narrative review. We performed a comparative analysis of the benefits of studied interventions by means of estimating the number needed to treat (NNT). Evaluated interventions: counseling activities for behavior change to prevent exposure to HIV; antiretroviral pre-exposure prophylaxis (PrEP) and antiretroviral post-exposure prophylasis (PEP) for HIV and treatment of serodiscordant couples as a strategy for prevention of HIV transmission (TasP). counseling interventions and TasP have smaller NNTs, equal to, respectively, 11 (95%CI 9 - 18) at 12 months and 34 (95%CI 23 - 54) in 42 months comparatively to PrEP interventions, that resulted in 41 (95%CI 28 - 67) individuals receiving antiretrovirals in order to prevent one case of HIV infection at 36 months for men and serodiscordant couples. PEP interventions are associated with protective effects estimated at 81%. Lack of trials evaluating PEP prevents estimate of NNT. The estimate of the NNT can be a helpful parameter in the comparison between the effectiveness of different behavioral and biomedical HIV prevention strategies. Studies evaluating the benefit and safety of combined behavioral and biomedical interventions are needed, especially considering the attributable fraction of each component. Integration of behavioral and biomedical interventions is required to achieve complete suppression of the virus, and thus reducing viral replication, infectivity and the number of cases.

BackgroundThe reported coverage of any antiretroviral (ARV) prophylaxis for prevention of mother-to-child transmission (PMTCT) has increased in sub-Saharan Africa in recent years, but was still only 60% in 2010. However, the coverage estimate is subject to overestimations since it only considers enrolment and not completion of the PMTCT programme. The PMTCT programme is complex as it builds on a cascade of sequential interventions that should take place to reduce mother-to-child transmission (MTCT) of HIV: starting with antenatal care (ANC), HIV testing, and ARVs for the woman and the baby.ObjectiveThe objective was to estimate the number of children infected with HIV in a district population, using empirical data on uptake of PMTCT components combined with data on MTCT rates.DesignThis study is based on a population-based cohort of pregnant women recruited in the Iganga-Mayuge Health and Demographic Surveillance Site in rural Uganda 2008–2010. We later modelled different scenarios assuming increased uptake of specific PMTCT components to estimate the impact on MTCT for each scenario.ResultsIn this setting, HIV infections in children could be reduced by 28% by increasing HIV testing capacity at health facilities to ensure 100% testing among women seeking ANC. Providing ART to all women who received ARV prophylaxis would give an 18% MTCT reduction.ConclusionsOur results highlight the urgency in scaling-up universal access to HIV testing at all ANC facilities, and the potential gains of early enrolment of all pregnant women on antiretroviral treatment for PMTCT. Further, to determine the effectiveness of PMTCT programmes in different settings, it is crucial to analyse at what stages of the PMTCT cascade that dropouts occur to target interventions accordingly.

This study has been conducted to identify health promotion methods in the Prevention of Mother-to-Child HIV Transmission (PMTCT) program among pregnant women and barriers to implementation. In this literature review study, we included published original articles which were published from 2010-2020 in Pubmed, ProQuest and Science Direct. The search was limited by the independent variable of health promotion methods and the dependent variable of the PMTCT program among pregnant women. Researchers have found 9 articles and 5 kinds of health promotion methods in the PMTCT program, namely community-based, home-based, short messaging service, partner-based, and integration between traditional birth attendants and primary health care. Lack of knowledge and collaboration on promotional methods that are appropriate for the conditions and situations of pregnant women can hinder the implementation of the PMTCT program. Therefore we need a health promotion method that suits the needs of pregnant women. How to Cite this Article Pubmed Style Astuti DA, Hakimi M, Prabandari YS, Laksanawati IS, Triratnawati A. of Health Promotion Methods for the Prevention of Mother-to-Child HIV Transmission among Pregnant Women: A Literature SRP. 2020; 11(10): 361-366. doi:10.31838/srp.2020.10.58 Web Style Astuti DA, Hakimi M, Prabandari YS, Laksanawati IS, Triratnawati A. of Health Promotion Methods for the Prevention of Mother-to-Child HIV Transmission among Pregnant Women: A Literature http://www.sysrevpharm.org/?mno=27940 [Access: March 28, 2021]. doi:10.31838/srp.2020.10.58 AMA (American Medical Association) Style Astuti DA, Hakimi M, Prabandari YS, Laksanawati IS, Triratnawati A. of Health Promotion Methods for the Prevention of Mother-to-Child HIV Transmission among Pregnant Women: A Literature SRP. 2020; 11(10): 361-366. doi:10.31838/srp.2020.10.58 Vancouver/ICMJE Style Astuti DA, Hakimi M, Prabandari YS, Laksanawati IS, Triratnawati A. of Health Promotion Methods for the Prevention of Mother-to-Child HIV Transmission among Pregnant Women: A Literature SRP. (2020), [cited March 28, 2021]; 11(10): 361-366. doi:10.31838/srp.2020.10.58 Harvard Style Astuti, D. A., Hakimi, . M., Prabandari, . Y. S., Laksanawati, . I. S. & Triratnawati, . A. (2020) of Health Promotion Methods for the Prevention of Mother-to-Child HIV Transmission among Pregnant Women: A Literature SRP, 11 (10), 361-366. doi:10.31838/srp.2020.10.58 Turabian Style Astuti, Dhesi Ari, Mohammad Hakimi, Yayi Suryo Prabandari, Ida Safitri Laksanawati, and Atik Triratnawati. 2020. of Health Promotion Methods for the Prevention of Mother-to-Child HIV Transmission among Pregnant Women: A Literature Systematic Reviews in Pharmacy, 11 (10), 361-366. doi:10.31838/srp.2020.10.58 Chicago Style Astuti, Dhesi Ari, Mohammad Hakimi, Yayi Suryo Prabandari, Ida Safitri Laksanawati, and Atik Triratnawati. Implementation of Health Promotion Methods for the Prevention of Mother-to-Child HIV Transmission among Pregnant Women: A Literature Review. Systematic Reviews in Pharmacy 11 (2020), 361-366. doi:10.31838/srp.2020.10.58 MLA (The Modern Language Association) Style Astuti, Dhesi Ari, Mohammad Hakimi, Yayi Suryo Prabandari, Ida Safitri Laksanawati, and Atik Triratnawati. Implementation of Health Promotion Methods for the Prevention of Mother-to-Child HIV Transmission among Pregnant Women: A Literature Review. Systematic Reviews in Pharmacy 11.10 (2020), 361-366. Print. doi:10.31838/srp.2020.10.58 APA (American Psychological Association) Style Astuti, D. A., Hakimi, . M., Prabandari, . Y. S., Laksanawati, . I. S. & Triratnawati, . A. (2020) of Health Promotion Methods for the Prevention of Mother-to-Child HIV Transmission among Pregnant Women: A Literature Systematic Reviews in Pharmacy, 11 (10), 361-366. doi:10.31838/srp.2020.10.58

HIV Prevention

This AIDS supplement brings to the forefront the latest advances in family planning/HIV integration research programs and policy. It also offers insights into strategic directions for future investments in this area. Topics include: biomedical and basic science research on the relationship between reproductive health and HIV transmission and disease behavioral research examining contraceptive practices and fertility choices among women and couples affected by HIV implementation science evaluating integrated service delivery innovations and evidence-based recommendations for programming.

Ultimately achieving an AIDS-free generation might rely more than we thought on developing adolescent leaders as agents of change -- not simply behavior change but societal and legal change. Innovative programming may be expanding adolescents’ social networks and engagement increasing their HIV-specific knowledge and increasing demand for HIV testing and treatment; but what is to meet this demand; and how will the effects of these programs be rigorously measured? Technology companies and mobile host sites are not clinicians or experts in evaluation. Even dizzying advances in technology are useless if adolescents have no access to them or are not able to access health promoting information services or networks. Moving forward technology and social innovators -- young and old -- must task themselves with removing barriers to testing and treatment that will reduce the sheer numbers of HIV infections and AIDS deaths in this population. Innovations must support adolescents’ access to a wider array of confidential testing options available in the community and through the health sector link them to biomedical and other prevention services of proven efficacy such as antiretroviral therapy medical male circumcision and to specific harm reduction interventions. In the years to come it is network disruption -- of entrenched social mores stigma attitudes and discriminatory practices -- that will constitute true innovation. (Excerpts)

Mother-to-child transmission (MTCT) of human immune virus/acquired immune deficiency syndrome (HIV/AIDS) is the largest mode of HIV transmission among children. This study assesses the prevention of mother to child transmission (PMTCT) of HIV/AIDS service utilization and associated factors among mothers attending antenatal care (ANC) in selected public health facilities of Horo Guduru Wollega Zone, Oromia Region, Ethiopia. Facility-based cross sectional study was conducted among mothers attending ANC in five public health facilities of Horo Guduru Wollega Zone from February to March, 2016. Randomly selected four health centers and one public hospital were included in the study. The study participants from each health facility were recruited by using systematic sampling technique. Exit interviews were conducted among mothers attending ANC services. Bivariate and multiple logistic regression analyses were performed to identify factors associated with PMTCT service utilization of mothers. A total of 378 pregnant mothers having antenatal visit during the study period participated in the study. All of the study participants were offered HIV counseling and testing at that particular antenatal visit. Among these, 317 (83.8 %) were counseled and tested for HIV as part of PMTCT service. Age, residence, mother’s educational status, male partner involvement during antenatal HIV testing, and service providers’ perceived handling of clients were associated with PMTCT service utilization of mothers. The utilization of HIV testing as PMTCT service in this study was lower when compared to the national recommendation set forth in the national PMTCT guideline, which recommends that every pregnant woman coming for ANC visit to health facilities should get HIV counseling and testing. Key words: Prevention of mother to child transmission (PMTCT), HIV/AIDS, Horo Guduru Wollega Zone, Ethiopia.

HIV prevention – where now? Background and introduction