Abstract

SummaryBackgroundMany ways of preventing HIV infection have been proposed and more are being developed. We sought to construct a strategic approach to HIV prevention that would use limited resources to achieve the greatest possible prevention impact through the use of interventions available today and in the coming years.MethodsWe developed a deterministic compartmental model of heterosexual HIV transmission in South Africa and formed assumptions about the costs and effects of a range of interventions, encompassing the further scale-up of existing interventions (promoting condom use, male circumcision, early antiretroviral therapy [ART] initiation for all [including increased HIV testing and counselling activities], and oral pre-exposure prophylaxis [PrEP]), the introduction of new interventions in the medium term (offering intravaginal rings, long-acting injectable antiretroviral drugs) and long term (vaccine, broadly neutralising antibodies [bNAbs]). We examined how available resources could be allocated across these interventions to achieve maximum impact, and assessed how this would be affected by the failure of the interventions to be developed or scaled up.FindingsIf all interventions are available, the optimum mix would place great emphasis on the following: scale-up of male circumcision and early ART initiation with outreach testing, as these are available immediately and assumed to be low cost and highly efficacious; intravaginal rings targeted to sex workers; and vaccines, as these can achieve a large effect if scaled up even if imperfectly efficacious. The optimum mix would rely less on longer term developments, such as long-acting antiretroviral drugs and bNAbs, unless the costs of these reduced. However, if impossible to scale up existing interventions to the extent assumed, emphasis on oral PrEP, intravaginal rings, and long-acting antiretroviral drugs would increase. The long-term effect on the epidemic is most affected by scale-up of existing interventions and the successful development of a vaccine.InterpretationWith current information, a strategic approach in which limited resources are used to maximise prevention impact would focus on strengthening the scale-up of existing interventions, while pursuing a workable vaccine and developing other approaches that can be used if further scale-up of existing interventions is limited.FundingBill & Melinda Gates Foundation.

Highlights

  • The AIDS response has had outstanding success in the development and global scale-up of antiretroviral therapy (ART).[1]

  • Prevention interventions have been the focus of much research and development investment; programmes are in the fortunate position of having a range of interventions to consider, including male condoms, voluntary medical male circumcision (VMMC) services, increased HIV testing and initiation of ART for all diagnosed with HIV, and oral pre-exposure prophylaxis (PrEP)

  • Model design We developed a deterministic compartmental model of heterosexual HIV transmission in South Africa

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Summary

Introduction

The AIDS response has had outstanding success in the development and global scale-up of antiretroviral therapy (ART).[1] With a few exceptions, there has been less success in reducing the spread of the HIV epidemic.[2,3,4] the sustainability of the response rests upon there being large reductions in new HIV infections in the coming years.[5] To meet this challenge, prevention interventions have been the focus of much research and development investment; programmes are in the fortunate position of having a range of interventions to consider, including male condoms, voluntary medical male circumcision (VMMC) services, increased HIV testing and initiation of ART for all diagnosed with HIV (early ART), and oral pre-exposure prophylaxis (PrEP). Innovative approaches might be able to allow these barriers to increasingly be overcome

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