Preventing HIV

Combination prevention is defined as rights- based, evidence-informed, and community – owned programmes that use a mix of biomedical, behavioural, and structural interventions, prioritised to meet the current HIV prevention needs of particular individuals and communities, so as to have the greatest sustained impact on reducing new infections.

Navigating HIV prevention

To reach the new proposed global 95–95–95 targets for 2030 set by the United Nations Programme on HIV/AIDS (UNAIDS) in 2020, efforts need to be redoubled to avoid the worst-case scenario of 500 000 excess deaths in sub-Saharan Africa, increasing HIV infections due to service disruptions during COVID-19, and the slowing public health response, according to the World Health Organization (WHO)1.

Historically, HIV prevention programmes focused primarily on preventing the sexual transmission of HIV through behavioural change. For a number of years, UNAIDS and other stakeholders advocated the ABC approach (Abstinence, Be faithful, use a Condom) to reduce the risk of HIV transmission2.

However, by the mid-2000s, it became clear that the ABC approach was not working. Reasons cited for this is that the approach did not take socio-cultural, economic, political, legal, and other contextual factors into consideration. In 2009, UNAIDS relooked the ABC approach and determined that the complex nature of the global HIV epidemic required ‘combination prevention’2.

What is combination prevention?

UNAIDS defines combination prevention as: ‘rights-based, evidence-informed, and community-owned programmes that use a mix of biomedical, behavioural, and structural interventions, prioritised to meet the current HIV prevention needs of particular individuals and communities, so as  to have the greatest sustained impact on reducing new infections.

Well-designed combination prevention programmes are carefully tailored to national and local needs and conditions, focus resources on the mix of programmatic and policy actions required to address both immediate risks and underlying vulnerability, and they are thoughtfully planned and managed to operate synergistically and consistently on multiple levels (e.g. individual, relationship, community, society) and over an adequate period of time.

They mobilise community, private sector, government and global resources in a collective undertaking, require and benefit from enhanced partnership and coordination, and they incorporate mechanisms for learning, capacity building and flexibility to permit continual improvement and adaptation to the changing environment’2.

Summary of HIV prevention strategies

Strategy Recommendations Efficacy
Pre-exposure prophylaxis (PrEP) Oral PrEP is considered a key component of an HIV combination prevention programme and should routinely be offered to anyone who may be exposed to HIV, whether sexually or through other means.

 

PrEP is the daily use by the HIV-uninfected individual.  PrEP users are advised to take the prescribed number pills before sex, as indicated by their doctor. If sex occurs, they should follow up with one pill per day for the following two days after sex.3

PrEP is >95% effective if used consistently and correctly.3
Knowledge of HIV serostatus Couples’ voluntary HIV counselling and testing significantly reduces HIV transmission in one of the highest risk groups in sub-Saharan Africa – discordant couples – and has been shown to increase couple’s knowledge about

HIV serodiscordance and prevention behaviours.4

Studies report a 61.2% reduction in the risk of HIV transmission in discordant couples. Effectiveness was much lower in seroconcordant couples (38.4%).5
Antiretroviral therapy (ART) In South Africa, all patients who are diagnosed with HIV should be initiated on ART as soon as possible. Exceptions include patients presenting with cryptococcal meningitis or active tuberculosis.6 The HIV Prevention Trials Network (HPTN) 052 study showed a 93% reduction in HIV transmission when the HIV-infected person started ART when their immune system was relatively healthy.7
Condom use According to the South African National AIDs Council’s (SANAC) National Strategic Plan for HIV, TB and STIs 2017-2022, the aim was to increase the number of male condoms distributed annually to 850 million by 2018.

 

South Africa’s female condom programme is also one of the biggest and most established in the world, with over 26 million female condoms (also known as internal condoms) distributed in 2016. By 2022, SANAC hopes to increase this to 40 million.8,9

Condoms prevent 92% of HIV infections in anal sex between men, and between 71% to 77% in heterosexual couples.10
Voluntary medical male circumcision Male circumcision should never replace other known effective prevention methods and should always be considered as part of a comprehensive prevention programme.11

 

Reduces the female-to-male sexual transmission of HIV by 60%

if used correctly and consistently.11

Post-exposure prophylaxis (PEP) The 2020 National Department of Health Clinical Guidelines of PEP in Occupational and Non-Occupational Exposures, stress that all occupational, non-occupational and in inadvertent exposures should be treated as a medical emergency (ideally within two hours of an exposure but no later than 72 hours after an exposure)

 

Studies show that PEP can

reduce the risk of HIV transmission by more than 80%.12

References

  1. World Health Organization (2020). HIV/AIDS. https://www.who.int/news-room/fact-sheets/detail/hiv-aids
  2. No author HIV prevention programmes overview. https://www.avert.org/professionals/hiv-programming/prevention/overview#footnote10_q51fulx
  3. Bekker L-G, Brown B, Joseph-Davey D, et al. Southern African guidelines on the safe, easy and effective use of pre-exposure prophylaxis: 2020. Southern African Journal of HIV Medicine, 2020.
  4. Kilembe W, Wall KM, Mokgoro M, et al. Knowledge of HIV Serodiscordance, Transmission, and Prevention among Couples in Durban, South Africa. PLoSOne, 2015.
  5. O’Connell AA, Reed SJ and Serovich The Efficacy of Serostatus Disclosure for HIV Transmission Risk Reduction. AIDS Behav, 2015.
  6. South African National Department of National Consolidated Guidelines for the management of HIV In Adults, Adolescents, Children And Infants And Prevention of Mother-to-Child Transmission, 2020.
  7. Cohen MS, Chen YQ, McCauley M, et Antiretroviral Therapy for the Prevention of HIV-1 Transmission. NEJM, 2015.
  8. South African National AIDS Council (SANAC) (2017). ‘Let our actions count: South Africa’s National Strategic Plan for HIV, TB and STIs 2017-2022’.
  9. Health Systems Trust (2019). ‘District Health Barometer 2017/18’, 155.
  10. Pett W (2019). Do condoms work? A research https://www.aidsmap.com/about-hiv/do-condoms-work
  11. No author listed. Voluntary medical male circumcision for HIV prevention. https://www.avert.org/professionals/hiv-programming/prevention/voluntary-medical- male-circumcision
  12. South African National Department of National Of Post-Exposure Prophylaxis (Pep) In Occupational And Non-Occupational Exposures Clinical Guidelines, 2020.