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01 Dr Shisana Presentation At Sahara 2 Dec


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01 Dr Shisana Presentation At Sahara 2 Dec

  1. 1. Implementation of HIV prevention interventions that work Dr Olive Shisana 5th SAHARA conference 1 December 2009
  2. 2. In this presentation • Introduction • HIV prevention interventions that work • Challenges with implementation of interventions that work • Way forward • Conclusion 2
  3. 3. Introduction • 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. 3
  4. 4. Quality of evidence and level of effectiveness or efficacy Quality of evidence % Effectiveness or efficacy (in RCT) Strong evidence 65% + Moderate 40-64% evidence Weak 25-40% evidence No 0-24% evidence 4
  5. 5. Summary of Biomedical HIV prevention interventions that work Quality of evidence Biomedical Interventions % Effectiveness or efficacy Male Condoms 80-95% [Natural experiment] Female Condoms 94-97% [Natural experiment] Strong evidence PMTCT [Dual & triple therapy] 92-98% [RCTs] HAART 60-80% [RCTs] Male Circumcision 65% [3 RCTs] Moderate STI treatment 40% [1 RCT] evidence RV 144 Thai Vaccine trial 31.2% [1 RCT] HPTN 035 (PRO 2000) 30% [1 RCT] Weak or No HIV Vaccine Trials Network(HVTN) No efficacy [RCT] evidence Early-generation microbicides & Failed [RCTs] and negative topical microbicides results [10 RCTs] 5
  6. 6. Summary: Behavioural and structural interventions that work Quality of Interventions % Effectiveness or efficacy evidence HCT for PLWHA 68% reduction in high risk sexual Strong evidence behaviors [1 comm RCT] Moderate evidence None Abstinence-only interv’s 7/13 reported sex [Systematic Review] Weak or No evidence HCT on untested No impact of C&T on behavior of untested Microfinance (IMAGE) No effect on HIV incidence [comm RCT] Concurrency No conclusive evidence 6
  7. 7. 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) 7
  8. 8. HIV prevention interventions with Moderate evidence • Treatment of Sexually Transmitted Infections (STI) 8
  9. 9. 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 9
  10. 10. 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 10
  11. 11. 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 11
  12. 12. Way 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) 12
  13. 13. Combination prevention or Highly Active HIV Prevention is the way to go! 13
  14. 14. Conclusion • 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. 14