This document discusses HIV prevention interventions that have been shown to work based on evidence. Interventions with strong evidence of effectiveness include male circumcision, HAART, PMTCT, and condoms. Treatment of STIs has moderate evidence. Microbicides, vaccines, and abstinence-only programs have weak or no evidence. Barriers to implementing effective interventions include inadequate funding, resource misallocation, capacity limitations, and socio-cultural factors. A combination of evidence-based interventions delivered at scale is needed to reverse the HIV epidemic.

1. Implementation of HIV prevention
interventions that work
Dr Olive Shisana
5th SAHARA conference
1 December 2009

2. In this presentation
• Introduction
• HIV prevention interventions that work
• Challenges with implementation of
interventions that work
• Way forward
• Conclusion
2

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. 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. 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. 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. 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. HIV prevention interventions with
Moderate evidence
• Treatment of Sexually Transmitted Infections (STI)
8

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. 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. 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. 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. Combination prevention or Highly Active
HIV Prevention is the way to go!
13

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