PEPFAR releases new guidance on HIV prevention, community experts respond

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The Office of the U.S. Global AIDS Coordinator released the U.S President’s Emergency Plan for AIDS Relief (PEPFAR) Guidance for the Prevention of Sexually Transmitted HIV Infections this week. The 50-plus page document is intended to “assist PEPFAR country teams in developing Country Operational Plans (COPs) that align activities to prevention sexual transmission of HIV with country-specific epidemiology and country-owned responses,” according to the introduction statement. PEPFAR released the 2012 COP guidance late last month.

The prevention guidance details PEPFAR’s combination prevention strategy, and outlines the good and the bad of using estimates of population-level effects of HIV prevention activities with computer modeling.  Behavioral and biomedical interventions are discussed, as well as structural supports needed for sexual prevention programs to flourish – to include legal and policy reform – and prevention packages for specific populations such as those living with HIV and most at risk populations (MARPs).

“I was very glad to see the close attention to the prevention needs of MARPs,” said Chris Collins, vice president and director of public policy at The Foundation for AIDS Research (amfAR). “On the prevention impact of treatment, the guidance acknowledges the science and says further guidance will be forthcoming,” Collins said, referring to the recent HPTN 052 study results which showed that relatively healthy people living with HIV who started antiretroviral treatment early on were 96 percent less likely to transmit the virus to their uninfected sexual partners than their counterparts who delayed treatment.

“Treatment is clearly going to be a core component of effective comprehensive prevention, so we need that additional guidance presented in a time frame and with sufficient clarity that it will impact implementation without delay,” Collins said.

“Leading with combination prevention set the tone of the document and recognizes the complexity of prevention programming,” said Helen Cornman, co-chair of the HIV Prevention Working Group and senior prevention officer for John Snow, Inc.  Cornman provided substantial comments, a selection of what she saw as positive aspects of the guidance include:

  • Providing specific examples and a very comprehensive knowledge base of interventions (including male and female condoms, voluntary medical male circumcision, HIV testing and counseling, etc.) and evidence supporting their effectiveness.
  • Reliance of mapping all services, as duplication of services, uncoordinated messaging and in-fighting continue to hamper the response, she said. Also, by PEPFAR country teams completing this task, it can provide readily accessible mapping data to all contractors.
  • Linking prevention to care and treatment services and discussing the continuum of care response, which displays PEPFAR’s commitment to breaking down the divisions between prevention and treatment.
  • Addressing real issues raised by community members such as condom stock outs.
  • Including structural drivers and specifically naming stigma against people living with HIV, gender-based violence, economic empowerment and education, which will hopefully push country teams to push beyond limited views of “structural.”

As for some of the “negatives,” Cornman said it was a shame not to include treatment as prevention in core interventions in the portfolio discussion, and also lamented the fact that there is very little mention of family planning or reproductive health.

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