Combination Prevention: New Hope for Stopping the Epidemic

Abstract

HIV research has identified approaches that can be combined to be more effective in transmission reduction than any 1 modality alone: delayed adolescent sexual debut, mutual monogamy or sexual partner reduction, correct and consistent condom use, pre-exposure prophylaxis with oral antiretroviral drugs or vaginal microbicides, voluntary medical male circumcision, antiretroviral therapy (ART) for prevention (including prevention of mother to child HIV transmission [PMTCT]), treatment of sexually transmitted infections, use of clean needles for all injections, blood screening prior to donation, a future HIV prime/boost vaccine, and the female condom. The extent to which evidence-based modalities can be combined to prevent substantial HIV transmission is largely unknown, but combination approaches that are truly implementable in field conditions are likely to be far more effective than single interventions alone. Analogous to PMTCT, “treatment as prevention” for adult-to-adult transmission reduction includes expanded HIV testing, linkage to care, antiretroviral coverage, retention in care, adherence to therapy, and management of key co-morbidities such as depression and substance use. With successful viral suppression, persons with HIV are far less infectious to others, as we see in the fields of sexually transmitted infection control and mycobacterial disease control (tuberculosis and leprosy). Combination approaches are complex, may involve high program costs, and require substantial global commitments. We present a rationale for such investments and cite an ongoing research agenda that seeks to determine how feasible and cost-effective a combination prevention approach would be in a variety of epidemic contexts, notably that in a sub-Saharan Africa.

Bridging barriers to clinic-based HIV testing with new technology: translating self-implemented testing for African American youth

“…The Centers for Disease Control and Prevention has mandated a comprehensive HIV prevention approach (CHPA) for implementation throughout the USA and its territories [1][2][3].…”

Strategic Roles for Health Communication in Combination HIV Prevention and Care Programs

“…Observational data suggest the impact of health communication to date, but perhaps, the most crucial challenges and most telling evidence will come from work on the continuum of care that is being rolled out in "treatment as prevention" initiatives, preexposure prophylaxis, voluntary medical male circumcision, and combination prevention initiatives. [32][33][34][35][36][37][38][39][40][41][42][43][44][45][46][47] Integration of behavioral approaches facilitated by health communication into these biomedical approaches will determine the degree, and speed, of their success. The true test of all HIV prevention and treatment efforts is whether, working in concert, they reduce HIV incidence, transmission rates, and deaths.…”

Reducing the overall HIV-burden in South Africa: is ‘reviving ABC’ an appropriate fit for a complex, adaptive epidemiological HIV landscape?

“…While we concur that, more often than not, people are operating on 'blind faith' (Patient 2014) when it comes to prevention, we do not agree that restricting public education to ABC is an appropriate basis for reducing the overall burden of HIV in 2014 -as supporters of 'combination' approaches to prevention have argued for some years (Vermund and Hayes 2013). The primary reason for this is that the contemporary context of the epidemiological landscape is dynamic and includes the mass roll-out of antiretroviral therapy (ART); increased scientific knowledge about other risk-reduction strategies; a general population that has been affected by HIV -and has had time to make sense of and embody those diverse experiencesand that the epidemiological context is going to continue to change as issues such as other chronic diseases (Deeks et al 2013) or drug resistance (Manasa et al 2013, WHO 2014 intersect with the epidemic.…”