Investigating combination HIV prevention: isolated interventions or complex system

Abstract

IntroductionTreatment as prevention has mobilized new opportunities in preventing HIV transmission and has led to bold new UNAIDS targets in testing, treatment coverage and transmission reduction. These will require not only an increase in investment but also a deeper understanding of the dynamics of combining behavioural, biomedical and structural HIV prevention interventions. High-income countries are making substantial investments in combination HIV prevention, but is this investment leading to a deeper understanding of how to combine interventions? The combining of interventions involves complexity, with many strategies interacting with non-linear and multiplying rather than additive effects.DiscussionDrawing on a recent scoping study of the published research evidence in HIV prevention in high-income countries, this paper argues that there is a gap between the evidence currently available and the evidence needed to guide the achieving of these bold targets. The emphasis of HIV prevention intervention research continues to look at one intervention at a time in isolation from its interactions with other interventions, the community and the socio-political context of their implementation. To understand and evaluate the role of a combination of interventions, we need to understand not only what works, but in what circumstances, what role the parts need to play in their relationship with each other, when the combination needs to adapt and identify emergent effects of any resulting synergies. There is little development of evidence-based indicators on how interventions in combination should achieve that strategic advantage and synergy. This commentary discusses the implications of this ongoing situation for future research and the required investment in partnership. We suggest that systems science approaches, which are being increasingly applied in other areas of public health, could provide an expanded vocabulary and analytic tools for understanding these complex interactions, relationships and emergent effects.ConclusionsRelying on the current linear but disconnected approaches to intervention research and evidence we will miss the potential to achieve and understand system-level synergies. Given the challenges in sustaining public health and HIV prevention investment, meeting the bold UNAIDS targets that have been set is likely to be dependent on achieving systems level synergies.

Stigma, gay men and biomedical prevention: the challenges and opportunities of a rapidly changing HIV prevention landscape

“…20,22,38,45 Structural or multilayered responses to the social and political drivers of the HIV epidemic among GMSM are required to tackle stigma and to respond to HIV. 18,24,25,40 Discriminatory legislation, criminalisation of HIV exposure or transmission, differential access to health care across minority groups, and negative social attitudes regarding homosexuality and HIV, and their complex intersections with racism, all undermine access to HIV prevention and health promotion programs and diffusion of community-level knowledge.…”

“…PrEP has the capacity to simultaneously increase judgement and stigma about sexual behaviour and to decrease fear and stigma in sexual encounters. 45 The sero-status divide in GMSM communities has long been a characteristic of the HIV epidemic. 21,49 How will TasP and PrEP disrupt these social meanings?…”

“…This may require rethinking of the approaches and sources of data for such monitoring. 45 If we get this right, there are significant stigmareduction opportunities afforded by PrEP and TasP and other social and biomedical developments that could be maximised.…”

“…Although the community sector is where the majority of such programs are conducted, currently, most have few resources for evaluation and are not present in the peerreviewed and grey literature. 22,45 While there is much in the literature about impact stigma has on HIV programs, there is much less on the role that general HIV prevention programs and health services could play in disrupting the manifestation of HIV and GMSM stigma. 22,45,53 We need collaborative multilevel research models to identify the most critical areas to target for reducing structural stigma in future interventions.…”

“…[55][56][57] However, structural interventions, aimed at influencing social, political and institutional enablers, barriers and drivers of HIV epidemics, such as stigma, are often least emphasised in practice. 45,47,58 If we are to maximise the health of GMSM as we head towards and beyond 2020, we need to enhance the positive social changes occurring for GMSM communities in many countries and maximise the opportunities and benefits of PrEP and TasP, not only to prevent transmission, but also to disrupt the stigmatising experiences and meanings of HIV and GMSM sexuality. As we have outlined in this article, achieving this will likely need investment in HIV research, policy and programs that target four critical areas: (1) responding to structural and institutional stigma; (2) health promotion and health services that recognise and work to address the impact of stigma on GMSM's uptake and use of new HIV prevention biotechnologies in a rapidly changing environment; (3) enhanced mobilisation and participation of GMSM and PLHIV in new approaches to HIV prevention; and (4) expanded approaches to research and evaluation in stigma reduction and its relationship with HIV prevention.…”