Prevention trials in the region behavioral trials
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Prevention Trials in the Region Behavioral Trials*. *Limited to interventions evaluated by randomized controlled designs with HIV incidence as an outcome. Prevention Trials in the Region Microcredit Trials*.

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Prevention trials in the region behavioral trials

Prevention Trials in the Region Behavioral Trials*

*Limited to interventions evaluated by randomized controlled designs with HIV incidence as an outcome


Prevention trials in the region microcredit trials

Prevention Trials in the Region Microcredit Trials*

*Limited to interventions evaluated by randomized controlled designs with HIV incidence as an outcome


Prevention trials in the region male circumcision trials

Prevention Trials in the Region MaleCircumcision Trials*

*Limited to interventions evaluated by randomized controlled designs with HIV incidence as an outcome


Male circumcision

Male Circumcision

  • Reduces FM transmission by ~ 58%

  • Challenge for reduction in MF is ensuring sufficient time for wound healing before resumption of sexual activity

  • Little evidence of risk compensation in RCTs: critical consideration for scale-up


Prevention trials in the region microbicide trials

Prevention Trials in the Region Microbicide Trials*

*Limited to interventions evaluated by randomized controlled designs with HIV incidence as an outcome


Microbicide evolution non specific arv containing products

Microbicide evolution: Non-specific  ARV-containing products

  • Holds more promise

    • Topical, vaginal PREP

    • To prevent transmission (reduce infectiousness)?

  • Shift from original concept of low-tech, low-cost product

  • Challenges with resistance

    • Use during pregnancy

  • Not effective on other STI outcomes

  • Not a contraceptive


Prevention trials in the region cervical barrier trials

Prevention Trials in the Region Cervical Barrier Trials*

*Limited to interventions evaluated by randomized controlled designs with HIV incidence as an outcome


Prevention trials in the region sti treatment trials

Prevention Trials in the Region STI Treatment Trials*

*Limited to interventions evaluated by randomized controlled designs with HIV incidence as an outcome


Prevention trials in the region sti treatment trials con t

Prevention Trials in the Region STI Treatment Trials* (con’t)

*Limited to interventions evaluated by randomized controlled designs with HIV incidence as an outcome


Prevention trials in the region behavioral trials

Epidemic Phase: A Guide in Designing HIV Prevention Strategy

HIV Epidemic Pattern

Mature/Generalized

Nascent  Concentrated

EpidemicPhase

Hyperendemic

Decline

Growth

Endemic

Modified from: Wasserheit & Aral. JID 1996;174:S201-213


Prevention trials in the region vaccine trials

Prevention Trials in the Region Vaccine Trials*

*Limited to interventions evaluated by randomized controlled designs with HIV incidence as an outcome


What works

What works?

  • No HIV vaccine or topical prophylaxis will be available in the foreseeable future

  • For now: male condoms (condom promotion, distribution & IES); VCT and peer-based programs; male circumcision; and the prophylactic use of ARVs to reduce MTCT or contraception to prevent unwanted pregnancy

  • Treatment of sexually transmitted infections, a strong public health intervention in its own right, has had mixed results

    • Might be more effective if focused on reducing infectiousness than acquisition


Levels of evidence for hiv prevention

Levels of evidence for HIV prevention

  • Abstinence

  • Male circumcision

  • Male condom

  • Female condom

  • Reducing # of sex partners (absolute and concurrent)

  • STD tx for HIV

  • Abstinence promotion,

  • with or without

  • Postponing sexual debut

More evidence

Less evidence


What we need to do combination prevention packages

What we need to do: Combination prevention packages

  • No single magic bullet

  • + behavior: Essential to maintain adherence, to avoid sexual dis-inhibition (risk compensation)

  • + structural: Essential for addressing mechanisms that are necessary for scale-up to optimize effects

  • + biological: (e.g. male circumcision plus condoms; cervical barrier plus vaginal antimicrobial or antiretroviral gel)


Whom to target

Whom to target

Prioritization/targeting/tailoring

Universalistic

Dilution

Equality

Equal access

Tipping point for social norms

  • Precision with or without diffusion

  • Potential for greater yet limited impact

  • Stigma

  • Restricted benefits

  • Restricted effects


Relevant issues

Relevant issues

  • UNAIDS guidelines for planning purposes useful first step

    • Epidemics: low-level, concentrated, generalized or hyper-endemic

    • Key steps:

      • “know epidemic and current response”

      • “match and prioritize response”

      • “set ambitious, realistic and measurable prevention targets”

      • “tailor prevention plans”

      • “utilize and analyze strategic information”

    • Guidelinesmay not accurately reflect real setting complexities, no specifics on how to choose optimal sets of interventions by situation, no focus on best-buys 

  • Academic studies have serious limitations


Challenges for decision makers

Challenges for decision makers

Finding the optimal balance between treatment, prevention, and palliative interventions

Few good tools to choose sets of interventions that yield optimal results for specific settings (demographics, epidemic characteristics, economic context, etc.) and financing levels.

Political and social considerations affect decision making: some cost-effective interventions hard to promote


Levels of outcomes impact

Levels of outcomes/impact

Environmental

e.g. Changes in social and sexual norms

Cognitive, attitudinal, affectivee.g. fear of stigma

Behavioral

e.g. Condom use

Biological

HIV

STI

Pregnancy


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