Guidance for the Prevention of Sexually Transmitted HIV Infections

The plan focuses on identifying and addressing gaps in prevention activities among priority populations, ensuring interventions address communities with high levels of risk, and using resources to maximize impact on HIV incidence. PEPFAR prioritizes biomedical, behavioral, and structural interventions and enhances coordination across prevention, care, and treatment activities. Thirty years into the global HIV epidemic, HIV prevalence and incidence remain high. An estimated 1.8 million people were newly infected with HIV worldwide in 2010. The human toll of these infections is significant, as each person will require a lifetime of antiretroviral treatment (ART) to stay alive. HIV prevention is the single most important challenge in the fight against HIV/AIDS. The world has witnessed remarkable declines in HIV incidence over the past decade, coinciding with increased global funding through PEPFAR and other donors. New infections dropped from 16,000 a day in 2001 to about 7,000 a day in 2009. The largest reductions occurred in sub-Saharan Africa, with 22 countries experiencing declines in new infections of 25% or more among young people. Countries in southern Africa, such as Namibia, Swaziland, and Malawi, saw significant reductions in new infections. The contributors to these declines are not well understood but likely include increased coverage of HIV prevention and treatment activities. Improved HIV surveillance and the natural evolution of the HIV epidemic may also have contributed to these declines. Despite these successes, multiple factors have made HIV prevention a continuing challenge, including the limited availability of effective interventions. PEPFAR's strategy focuses on identifying and addressing gaps in prevention activities among priority populations, ensuring interventions address communities with high levels of risk, and using resources to maximize impact on HIV incidence. The plan prioritizes biomedical, behavioral, and structural interventions and enhances coordination across prevention, care, and treatment activities. The Four "Knows" framework guides PEPFAR's prevention strategy. This framework includes knowing the epidemic, the epidemic's context, the response, and the costs of the response. Using computer modeling to estimate population-level effects of HIV prevention activities is essential in identifying the most effective interventions. HIV prevention is part of the country continuum of response, which includes prevention, care, and treatment activities. PEPFAR supports the country continuum of response by providing funding and technical assistance to countries. The overarching principles of PEPFAR's prevention programming include addressing gaps in prevention activities among priority populations, ensuring interventions address communities with high levels of risk, and using resources to maximize impact on HIV incidence. PEPFAR provides evidence-based guidance on specific interventions, including biomedical interventions, behavioral interventions, and structural interventions. Biomedical interventions include male and female condoms, voluntary medical male circumcision (VMMC), HIV testing and counseling (HTC), diagnosis and treatment of sexually transmitted infections (STIs), and antiretroviral drug (ArV)-based prevention. Behavioral interventions include standalone behavioral interventions to minimize sexual risk or increase protection and support behavioral interventions to optimize biomedical prevention. Structural interventions include legal and policy reform, which is essential in creating an enabling environment for HIV prevention. Prevention packages are also tailored to specific populations, including comprehensive packages for most-at-risk populations (MARs), positive health, dignity, and prevention (PHDP) for people living with HIV, and prevention interventions for young people. Assembling a portfolio of interventions is essential in maximizing the impact of PEPFAR's prevention strategy. This involves categorizing activities into different types, prioritizing and assembling the portfolio, and ensuring that the continuum of response is supported by the portfolio.