Combination prevention

Definition

Com­bi­na­tion pre­ven­tion are rights-, evi­dence-, and com­mu­nity-based pro­grams that pro­mote a com­bi­na­tion of bio­med­ical, behav­ioral, and struc­tural inter­ven­tions designed to meet the HIV pre­ven­tion needs of spe­cific peo­ple and com­mu­ni­ties. Com­bi­na­tion pre­ven­tion has the poten­tial to reduce HIV infec­tions through activ­i­ties with a greater sus­tained impact. Exam­ples of com­bi­na­tion pre­ven­tion pro­grams include the focus on edu­cat­ing and train­ing vul­ner­a­ble groups to coun­sel and advo­cate for pol­icy change while at the same time ensur­ing inte­grated pre­ven­ta­tive health­care ser­vices and prod­ucts. Com­bi­na­tion pre­ven­tion requires evi­dence-based, stake­holder dri­ven, rights-based and inclu­sive pro­grammes with account­abil­ity mech­a­nisms. While applic­a­ble for HIV, com­bi­na­tion pre­ven­tion approaches can also be used for other dis­eases.

Inter­na­tion­ally agreed com­mit­ments reflected in the Lan­guage Com­pendium have rec­og­nized the need to increase national lead­er­ship, resource allo­ca­tion, and other mea­sures for proven HIV com­bi­na­tion pre­ven­tion, “includ­ing con­dom pro­mo­tion and dis­tri­bu­tion, pre-expo­sure pro­phy­laxis, post-expo­sure pro­phy­laxis, vol­un­tary male med­ical cir­cum­ci­sion, harm reduc­tion, in accor­dance with national leg­is­la­tion, sex­ual and repro­duc­tive health-care ser­vices, includ­ing screen­ing and treat­ment of sex­u­ally trans­mit­ted infec­tions, enabling legal and pol­icy envi­ron­ments, full access to com­pre­hen­sive infor­ma­tion and edu­ca­tion, in and out of school.”

Prece­dents rec­og­niz­ing the need to tai­lor HIV com­bi­na­tion pre­ven­tion approaches to meet the diverse needs of key pop­u­la­tions have also been adopted, as reflected in the Lan­guage Com­pendium. Inter­na­tional com­mit­ments to ensure by 2025 that 95 per­cent of peo­ple at risk of HIV infec­tion have access to and use appro­pri­ate, pri­or­i­tized, per­son-cen­tered, and effec­tive com­bi­na­tion pre­ven­tion options also exists.

Precedents

2021 Political declaration on HIV and AIDS

• “Note with grave con­cern that the holis­tic needs and human rights of peo­ple liv­ing with, at risk of and affected by HIV, and of women and young peo­ple, remain insuf­fi­ciently addressed because of inad­e­quate inte­gra­tion of health ser­vices, includ­ing sex­ual and repro­duc­tive health-care ser­vices and HIV ser­vices, includ­ing for peo­ple who have expe­ri­enced sex­ual or gen­der-based vio­lence, includ­ing post-expo­sure pro­phy­laxis, legal ser­vices and social pro­tec­tion.” (para­graph 30)

• “Increas­ing national lead­er­ship, resource allo­ca­tion and other evi­dence - based enabling mea­sures for proven HIV com­bi­na­tion pre­ven­tion, includ­ing con­dom pro­mo­tion and dis­tri­bu­tion, pre-expo­sure pro­phy­laxis, post-expo­sure pro­phy­laxis, vol­un­tary male med­ical cir­cum­ci­sion, harm reduc­tion, in accor­dance with national leg­is­la­tion, sex­ual and repro­duc­tive health-care ser­vices, includ­ing screen­ing and treat­ment of sex­u­ally trans­mit­ted infec­tions, enabling legal and pol­icy envi­ron­ments, full access to com­pre­hen­sive infor­ma­tion and edu­ca­tion, in and out of school.” (para­graph 30(a))

• “Com­mit to pri­or­i­tize HIV pre­ven­tion and to ensure by 2025 that 95 per cent of peo­ple at risk of HIV infec­tion, within all epi­demi­o­log­i­cally rel­e­vant groups, age groups and geo­graphic set­tings, have access to and use appro­pri­ate, pri­or­i­tized, per­son-cen­tred and effec­tive com­bi­na­tion pre­ven­tion options.” (para­graph 60)

• “Tai­lor­ing HIV com­bi­na­tion pre­ven­tion approaches to meet the diverse needs of key pop­u­la­tions, includ­ing among sex work­ers, men who have sex with men, peo­ple who inject drugs, trans­gen­der peo­ple, peo­ple in pris­ons and other closed set­tings and all peo­ple liv­ing with HIV.”” (para­graph 60(b))

• “Com­mit­ting to accel­er­at­ing efforts to scale up sci­en­tif­i­cally accu­rate, age- appro­pri­ate com­pre­hen­sive edu­ca­tion, rel­e­vant to cul­tural con­texts, that pro­vides ado­les­cent girls and boys and young women and men, in and out of school, con­sis­tent with their evolv­ing capac­i­ties, with infor­ma­tion on sex­ual and repro­duc­tive health and HIV pre­ven­tion, gen­der equal­ity and women’s empow­er­ment, human rights, phys­i­cal, psy­cho­log­i­cal and puber­tal devel­op­ment and power in rela­tion­ships between women and men, to enable them to build self-esteem and informed deci­sion-mak­ing, com­mu­ni­ca­tion and risk reduc­tion skills and develop respect­ful rela­tion­ships, in full part­ner­ship with young per­sons, par­ents, legal guardians, care­givers, edu­ca­tors and health-care providers, in order to enable them to pro­tect them­selves from HIV infec­tion.” (para­graph 60(g))

2019 Political declaration of the HLM on UHC

• “Strengthen pub­lic health sur­veil­lance and data sys­tems, improve rou­tine immu­niza­tion and vac­ci­na­tion capac­i­ties, includ­ing by pro­vid­ing evi­dence-based infor­ma­tion on coun­ter­ing vac­cine hes­i­tancy, and expand vac­cine cov­er­age to pre­vent out­breaks as well as the spread and re-emer­gence of com­mu­ni­ca­ble and non‐com­mu­ni­ca­ble dis­eases, includ­ing for vac­cine-pre­ventable dis­eases already elim­i­nated as well as for ongo­ing erad­i­ca­tion efforts, such as for poliomyelitis.” (para­graph 31)

• “Strengthen efforts to address com­mu­ni­ca­ble dis­eases, includ­ing HIV/AIDS, tuber­cu­lo­sis, malaria and hepati­tis, as part of uni­ver­sal health cov­er­age and to ensure that the frag­ile gains are sus­tained and expanded by advanc­ing com­pre­hen­sive approaches and inte­grated ser­vice deliv­ery and ensur­ing that no one is left behind.” (para­graph 32)

• “Ensure, by 2030, uni­ver­sal access to sex­ual and repro­duc­tive health-care ser­vices, includ­ing for fam­ily plan­ning, infor­ma­tion and edu­ca­tion, and the inte­gra­tion of repro­duc­tive health into national strate­gies and pro­grammes, and ensure uni­ver­sal access to sex­ual and repro­duc­tive health and repro­duc­tive rights as agreed in accor­dance with the Pro­gramme of Action of the Inter­na­tional Con­fer­ence on Pop­u­la­tion and Devel­op­ment and the Bei­jing Plat­form for Action and the out­come doc­u­ments of their review con­fer­ences.” (para­graph 68)

2017 Resolution on international cooperation to address and counter the world drug problem

• “Urges Mem­ber States to increase the avail­abil­ity, cov­er­age and qual­ity of sci­en­tific evi­dence-based pre­ven­tion mea­sures and tools that tar­get rel­e­vant age and risk groups in mul­ti­ple set­tings, reach­ing youth in school as well as out of school, among oth­ers, through drug abuse pre­ven­tion pro­grammes and pub­lic aware­ness-rais­ing cam­paigns, includ­ing by using the Inter­net, social media and other online plat­forms, to develop and imple­ment pre­ven­tion cur­ric­ula and early inter­ven­tion pro­grammes for use in the edu­ca­tion sys­tem at all lev­els, as well as in voca­tional train­ing, includ­ing in the work­place, and to enhance the capac­ity of teach­ers and other rel­e­vant pro­fes­sion­als to pro­vide or rec­om­mend coun­sell­ing, pre­ven­tion and care ser­vices.” (para­graph 15)

• “Invites Mem­ber States to con­sider enhanc­ing coop­er­a­tion among pub­lic health, edu­ca­tion and law enforce­ment author­i­ties when devel­op­ing pre­ven­tion ini­tia­tives.” (para­graph 16)

• “Encour­ages the devel­op­ment, adop­tion and imple­men­ta­tion, with due regard for national, con­sti­tu­tional, legal and admin­is­tra­tive sys­tems, of alter­na­tive or addi­tional mea­sures with regard to con­vic­tion or pun­ish­ment in cases of an appro­pri­ate nature, in accor­dance with the three inter­na­tional drug con­trol con­ven­tions and tak­ing into account, as appro­pri­ate, rel­e­vant United Nations stan­dards and rules, such as the United Nations Stan­dard Min­i­mum Rules for Non-cus­to­dial Mea­sures (the Tokyo Rules).” (para­graph 24)

2016 Outcome Document of the Session on the World Drug Problem

• “Pro­mote the well-being of soci­ety as a whole through the elab­o­ra­tion of effec­tive sci­en­tific evi­dence-based pre­ven­tion strate­gies cen­tred on and tai­lored to the needs of indi­vid­u­als, fam­i­lies and com­mu­ni­ties as part of com­pre­hen­sive and bal­anced national drug poli­cies, on a non-dis­crim­i­na­tory basis” (para­graph 1(d))

2016 Resolution on Women, the Girl Child and HIV and AIDS

• “Also calls upon gov­ern­ments to take con­crete long-term mea­sures to achieve uni­ver­sal access to com­pre­hen­sive HIV pre­ven­tion, pro­grammes, treat­ment, care and sup­port for all women and girls and to remove all bar­ri­ers to achiev­ing uni­ver­sal health cov­er­age and improve access to inte­grated sex­ual repro­duc­tive health-care ser­vices, infor­ma­tion, vol­un­tary coun­sell­ing and test­ing and com­modi­ties, while build­ing the capac­ity of ado­les­cent girls and boys, young women and men to pro­tect them­selves from HIV infec­tion and enabling their use of avail­able com­modi­ties, includ­ing female and male con­doms, post-expo­sure pro­phy­laxis and pre-expo­sure pro­phy­laxis, while seek­ing to avoid risk-tak­ing behav­iour and encour­ag­ing respon­si­ble sex­ual behav­iour.” (para­graph 12)

• “Also calls upon gov­ern­ments and stake­hold­ers to inten­sify com­bi­na­tion pre­ven­tion ini­tia­tives for women and girls for the pre­ven­tion of new infec­tions and to reverse the spread of HIV and reduce mater­nal mor­tal­ity” (para­graph 12)

2016 Political Declaration on HIV and AIDS

• “Com­mit to adopt­ing, review­ing and accel­er­at­ing effec­tive imple­men­ta­tion of laws that crim­i­nal­ize vio­lence against women and girls, as well as com­pre­hen­sive, mul­ti­dis­ci­pli­nary and gen­der-respon­sive pre­ven­tive, pro­tec­tive and pros­e­cu­to­r­ial mea­sures and ser­vices to elim­i­nate and pre­vent all forms of vio­lence against all women and girls, in pub­lic and pri­vate spaces, as well as harm­ful prac­tices.” (para­graph 61(i))

• “Com­mit to redou­bling non-dis­crim­i­na­tory HIV pre­ven­tion efforts by tak­ing all mea­sures to imple­ment com­pre­hen­sive, evi­dence-based pre­ven­tion approaches to reduce new HIV infec­tions, includ­ing by con­duct­ing pub­lic aware­ness cam­paigns and tar­geted HIV edu­ca­tion to raise pub­lic aware­ness.” (para­graph 62(b))

• “Com­mit to accel­er­at­ing efforts to scale up sci­en­tif­i­cally accu­rate, age-appro­pri­ate com­pre­hen­sive edu­ca­tion, rel­e­vant to cul­tural con­texts, that pro­vides ado­les­cent girls and boys and young women and men, in and out of school, con­sis­tent with their evolv­ing capac­i­ties, with infor­ma­tion on sex­ual and repro­duc­tive health and HIV pre­ven­tion, gen­der equal­ity and women’s empow­er­ment, human rights, phys­i­cal, psy­cho­log­i­cal and puber­tal devel­op­ment and power in rela­tion­ships between women and men, to enable them to build self-esteem and informed deci­sion-mak­ing, com­mu­ni­ca­tion and risk reduc­tion skills and develop respect­ful rela­tion­ships, in full part­ner­ship with young per­sons, par­ents, legal guardians, care­givers, edu­ca­tors and health-care providers, in order to enable them to pro­tect them­selves from HIV infec­tion.” (para­graph 62(c))

• “Com­mit to sat­u­rat­ing areas with high HIV inci­dence with a com­bi­na­tion of tai­lored pre­ven­tion inter­ven­tions, includ­ing out­reach through tra­di­tional and social media and peer-led mech­a­nisms, male and female con­dom pro­gram­ming, vol­un­tary med­ical male cir­cum­ci­sion and effec­tive mea­sures aimed at min­i­miz­ing the adverse pub­lic health and social con­se­quences of drug abuse, includ­ing appro­pri­ate med­ica­tion-assisted ther­apy pro­grammes, inject­ing equip­ment pro­grammes, pre-expo­sure pro­phy­laxis for peo­ple at high risk of acquir­ing HIV, anti­retro­vi­ral ther­apy and other rel­e­vant inter­ven­tions that pre­vent the trans­mis­sion of HIV, with par­tic­u­lar focus on young peo­ple, par­tic­u­larly young women and girls, and encour­ag­ing the finan­cial and tech­ni­cal sup­port of inter­na­tional part­ners as appro­pri­ate.” (para­graph 62(d))

• “Pro­mote the devel­op­ment of and access to tai­lored com­pre­hen­sive HIV pre­ven­tion ser­vices for all women and ado­les­cent girls, migrants and key pop­u­la­tions.” (para­graph 62(e))

• “Encour­age Mem­ber States with high HIV inci­dence to take all appro­pri­ate steps to ensure that 90 per cent of those at risk of HIV infec­tion are reached by com­pre­hen­sive pre­ven­tion ser­vices, that 3 mil­lion per­sons at high risk access pre-expo­sure pro­phy­laxis and that an addi­tional 25 mil­lion young men are vol­un­tar­ily med­ically cir­cum­cised by 2020 in high HIV-inci­dence areas, and ensure the avail­abil­ity of 20 bil­lion con­doms in low- and mid­dle-income coun­tries.” (para­graph 62(f))

• “Com­mit to elim­i­nat­ing bar­ri­ers, includ­ing stigma and dis­crim­i­na­tion in health-care set­tings, to ensure uni­ver­sal access to com­pre­hen­sive HIV diag­nos­tics, pre­ven­tion, treat­ment, care and sup­port for peo­ple liv­ing with, at risk of and affected by HIV, per­sons deprived of their lib­erty, indige­nous peo­ple, chil­dren, ado­les­cents, young peo­ple, women, and other vul­ner­a­ble pop­u­la­tions.” (para­graph 62(j))

2016 Resolution on the girl child

• “Urges States and the inter­na­tional com­mu­nity to increase resources at all lev­els, par­tic­u­larly in the edu­ca­tion and health sec­tors, so as to enable young peo­ple, espe­cially girls, to gain the knowl­edge, atti­tudes and life skills that they need to ful­fil their social, eco­nomic and other poten­tial and over­come their chal­lenges, includ­ing the pre­ven­tion of HIV infec­tion and early preg­nancy, and to enjoy the high­est attain­able stan­dard of phys­i­cal and men­tal health, includ­ing sex­ual and repro­duc­tive health.” (para­graph 36)

Evidence

2021 WHO Updated Recommendations on HIV Prevention, EID and ART

• “Women will be coun­selled on the dapivirine vagi­nal ring along with other pre­ven­tion options such as daily oral PrEP. Male and female con­doms and part­ner ser­vices must also be avail­able and offered along­side the dapivirine vagi­nal ring. Some women may switch from oral daily PrEP to using the dapivirine vagi­nal ring and poten­tially back to oral PrEP use. These pos­si­ble pat­terns of using ARV drugs for pre­ven­tion are cur­rently not known or under­stood and require care­ful sup­port and assess­ment.” (p. 14)

2021 WHO Consolidated Guidelines on HIV Prevention, Testing, Treatment, Service Delivery and Monitoring

• “A global con­sul­ta­tion of ado­les­cents and young adults liv­ing with HIV was con­ducted among 388 respon­dents across 45 coun­tries, sup­ple­mented by 10 focus group dis­cus­sions with 61 ado­les­cents and young adults with HIV across 10 coun­tries. There was near uni­ver­sal agree­ment (95–98% of respon­dents) that psy­choso­cial sup­port inter­ven­tions would help sub­stan­tially across the HIV cas­cade and a range of out­comes. Psy­choso­cial sup­port was con­sid­ered crit­i­cal to both the men­tal and phys­i­cal health of ado­les­cents and young adults liv­ing with HIV.” (p. 408)

2020 Evidence Review of the UNAIDS Strategy 2016-2021

• “The num­ber of peo­ple reported to have received PrEP at least once in the pre­vi­ous year rose from fewer than 2000 in 2016 to more than 590 000 in 2019. In places where PrEP has been scaled up—e.g. Aus­tralia, Brazil and many coun­tries in west­ern and cen­tral Europe and North Amer­ica—HIV inci­dence among gay men and men who have sex with men has declined. New data from the SEARCH trial indi­cates that scale-up of PrEP along­side inten­si­fied health ser­vices reduced HIV infec­tions in 16 com­mu­ni­ties in Kenya and Uganda by 74%.” (p. 53)

• “Sim­i­larly, imple­men­ta­tion of effec­tive harm reduc­tion has improved pre­ven­tion out­comes in Ukraine, where par­tic­i­pants of peer-led com­mu­nity out­reach are now more likely to use ster­ile inject­ing equip­ment, con­doms and opi­oid sub­sti­tu­tion ther­apy and are achiev­ing bet­ter out­comes on all stages of the HIV treat­ment cas­cade.” (p. 53)

• “A num­ber of coun­tries have had strik­ing suc­cess in reduc­ing HIV inci­dence through the sup­port of scaled-up com­bi­na­tion pre­ven­tion pro­grammes. In Cam­bo­dia, a com­bi­na­tion of strong polit­i­cal lead­er­ship, out­reach to key pop­u­la­tions, robust con­dom pro­gram­ming and high lev­els of viral load sup­pres­sion led to a 95% reduc­tion in new HIV infec­tions over two decades. Like­wise, the scale-up of com­bi­na­tion pre­ven­tion in Zim­babwe was asso­ci­ated with a reduc­tion in new HIV infec­tions of at least 80% over 25 years. In South Africa, where new HIV infec­tions have decreased by 53% since 2010, reduc­tions in HIV inci­dence between 2000 and 2008 were par­tially attrib­uted to increased con­dom use. Since 2010, South Africa has achieved one of the steep­est declines in HIV inci­dence in the region, a feat that is attrib­uted to the coun­try’s simul­ta­ne­ous expan­sion of ART and vol­un­tary med­ical male cir­cum­ci­sion.” (p. 55)

• “We have the tools to sharply reduce the num­ber of new HIV infec­tions, since evi­dence clearly demon­strates that com­bi­na­tion pre­ven­tion works. Evi­dence from both clin­i­cal tri­als and real-world imple­men­ta­tion of com­bi­na­tion pre­ven­tion shows the effec­tive­ness of diverse, lay­ered HIV pre­ven­tion strate­gies and approaches. Case stud­ies of high-bur­den coun­tries that have sharply low­ered HIV inci­dence under­score the impor­tance of chang­ing sex­ual risk behav­iours and the added pre­ven­tion ben­e­fits of increased cov­er­age of ART. Stud­ies in Kenya and South Africa indi­cate that pre­ven­tion and treat­ment work best when brought to scale simul­ta­ne­ously. Mod­el­ling exer­cises have quan­ti­fied the num­ber of infec­tions averted for key pre­ven­tion inter­ven­tions. It is esti­mated that vol­un­tary med­ical male cir­cum­ci­sion averted about 250 000 new HIV infec­tions by 2018 and could avert 1.6 mil­lion new infec­tions by 2030, along with pre­vent­ing other sex­u­ally trans­mit­ted infec­tions, as well. It is esti­mated that con­dom use has averted nearly 50 mil­lion HIV infec­tions since the begin­ning of the HIV response. Com­bi­na­tion HIV pre­ven­tion entails an expand­ing array of bio­med­ical, behav­ioural and struc­tural inter­ven­tions. Stud­ies have found that sev­eral inter­ven­tions—includ­ing ART, PrEP, con­doms and ster­ile inject­ing equip­ment—have a very high level of effec­tive­ness (80–100%) if con­sis­tently used. Evi­dence also shows that vol­un­tary med­ical male cir­cum­ci­sion is an effec­tive one-time pro­ce­dure which reduces men’s risk of acquir­ing HIV from female part­ners by 38–66%. Opi­oid sub­sti­tu­tion ther­apy can reduce the risk of acquir­ing HIV by up to 54% for peo­ple who inject drugs and has a range of addi­tional health and social ben­e­fits.” (pp. 52–53)

• “Com­pre­hen­sive sex­u­al­ity edu­ca­tion has been shown to improve HIV-related knowl­edge and encour­age safer sex­ual behav­iours. It is also rel­a­tively inex­pen­sive: one mul­ti­coun­try eval­u­a­tion found that com­pre­hen­sive sex­u­al­ity edu­ca­tion need avert only 4% of pro­jected HIV infec­tions to be cost-sav­ing. Other behav­ioural inter­ven­tions also have pos­i­tive out­comes in spe­cific con­texts. Short-term HIV pre­ven­tion cam­paigns in schools have been found to be effec­tive in reduc­ing sex­ual rela­tions with older higher-risk part­ners, as well as teenage preg­nan­cies. Com­bined behav­ioural and struc­tural inter­ven­tions using gen­der-trans­for­ma­tive HIV pre­ven­tion approaches are effec­tive in chang­ing sex­ual behav­iours and in pre­vent­ing HIV in some set­tings.” (pp. 53)

2016 Prevention Gap Report

• “How­ever, few coun­tries have con­sis­tently applied a com­bi­na­tion HIV pre­ven­tion approach, which pro­vides pack­ages of ser­vices—includ­ing behav­ioural, bio­med­ical and struc­tural com­po­nents—tai­lored to pri­or­ity pop­u­la­tion groups within their spe­cific local con­texts. For exam­ple, young peo­ple in high preva­lence coun­tries need more than con­doms and behav­iour change com­mu­ni­ca­tions. They also require com­pre­hen­sive sex­u­al­ity edu­ca­tion and access to effec­tive HIV and sex­ual and repro­duc­tive health ser­vices with­out eco­nomic bar­ri­ers, such as pro­hib­i­tive costs, or struc­tural bar­ri­ers, such as parental con­sent laws. A com­bi­na­tion pack­age for gay men and other men who have sex with men should include easy access to con­doms, lubri­cant and PrEP, as well as efforts to address homo­pho­bia; a pack­age for peo­ple who inject drugs should fea­ture com­pre­hen­sive harm reduc­tion ser­vices, includ­ing nee­dle-syringe pro­grammes and opi­oid sub­sti­tu­tion ther­apy.” (p. 10)

• “Get­ting back on track to reduc­ing new infec­tions to 500 000 by 2020 requires con­tin­ued progress towards the 90–90–90 tar­get and inten­sive focus on five pre­ven­tion pil­lars deliv­ered through a peo­ple-cen­tred, com­bi­na­tion approach:Com­bi­na­tion pre­ven­tion, includ­ing com­pre­hen­sive sex­u­al­ity edu­ca­tion, eco­nomic empow­er­ment and access to sex­ual and repro­duc­tive health ser­vices for young women and ado­les­cent girls and their male part­ners in high-preva­lence loca­tions.” (p. 10)

• “Indi­vid­ual harm reduc­tion approaches are suc­cess­ful in reduc­ing the harms related to drug use, but they are even more effec­tive when deliv­ered as a pack­age, not only together but com­bined with other pre­ven­tion ser­vices such as con­dom pro­grammes and treat­ment. Con­dom pro­vi­sion within harm-reduc­tion pro­grammes can help to reduce the trans­mis­sion of HIV from peo­ple who inject drugs to their sex­ual part­ners. Ensur­ing HIV tests are offered rou­tinely to peo­ple who access nee­dle-syringe ser­vices and opi­oid sub­sti­tu­tion ther­apy helps to iden­tify peo­ple liv­ing with HIV as soon as pos­si­ble after infec­tion and the imme­di­ate ini­ti­a­tion of anti­retro­vi­ral ther­apy. Peo­ple liv­ing with HIV who inject drugs are more likely to remain on anti­retro­vi­ral ther­apy if they are also access­ing opi­oid sub­sti­tu­tion ther­apy; in addi­tion, early ini­ti­a­tion of treat­ment con­trib­utes to the sup­pres­sion of viral load and max­i­mizes the pre­ven­tion ben­e­fits of such treat­ment. Increas­ing the pro­vi­sion of such com­bined approaches—includ­ing those that incor­po­rate pre-expo­sure pro­phy­laxis for peo­ple who inject drugs at par­tic­u­larly high risk, and for their sex­ual part­ners—will enhance the ben­e­fits of harm reduc­tion.” (p. 52)

2015 Fast-Tracking Combination Prevention

• “Sev­eral HIV pre­ven­tion meth­ods have proved effec­tive when used con­sis­tently, but no sin­gle pre­ven­tion approach has the abil­ity to stop the epi­demic on its own. Com­bi­na­tions of pre­ven­tion inter­ven­tions are needed. Dif­fer­ent set­tings and pop­u­la­tions will require dif­fer­ent com­bi­na­tions of inter­ven­tions. The best HIV pre­ven­tion impact comes from offer­ing a pack­age of inter­ven­tions care­fully selected to suit the epi­demic set­ting and the pop­u­la­tion.” (p. 17)

• “HIV pre­ven­tion resources should be focused more intensely on geo­graphic areas at ele­vated risk. Recent mod­el­ling found that in Kenya a uni­formly dis­trib­uted com­bi­na­tion of pre­ven­tion approaches could reduce new HIV infec­tions by 40% over 15 years. But new infec­tions could be reduced by another 14% if a pre­ven­tion strat­egy with the same bud­getary resources focused on peo­ple and loca­tions of great­est risk. India has used geo­graph­i­cal and pop­u­la­tion pri­or­i­ti­za­tion in its pre­ven­tion efforts and, as a result, has seen a marked decrease in new infec­tions between 2000 and 2010.” (p. 20)

• “More than ever before, it is crit­i­cal that national HIV pre­ven­tion responses focus on com­bi­na­tions of these proven high-impact tools, includ­ing con­doms, VMMC, PrEP and ART. Con­text-spe­cific, evi­dence-based behav­ioural and struc­tural pro­gramme ele­ments are impor­tant as well. Approaches pro­vid­ing basic knowl­edge, aware­ness and gen­eral behav­iour change mes­sages need to be replaced with approaches informed by local evi­dence on fac­tors shap­ing behav­iours and pro­gramme mod­els, which have been effec­tive in achiev­ing the intended out­comes in sim­i­lar con­texts.” (p. 20)