Combination HIV Prevention: Crafting a New Standard for the Long-term Response to HIV Carlos F. Cáceres, Cayetano Heredia University/IESSDEH, Peru Barbara de Zalduondo, UNAIDS, Switzerland Timothy Hallett, Imperial College London, UK Carlos Avila, UNAIDS, Switzerland Michaela Clayton, AIDS Rights Alliance for Southern Africa, Namibia “A sensible way to go…” • “Combination Prevention” highlighted in discussions in 2008 Conference – See The Lancet Series 2008 • Increasingly regarded as the ‘sensible’ way to go – 2008 Global Prevention Working Group, – 2009 UNAIDS Outcome Framework; – 2009 Implementers Meeting; – Global Fund Board 2009 recommendation; – UNAIDS Prevention Reference Group (PRG), 2009; etc …but not a guiding principle yet! • Yet still not a guiding principle applied systematically in HIV programming • Some doubts remain – is it anything new? Is it necessary? • Our goal today: – Clarify concepts around Combination Prevention – Argue that structural interventions, including human rights strategies, are core business of HIV prevention – Discuss how and why it can provide a standard for a longer-term response to HIV. What is Wrong with Prevention Now Risk Groups Risk Practices Vulnerability Cultural context What is Wrong with Prevention Now Most-at-risk populations Vulnerability Individual Cultural context Risk Practices …what is wrong? (2) • Inconsistent application of standards – “Know Your Epidemic and Response;” Know and engage with key audiences; allocate resources to suit Modes of Transmission, etc. – Lack of consensus on approaches • Fragmentation and scatter (see Bertozzi et al, The Lancet, 2008) …what is wrong? (3) • Focus on short-term results – Research and programme evaluations with 6-36 month follow-up – Low-hanging fruit - preference for solving bite-sized problems, neglecting the underlying causes of risk and vulnerability (aids2031 Social Drivers Workgroup) • Limited evaluation and cumulation of learning from country programmes – Limited investment in prevention evaluation research – Confused language describing prevention aims and actions: goal, activity, audience, setting, proximity of effect Percent Spending in Programs focusing on Most-at-risk Populations (as a Percentage of Total Prevention Spending) 8.00% 7% 7.00% 6.00% 5.00% Harm reduction programs for IDUs Programs for MSM Programs for sex workers and their clients 4.00% 3.00% 2.00% 1.00% 0.00% Low level Concentrated Generalized Source: UNAIDS HIV Expenditure Studies Individuals National/ Societal Group/ Community/ Organizations (women, girls, children, men, boys, transgender) Relationships Family/Partner Individuals (women, girls, children, men, boys, transgender) What is Combination Prevention? • Recapitulating: Analogy to combination treatment Cited by Coates et al., 2008 Combining what? • Type 1 – Common tactic combining two or more intervention strategies – E.g.. IDU: Needle & syringe programs + opiate substitution. – E.g. US NIH “MP3” (methods for prevention packages program) • Type 2 - Combining diverse strategies to fit the needs of diverse sub-groups in the population – E.g. strategies for MSM, trans, IDU, FSW, PMTCT, discordant couples • Type 3 – Strategic combinations of biomedical, behavioral and structural approaches to address key causes of HIV risk and vulnerability for a particular population – E.g. Synergistic interventions for interrelated sub-groups – E.g. MSM: BCC, STI Tx, decriminalization, mobilization – E.g. IDU: NSP, OSP, decriminalization, mobilization UNAIDS Prevention Reference Group Definition • “The strategic, simultaneous use of different classes of prevention activities (biomedical, behavioral, social/ structural) that operate on multiple levels (individual, relationship, community, societal), to respond to the specific needs of particular audiences and modes of HIV transmission, and to make efficient use of resources through prioritizing, partnership and engagement of affected communities” What Kind of Evidence is Needed? Human Rights Epidemiological • e.g. Data from Modes patterns and trends of Transmission Studies Main drivers of those epidemic trends Effective Interventions to address epidemic patterns and their drivers • e.g. Specific forms of social exclusion (class, gender, sexuality) and their confluence • e.g. Effective behavioral, biomedical, structural interventions Case et al., AIDS International Conference, 2010 Potential Effects Bringing Proven Prevention Programmes to Scale Status Quo 25M infections could be averted! Scaled Intervention In GE: Circumcision, HTC, Treatment, Community Mobilization In CE: Increase condom use and harm reductiong in MARPS Biomedical, Behavioral, Structural • Behavioral prevention – Traditional prevention work: Behavioral change (from 11 to groups to behavioral change communication) – Change individuals’ practices to reduce exposure and infectivity • Reduction of partners, condom use, use clean IDU equipment • Biomedical prevention – – – – Male circumcision ARV prophylaxis (PMTCT. PEP) Antiretroviral Treatment (ART) Experimental: PrEP; ART-based microbicides, vaccines Structural Interventions • Many definitions, many conceptual frameworks – e.g collections in collections in AIDS 1995; AIDS, 2000; aids2031 Social Drivers Working Group. • Focused on aspects of environment that increase people’s vulnerability to HIV infection or decrease access. • Body of work on Social Determinants of Health. • Main types (from Robin Vincent, 2009): – Changes in laws and regulations, – Promoting changes in culture and social norms (e.g. gender inequalities, HIV related stigma), – Environmental enablers (e.g. increasing access), – Community mobilization and empowerment, – Policy dialogue and prevention diplomacy Interacting causes of HIV risk and vulnerability Behavioural factors Social and cultural factors. Biomedical Political and economic factors SYNTHESIS Gap Analysis Biomedical factors Physical environment factors 17 Biomedical Behavioural Structural (Social and cultural, Political and economic; Physical) Combination Prevention Behavioural intervention strategies: Social and cultural intervention strategies: Behaviour change communication School based HIV education; •Community dialog and mobilization Peer-led advocacy and persuasion •Advocacy and coalition building for social justice Influence cost of access to serviceds Couseling •Media and interpersonnal communication to clarify values, change harmful social norms; Biomedical •Education curriculum reform, expansion and quality control •Etc. Political and economic intervention strategies: •Human rights programming; Intervention strategies addressing physical environment: •Housing policy and standards •Access to land; subsistence; •Infracstructure development – transportation, communications, etc. •Prevention diplomacy with leaders at all levels; •Community Microfinance/microcredit Etc. SYNTHESIS •Training/advocacy with police, judges; GapBiomedical Analysis intervention •Engaging leaders strategies: •Stakeholder analysis & alliance •Improved STI services; Appropriate & building; accessible clinical services; condoms •Strategic advocacy; •Opiod substitution therapy, detox; •Regulation/deregulation; •Male circumcision •Etc. •PMTCT services – ARV prophylaxis (PEP, PrEP, Microbicides) •ART for prevention •Etc. ; 18 ; Biomedical Behavioural Structural (Social and cultural, Political and economic; Physical) Human Rights: Beyond Rhetoric • Ethical Principle: CP is a strategy to reach Universal Access (Human Rights [HR]-based) • Technical reason: Sound consideration of HR is a necessary element of successful programs – Lack of HR perspective may lead to program failure • Condom use programming in Asia designed without considering sex workers’ HR issues led to abuses and failure. – Also need to face legal & HR-related structural barriers – Good prevention planning starts with a HR analysis – Insufficient to just ‘protect HR’ at implementation • Testing promotion programs: Understand people’s needs + rights and then design the best interventions within that framework. – Environments protective of people’s rights unleash community and individual motivation to avoid HIV Ukraine: Reducing Police Violence HIV Infections Averted By Structural Changes 1000 4 - 19% 800 600 3 - 9% 400 2 - 5% 200 0 662 343 209 Est for Odessa Est for Makeevka Est for Kiev Elimination of police beatings Strathdee, Hallett, Bobrova et al., Lancet 2010 Stigma Reduction can improve PMTCT Outcomes Per 100,000 women (assuming 15% prevalence at ANC) Watts, Zimmerman, Eckhaus and Nyblade, 2010. Modelling the Impact of Stigma on HIV and AIDS Programmes: Preliminary Projections for Mother-to-Child Transmission. ICRW and LSHTM Working Paper. Myths about Combination Prevention Combination prevention is “doing everything for everyone” It can’t be done No! – that’s poorly designed prevention! Not so – IMAGE, Avahan, Stepping Stones, Sonagachi Need political courage to focus where the need is Need capacity to deliver to scale HIV Prevalence Among Sex workers in Mysore DATA Fit with AVAHAN intervention removed Estimated Impact of intervention “Best fit” projection Source: Pickles, Foss, Vickerman et al., 2010 Beyrer et al, working paper Peru: Political Courage and Community Mobilization is Needed to Change the Epidemic’s Trajectory Present level 100% MSM coverage Null Current 100% MSM interventions Myths about Combination Prevention It can’t be evaluated True that it’s difficult to map and prove the causal chain. Easier to show effects at similar level of proximity. Need to better assess effects of programs that include structural interventions. Need Combination Evaluation! True that measuring impact of any intervention is difficult. No reliable, validated, working test for HIV incidence to compare combinations. But – analysis of HIV prevalence can allow a retrospective estimate of changes in incidence in relation to programme and context. Zimbabwe: Use of Modelling to Assess Impact over Time 10 10 Natural decline in incidence ~ 1990 HIVincidence incidence(per (per100pyar) 100pyar) HIV 8 8 Accelerated decline in incidence, due to behaviour change: ~ 2000 6 6 4 4 2 2 0 0 1980 1980 1985 1985 1990 1990 1995 1995 Year Year 2000 2000 Hallett, Gregson, Gonese, et al., Epidemics, 2009 2005 2005 2010 2010 Myths about Combination Prevention It’s too expensive Compared to what? The missing pieces are often the structural interventions. Contrary to common perception, the additive costs can be quite reasonable. Synergies. Economies of scale Human rights (HR) services are 1.4 % of ART programme costs in South Africa Source: Jones et al: Human Rights Costing of HIV for Prevention in a Southern African Setting. Poster at aids2010. • Charlotte watts/ICRW slide ( Watts, Zimmerman, Eckhaus and Nyblade, 2010. Modelling the Impact of Stigma on HIV and AIDS Programmes: Preliminary Projections for Motherto-Child Transmission. ICRW and LSHTM Working Paper. http://seofrecencaricias.blogspot.com Structural Interventions “float all boats” Gender Equity effects Sexual Inclusion Effects Poverty Reduction Effects HIV effects Social Change Takes Time – START NOW! Results in 1-2 years Results in 3-5 years Results in > 5 years e.g. Knowledge of HIV prevention, Awareness of risks of Multiple concurrent partners, supportive professional and workplace policies e.g. Supportive community attitudes, Enforcement of supportive policies Programmes have focused on those, shortterm results for 25 years! UNAIDS Social Change Communication Working Group, 2008. More Equitable Gender Norms Positive Health, Dignity and Prevention "Positive health, prevention and dignity highlights the importance of placing the person living with HIV at the centre of managing their health and well-being, within the sociocultural and legal context in which they live. It also stresses the importance of addressing prevention and treatment simultaneously and holistically and emphasizes the leadership of people living with HIV in responding to policy and legal barriers and in driving the agenda forward.“ Kevin Moody, Director and CEO, GNP+ Challenges • Need better tools to ‘know our epidemics’ – Ascertaining incidence, size estimations – Standardizing terminology • Need more evidence about our responses – Insufficient data on what works, contradictions, how to improve conceptualization of CP – What combinations are necessary and sufficient in specific settings? Coverage, intensity? Take-Home Messages • Focus on individuals for prevention (w/biomedical and behavioral approaches) is not sufficient • CP is not about implementing rigid panel of redundant/irrelevant interventions. • Rather, CP is strategic, evidence-informed, combination of biomedical, behavioral and structural strategies in a HR framework. • Investing in structural interventions is not only an ethical obligation – it is a worthwhile investment • Needed for a sustained, long-term response • A flagship of a “prevention revolution”! “The successful implementation of HIV interventions therefore demands, first of all, that local-level barriers be addressed and that an ‘enabling environment’ be created. This is not difficult to achieve. Often, what appears to be intractable resistance to respecting the basic rights of most-at-risk groups yields to thoughtful advocacy and bridgebuilding with local authorities and powerbrokers.” Commission on AIDS in Asia. 2008. Redefining AIDS in Asia: Crafting an Effective Response. Report of the Commission on AIDS in Asia, . New Delhi, India: Oxford University Press Acknowledgements • • • • • • • • • • B. Zalduondo, T. Hallett, C. Avila, M. Clayton K. Daly (ICASO), K. Thomson (UNAIDS) All authors who shared their work with us C. Beyrer et al. (JHUSPH/WB) Auerbach et al, 2009 (aids2031) Social Drivers Workgroup, aids2031 Sam McPherson (International HIV Alliance) UNAIDS Prevention Reference Group WHO HIV Department IESSDEH and USSDH/Cayetano Heredia University Thanks!