Centers for Disease Control and Prevention
Global AIDS Program
Prevention Interventions for People Living
with HIV: 5 HIV Prevention Steps
and Tools for Implementation
Pamela Bachanas, PhD
Washington, DC
August, 2008
Prevention for People Living with HIV
• Scale up of care and treatment programs
in SSA have been an extraordinary
success – 2.5 million people on ARVs
• However, in 2007 alone, 2.5 million people
were newly infected with HIV, most of whom
will eventually need ARVs
• Effective and efficient HIV prevention
interventions are critically needed
Prevention for People Living with HIV
• Traditional focus of prevention efforts
have been on preventing acquisition
among HIV- individuals
• To have a significant impact on slowing
the spread of the epidemic, prevention
efforts must also be directed toward
individuals living with HIV who can
transmit the virus
Only HIV+ individuals
can transmit HIV
HIV
prevalence,
Kenya, 2006
HIV positive, 6%
HIV negative, 94%
►Focusing on ~1.3m HIV-infected people
rather than ~21.6m uninfected people is an
efficient, targeted prevention approach
HIV Prevention in
Care and Treatment
• Due to increasing availability of HIV treatment, many
HIV+ persons are accessing health care settings and
clinics, providing an opportunity to reach a large
number of infected persons with prevention
messages and interventions
• Health care providers in HIV clinic settings meet with
patients regularly and can deliver consistent, targeted
prevention messages and strategies during routine
visits
• Providers are considered authority figures and
trusted sources of health information
HIV Prevention in
Care and Treatment
• For any disease, preventive information on infection
control is regarded as quality standard of care
• Health care providers can also address biomedical
prevention strategies, such as reproductive health and
STI management
• Given clinic burden and complexity of patients’ needs,
many patients need more in-depth counseling on
prevention issues (e.g. disclosure, alcohol use).
Incorporating counselors (including PLWHA) into clinic
settings is essential for a comprehensive prevention
program
Prevention for People Living with HIV
• Multiple approaches to prevention are
needed; integration of prevention into care
and treatment settings is critical
• Integrating prevention services into care and
treatment can be overwhelming and can
require a great deal of effort and resources
• However, we can’t afford not to do it
ART Need in Namibia Assuming
Immediate End to Transmission
200,000
180,000
160,000
140,000
120,000
100,000
80,000
60,000
40,000
20,000
0
2007 2008 2009 2010 2011 2012 2013 2014 2015
ART Need in Namibia Assuming
Ongoing Transmission
350,000
300,000
250,000
200,000
150,000
100,000
50,000
0
2007 2008 2009 2010 2011 2012 2013 2014 2015
Prevention for People Living with HIV
• The question isn’t can we do prevention in
care and treatment…
• The question is how do
we do prevention in care
and treatment…
– What are the specific interventions
– How can they be implemented most efficiently
(task shifting, etc,)
Step 1 – Give prevention
recommendations to every
patient at every visit
Critical Need for Prevention
Interventions with PLWHA
• Vast majority of PLWHA are married in Kenya (70%),
Malawi (82%), & Uganda (57%) [DHS & AIS data]
• Rates of partner testing among PLWHA very low
• Rates of disclosure of serostatus to partner(s) low
and challenging
• Condom use in stable relationships very low
HIV status of spouses of HIV-infected
persons in Kenya, DHS, 2003
HIV DISCORDANT:
CONCORDANT POSITIVE:
One partner positive, one
partner negative: 50%
Both partners HIV-infected:
50%
►In Kenya, 50% of married HIV+ persons
(450,000) have an HIV-negative spouse
Nature of Incident Infection, Uganda
Sero-behavioral Survey, 2004-5
38%
Spouse with longstanding infection
Spouse with
recent infection
49%
Spouse was
uninfected
13%
Note: among 79 couples
CONDOM USE IN REGULAR PARTNERSHIPS
Discordant Couple Interventions:
Couple Counseling and Testing
963 discordant couples in
Lusaka (Allen et al., 2003)
Self-reported condom use
increased from 3% to 80% after
1 year
53 discordant couples in Kigali
(Allen et al., 1992)
Self-reported condom use
increased from 4% to 57% after
1 year
149 discordant couples in
Kinshasa (Kamenga et al.,
1991)
Self-reported condom use
increased from <5% to 77%
after 1 year
Step 1 – Give prevention
recommendations to every patient
at every visit
• Providers and counselors must assess
whether each patient’s partner has been
tested; test or refer to counselor for testing
• Provider- and/or counselor-assisted
disclosure
• Counselor who can conduct rapid testing
available in clinic and community settings
• Children of HIV+ moms tested
Step 1 – Give prevention
recommendations to every patient
at every visit
• Discordant couples identified and counseled
– Positive partners linked to care and treatment
– Negative partners counseled on prevention practices to stay
negative (condoms!)
• Provider delivers brief messages on patient selfprotection & partner protection
– Consequences of unprotected sex
• Provider assesses patient for alcohol use that affects
adherence or risky behavior
– Refer drinkers to counselor
HIV Acquisition among Male Partners of
HIV + Female Partners By Circumcision
Status In Rakai
Acquisition/100py
30
25
27.7
27.7
Circumcised
Uncircumcised
20
15
8.2
10
5
0
0
0
0
<10,000
10,000-49,999
>50,000
Female viral load
Quinn et al; NEJM 2000; 342:921-9
Step 2 – Assess adherence to
ARVs
• Provide adherence support or refer to
counselor for support
Step 3 – STI Management
Integrated into HIV Clinics
STI Management
Integrated into HIV Care
• In HIV+ individuals, STIs have been shown to increase
genital HIV shedding, increasing likelihood of HIV
transmission.
• STIs have been associated with increased genital HIV
shedding in persons on ARVs with suppressed plasma
viral loads.
• Genital ulcer disease has the strongest association with
HIV transmission; high rates of HIV/HSV co-infection.
• Urethritis, vaginitis, and bacterial vaginosis have also
been associated with transmission and acqusition.
STI Management
Integrated into HIV Care
• Assess for signs and symptoms of STIs at every visit
and treat as indicated
• Treating STIs in HIV+ persons is important for care,
as STIs can be more severe and more difficult to treat
in immunocompromised individuals
• Treating STIs in HIV+ persons is important for
prevention; may reduce chances of transmission of
HIV
• Treating partners of patients with STIs may reduce
reinfection and stop the spread of the STI
Step 4 - Family Planning Services
and Safer Pregnancy Counseling in
Care and Treatment
(through Wrap-Around Programs)
Family Planning
• Many women on ARVs resume sexual activity and have
unintended pregnancies (Bunnell et al., 2006)
• Preventing unintended pregnancy in HIV+ women who do
not want children can avert the need for and costs
associated with (Sweat et al., 2004)
– PMTCT
– care for HIV+ children
– support for orphans
• Other HIV+ women on treatment desire children (Nakayiwa
et al., 2006); they require counseling on safe timing of
pregnancy and referrals to PMTCT
Unmet need for family planning
among HIV-infected women
(Bunnell, 2007)
Kenya Malawi Uganda
Last pregnancy
unplanned/unwanted
HIV-infected women who do
not want more children
Unmet need for
contraception among those
who do not want more
children
54%
40%
41%
50%
49%
-
64%
79%
-
Step 4 – Assess pregnancy
status & intentions
• Inquire about pregnancy status/intentions every visit
Through wrap-around funding:
• Provide basic contraceptives in HIV clinic (pills,
injectables) and refer to FP for other contraceptives
• Provide basic counseling on safer conception,
pregnancy, and delivery for HIV+ women desiring
pregnancy in the HIV care and treatment setting
Step 5 – Give patient
condoms at every visit!!
Lay Counselors in Care and
Treatment Clinics
Lay Counselors
• Given clinic burden and complexity of patients’
needs, many patients need more in-depth counseling
on prevention issues than providers can manage
• Task shifting some responsibilities to lay counselors
may be a cost-effective and supportive way to meet
clinic and patient needs for services
• Training lay counselors to expand and reinforce
prevention messages delivered by providers and to
provide more in-depth counseling on specific
prevention issues is critical for prevention efforts
HIV Prevention for People Living with HIV/AIDS:
An Intervention Toolkit for HIV Care and Treatment Settings
Overhead 5-10
The 5 HIV Prevention Steps
Intervention
• 1-day Provider Training
– Sensitizes providers to their
critical role in influencing
patients’ risk behaviors
– Teaches them skills for
delivering behavioral
prevention messages
– Provides overview and
rationale for biomedical
interventions
– Allows providers to practice
delivering prevention
messages to patients
Family Planning and Safer
Pregnancy Counseling
• 2 day provider training
• Trains providers to integrate FP services into
routine care and treatment of HIV+ women
and partners of male patients
• Pills, injectables
• Safer pregnancy counseling
• Flip chart for health care providers – technical
resource
Management of Sexually
Transmitted Infections in People
Living with HIV/AIDS
• 2 day provider training
• Management of STIs in PLWHA as part
of routine care
– Assessment questions, exams, syndromic
management
• Partner management
HIV Prevention and Adherence
Counseling for PLWHA
• 2 week training on prevention and adherence
counseling for lay counselors (many of whom
are PLWHA)
• 2 week training on counseling and testing for
lay counselors (where permitted by national
guidelines
• Flip chart for group education on prevention
and adherence topics
• Individual counseling guide
Prevention for People Living with HIV in
Care and Treatment Settings
•
•
•
•
•
Kenya
Namibia
Nigeria
Haiti
Ethiopia
•
•
•
•
•
Tanzania
Rwanda
Cote d’ Ivoire
Botswana
South Africa (?)
Integrating HIV Prevention into
Clinic Settings
Family Planning
CCC
Prevention
for PLWHA
TB
Primary Care
PMTCT/
ANC
Male Circumcision
Testing and
counseling
Integrating HIV Prevention into
Community Settings
PLWHA support
networks
VCT
FBO services
Community counseling
centers
Prevention
for PLWHA
Home-based
Care
Community Health
Workers
Thank you!
Discussion Questions
• How can Track 1 partners assist MOH and
USG in developing and scaling up national
programs?
• How can Track 1 partners strengthen role as
technical leaders and TA providers in this
area?
• How can efforts be coordinated to reduce
duplication of program development and
increase implementation efforts?
• What are challenges and barriers to
implementation and scale-up?