5

Prevention

MAIN MESSAGES

Overall

•    PEPFAR’s support for the scale-up of HIV prevention activities across prevention modalities has been an achievement and a contribution to the response to the epidemic in partner countries. Within PEPFAR there has been an evolution in prevention programming, from an initial focus on a limited number of behavioral and biomedical interventions, to an expansion of prevention portfolios to reflect both existing and emergent evidence-based approaches.

•    Although PEPFAR has articulated a commitment to overarching goals for prevention, PEPFAR lacks clear target outcomes and objectives across all prevention modalities; this is especially the case for behavioral and structural interventions for prevention of sexual transmission, the primary global driver of HIV infection. To achieve its overall goal of reducing new infections and stopping the spread of the epidemic, PEPFAR will need a more comprehensive and balanced approach, with greater clarity in its operational guidance and mechanisms to support the development, implementation, monitoring, and evaluation of prevention portfolios in country programs that are aligned with the drivers of epidemics and the needs for prevention services. Greater attention to developing appropriate approaches to assess the effectiveness of prevention interventions across all modalities and modes of transmission would contribute to this more balanced and comprehensive operational approach.

•    There are limitations to measuring the effects of prevention programs across modalities, and in particular for behavioral and structural interventions. These limitations are not unique to PEPFAR and a substantial increase in attention and effort will be required to address them, yet more comprehensively identifying and understanding the outputs, coverage, and outcomes of prevention interventions would be of immense value in accurately assessing and documenting the impact of prevention efforts. Across modalities, measuring and achieving key intermediate outcomes for prevention efforts is as important a goal for PEPFAR as achieving estimated impact on the number of infections averted.



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5 Prevention MAIN MESSAGES Overall • PEPFAR’s support for the scale-up of HIV prevention activities across prevention modalities has been an achievement and a contribution to the response to the epidemic in partner countries. Within PEPFAR there has been an evolution in prevention programming, from an initial focus on a limited number of behavioral and biomedical interventions, to an expansion of prevention portfolios to reflect both existing and emergent evidence-based approaches. • Although PEPFAR has articulated a commitment to overarching goals for prevention, PEPFAR lacks clear target outcomes and objectives across all prevention modalities; this is especially the case for behav- ioral and structural interventions for prevention of sexual transmission, the primary global driver of HIV infection. To achieve its overall goal of reducing new infections and stopping the spread of the epidemic, PEPFAR will need a more comprehensive and balanced approach, with greater clarity in its operational guidance and mechanisms to support the development, implementation, monitoring, and evalu- ation of prevention portfolios in country programs that are aligned with the drivers of epidemics and the needs for prevention services. Greater attention to developing appropriate approaches to assess the effectiveness of prevention interventions across all modalities and modes of transmission would contribute to this more balanced and comprehensive operational approach. • There are limitations to measuring the effects of prevention programs across modalities, and in particular for behavioral and structural inter- ventions. These limitations are not unique to PEPFAR and a substan- tial increase in attention and effort will be required to address them, yet more comprehensively identifying and understanding the outputs, coverage, and outcomes of prevention interventions would be of im- mense value in accurately assessing and documenting the impact of prevention efforts. Across modalities, measuring and achieving key intermediate outcomes for prevention efforts is as important a goal for PEPFAR as achieving estimated impact on the number of infec- tions averted. 159

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160 EVALUATION OF PEPFAR Prevention of Sexual Transmission • Interventions targeted at prevention of sexual transmission, including biomedical, behavioral, and structural interventions, are all critical components of a balanced and comprehensive prevention portfolio. Yet, within PEPFAR, there is disproportionately less program moni- toring data and rigorous research evidence available on these in- terventions, especially behavioral and structural interventions, than on prevention of mother-to-child transmission (PMTCT) and other biomedical prevention programs. As a result, the committee was un- able to assess the effectiveness or determine the outcomes or impact across partner countries of PEPFAR’s efforts to reduce sexually trans- mitted HIV infections. There is a critical need for improved application of advances in social and behavioral science–based research and eval- uation science for prevention to determine the most effective combi- nation of prevention interventions in diverse country contexts. Given the scale of its programs and its commitment to implementation research, PEPFAR can contribute to a more effective HIV response by serving as a platform for innovation to fill the gap in knowledge and availability of effective interventions. • There is recognition in PEPFAR of the important role of efforts for sex workers as a part of the national response in both concentrated and generalized epidemics. There are some examples of success as a result of PEPFAR-supported activities for this population, and increased flexibility over time for prevention budgeting and programming has enabled country programs to more readily plan activities for sex workers. • Over time PEPFAR has increasingly supported data collection efforts and prevention programming for men who have sex with men, which PEPFAR has recently codified in programmatic guidance. Men who have sex with men are recognized as an important population for prevention and other PEPFAR-supported programming. Prevention of Mother-to-Child Transmission • PEPFAR support for scale-up of services for PMTCT has made a ma- jor contribution to meet the need in partner countries. Integration of PMTCT into maternal and child health is occurring and is a sign of evolution of the program. However, integration at the facility level with other services is variable, and the link between PMTCT and antiretro- viral therapy for both women and children is still a challenge. Prevention with People Who Inject Drugs •  PEPFAR has been increasingly instrumental in facilitating and sup- porting some harm reduction approaches in countries with epidemics for which injection drug use is a major or emerging driver. Notwith-

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PREVENTION 161 standing restrictive U.S. and partner country policy and legal envi- ronments, a positive effect of these activities and programs is being seen in countries in which PEPFAR works, but substantial unmet need remains for harm reduction and other services for this population. Recommendation Presented in This Chapter Recommendation 5-1 To contribute to the sustainable management of the HIV epidemic in partner countries, PEPFAR should support a stron- ger emphasis on prevention. The prevention response should prioritize the reduction of sexual transmission, which is the primary driver of most HIV infections, while maintaining support for interventions tar- geted at other modes of transmission. The response should incorporate an approach balanced among biomedical, behavioral, and structural interventions that is informed by epidemiological data and intervention effectiveness evidence. PEPFAR should support advances in preven- tion science to expand the availability of effective interventions where knowledge is lacking. Further considerations for implementation of this recommendation: • PEPFAR has made a commitment to overarching goals for prevention and for achieving an AIDS-free generation, but this does not consti- tute a long-term prevention strategy that clearly states prevention objectives and the pathways to achieving them. The following ele- ments will be critical for a more comprehensive strategy to achieve successful execution of prevention programs: PEPFAR should continue to enhance its efforts to involve partner o  country stakeholders and incorporate country-specific epidemi- ology, context, and priorities in planning appropriately matched prevention programs that achieve a balanced approach to HIV prevention across the available modalities. To provide greater tech- nical and operational clarity, the Office of the U.S. Global AIDS Coordinator (OGAC) should provide mechanisms to support the development, implementation, and monitoring of comprehensive prevention portfolios, including how to determine what popula- tions need which directed prevention activities in which settings. Areas of prevention where current interventions are successful and effective, such as PMTCT, should be continued and scaled up to ensure access, coverage, and quality. As new PEPFAR-supported prevention activities are adopted, OGAC should communicate its objectives and the methods for introducing or scaling up with specified populations. OGAC should improve mechanisms to collect and incorporate evi- o  dence on the effectiveness of prevention activities implemented in partner countries. The key components for future assessment

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162 EVALUATION OF PEPFAR and evaluation of HIV prevention should include need, coverage of need, quality of services provided, and behavioral and epidemio- logical outcomes. OGAC should provide clearly defined process and outcome measures as well as impact assessment methods to evaluate progress. o PEPFAR’s prevention strategy should include balanced support for innovation, research, and evaluation to contribute to the evolving evidence base and advance understanding of the effectiveness of interventions within all prevention modalities. To define and ensure this balance, OGAC should, through its existing mechanisms, con- vene and use expertise spanning behavioral, structural, and bio- medical prevention intervention approaches. PEPFAR-supported research and evaluation activities should employ appropriate methodologies and study designs, without unduly emphasizing random assignment designs. PEPFAR should support innovations in prevention science methodologies where needed to achieve its programmatic research aims (see also Recommendation 11-1).