discussion of the role of counseling and testing within a prevention context, with more in-depth discussion and analysis of this topic in Chapter 6, “Care and Treatment.” Finally, there is a discussion of emerging prevention interventions and the committee’s recommendation for strategically strengthening PEPFAR’s prevention efforts. Further discussion of PEPFAR’s activities related to reducing HIV risk for women and girls and for men who have sex with men can be found in Chapter 8, “Gender.”

The IOM committee is mindful that, over the course of its existence, PEPFAR has had dual roles as both a catalyst and a respondent to various developments in global HIV prevention. The committee recognizes both the opportunities and the challenges inherent in these roles, and the results of this evaluation are described in this context.

EVOLUTION OF HIV PREVENTION SCIENCE

Throughout the history of the HIV epidemic, including the years of PEPFAR implementation, HIV prevention has been evolving, influenced by developments in science, policy, and advocacy in the context of an ever-changing epidemiological, political, and economic landscape. There are multiple, overlapping constructs through which HIV prevention efforts have been envisioned and organized. These include

•    modes of transmission (sexual, parenteral, perinatal);

•    populations and HIV-risk exposure behaviors (heterosexual men and women, men who have sex with men, transgender persons, people who inject drugs, HIV serodiscordant couples, pregnant women, young people, sex workers, etc.);

•    unit- or level-targeted (individual, couple, network, community); and

•    disciplinary, science-based approaches (biomedical, epidemiological, behavioral, social/structural).

Over time and in different geographic locations, some of these constructs have been emphasized over others, based on current science, epidemiological trends, or political shifts.

Evolution of Interventions to Prevent or Reduce HIV Infection

The search for an AIDS vaccine—considered an ultimate goal to prevent infection—began as soon as HIV was discovered to be the causative agent of AIDS. Finding an effective vaccine quickly proved to be elusive, and it remains a challenge given the rapidly adaptive nature of the virus (NIAID, 2012). Meanwhile, in the early years of the HIV response most



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