Greater Focus on Prevention
There is some global enthusiasm that OGAC quickly moved forward to respond to emerging scientific evidence from the results of recent biomedical interventions showing an impact on ART on HIV transmission. To determine how best to incorporate this evidence into the PEPFAR portfolio for prevention, OGAC convened a consultation on “unresolved issues in HIV prevention in generalized epidemics” (Ryan et al., 2012, p. S75). This consultation focused on the available evidence and determined a set of “core interventions” which had the strongest evidence. The consultation acknowledged that “treatment would play a critical role in reducing new infections and that behavioral interventions to support these core interventions and reduce risk are critical” (Ryan et al., 2012, p. S75). Even though the Five-Year Strategy for the reauthorization legislation emphasized prevention as a high priority toward sustainability, as discussed in Chapter 5 of this report there is still a concern about the focus and prioritization of behavioral interventions for their singular as well as combinative contribution to prevention of sexual transmission, as well as the funding that is allocated programmatically and the way in which these interventions are studied and measured, despite this scientific advancement. Palen et al. (2012, p. S117) stated that “if low-income countries do not do better with prevention, all ‘efficiencies’ achieved within their delivery systems are simply more efficient ways to commit ever-expanding resources to an interminable pandemic.” Some interviewees also voiced a similar concern that behavioral and structural prevention has been largely ignored compared to scaling up of care and treatment (636-ES; 953-ES). Chapter 5 on prevention and Chapter 6 on care and treatment also discuss the role ART can have on prevention of HIV transmission.
The committee heard specific concerns from country visit interviewees about the link between prevention and sustainability. Participants in nearly all countries visited associated prevention with the concept of sustainability and several participants noted that their country would be unable to maintain all of its current activities, including prevention activities, if PEPFAR funding were withdrawn. Some interviewees in national planning positions stated that their national attention to HIV prevention had waned and prevention as a stronger part of the national response needed re-emphasis (166-7-PCGOV; 636-4-PCGOV; 240-ES) to yield a longer return investment to reduce incidence, which in turn makes sustainability more likely (934-12-CCM). A mix of USG and partner country interviewees identified a shift to prevention activities as a step on the path to sustainability (240-2-USG; 331-43-USG; 587-1-USG; 116-23-USPS; 461-10-PCNGO; 934-12-CCM). There was more concern among participants in different countries about the reach of prevention messaging and the differential coverage for funding allocated to support population-based