Combination Prevention: A Deeper Understanding of Effective HIV Prevention

Published in the journal AIDS (Vol. 24 Suppl. 4, pp. S70-S80), this editorial explores combination prevention, which is a mix of behavioural, biomedical, and structural interventions, ideally informed by evidence and based on human rights, that address both the immediate risks and the underlying causes of vulnerability to HIV. According to the authors, tailoring programmes with the Modes of Transmission methodology - a single-year "snapshot" of incident infections using HIV and sexually transmitted infection (STI) prevalence and behavioural data - shifts the focus from where the epidemic has been to where the epidemic may be going and to the social, economic, geographic, and cultural conditions that shape the epidemic country by country.

The article begins by tracing some of the history of HIV prevention as central to the AIDS response. Following an emphasis on individual agency in HIV prevention, which drew on information, education, and communication (IEC) and subsequently behaviour change communication (BCC) strategies, combination prevention was introduced in 2003 as a strategy that was "inspired by the recognition that countries such as Uganda, Thailand, and Brazil had generated sharp, sustained declines in HIV incidence using an array of biomedical, behavioural, and structural approaches. Visible, consistent, political leadership, and community mobilization seemed critical components of these successful national programmes, each of which had deployed strategically chosen strategies to meet the diverse needs of key populations at risk."

Linking the wave of support for combination prevention that emerged at the 2008 International AIDS Society conference in Mexico, a series of broad consultations defined combination prevention in practical, programmatic terms: These programmes are "rights-based, evidence-informed, and community-owned programmes that use a mix of biomedical, behavioural, and structural interventions, prioritized to meet the HIV prevention needs of particular individuals and communities, so as to have the greatest sustained impact on reducing new infections. Well designed combination prevention programmes are carefully tailored to national and local needs and conditions; focus resources on the strategic mix of programmatic and policy actions required to address documented risks and needs; and are thoughtfully planned and managed to operate synergistically, strategically, and consistently over time and on multiple levels to address both immediate risks and underlying drivers of vulnerability and risk. They mobilize community, private sector, government, and global resources in a collective undertaking. They require and benefit from enhanced partnership and coordination. And they incorporate sufficient flexibility to permit ongoing assessment and continual improvement of strategies over time."

Also, "a broader recognition emerged that structural approaches, that is, public health programmes that promote health by altering the context within which health is produced and reproduced" are central to HIV prevention strategies. "Today, there is a growing desire to apply these principles systematically and consistently in HIV programme planning and implementation. This has been accompanied by greater willingness among policy-makers to budget for structural as well as biomedical and behavioural strategies and among donors to fund them..."

The authors emphasise the importance of research, arguing that adding a comprehensive review of HIV prevention policy and programmes as well as a costing analysis ("know your response") can reveal programme gaps and strengths in the national response and, when appropriate, lead to a reorientation of programming. The authors believe that tailoring programmes to local epidemiology and contexts while focusing on evidence-informed and human-rights-based interventions addresses barriers to prevention and allows for context-specific and cost-effective programming that can achieve intended outcomes. They stress that effective combination prevention requires enhanced coordination in programme design, resourcing, management, and evaluation, as well as flexible design to incorporate emerging biomedical prevention tools.