A Systematic Analysis of Three Promising Approaches to Combination HIV Prevention Programming

Presented at the 2009 HIV/AIDS Implementers' Meeting held in Namibia, this 44-slide PowerPoint presentation explores "combination HIV prevention", which includes a mix of strategies and risk reduction approaches that use current epidemiological and programmatic evidence to address different audiences with simultaneous behavioural, biomedical, social, normative, and structural interventions. Cross-cutting components of combination approaches to HIV prevention include: policy support (engaging appropriate leaders and opinion makers), community engagement, capacity building and management systems strengthening, and gender sensitivity. This strategy also involves responsiveness to local realities.

Combination approaches are assumed to be effective through the synergies they create between these multiple components; as such, scientific assessments are challenging. Real-world experience may hold lessons, however. Thus, AIDS Support and Technical Assistance Resources Project, Sector 1, Task Order 1 (AIDSTAR-One) is developing a series of case studies to identify core technical components and operational characteristics of promising combination prevention programmes for use by programme planners and managers.

As detailed here, combination prevention case studies describe how combination programmes are implemented, highlighting core technical components and operational characteristics. These case studies are epidemic/context-specific, action-oriented, and operational. AIDSTAR-One's Good and Promising Programmatic Practice (G3P) database was used to identify 25 promising combination programmes, 3 of which were selected by a committee of 8 people from AIDSTAR-One partner organisations and United States Agency for International Development (USAID). (Two additional programmes from southern Africa remain to be selected). Specifically, the AIDS, Population and Health Integrated Assistance Program (APHIA-II) Project (implemented in Kenya by Family Health International (FHI) with support from the President's Emergency Plan for AIDS Relief (PEPFAR)/USAID) represents combination programming in a generalised epidemic setting. Concentrated epidemic settings selected as case study cites include: the Avahan-India AIDS Initiative, supported by the Bill & Melinda Gates Foundation, and Alliance-Ukraine, supported by USAID (SUNRISE Project) and the Global Fund.

Once documents were collected, programme evidence was scored using 6 criteria (intended population, implementation, evaluation, monitoring and evaluation, quality assurance, funding). For each of the 3 interventions, a case study involving 2 weeks of field observation and a review of programme documents was conducted. Programmes were assessed along 3 dimensions, including the simultaneous implementation of: several risk-reduction options (behavioural, biomedical, and structural); activities to increase appropriate leadership and political support; and activities to increase community involvement. Other operational factors considered included: i) evidence-informed selection of targeted interventions; ii) hierarchical multi-level prevention messages; iii) addressing environmental factors in vulnerability; iv) bringing quality interventions to a scale with sufficient intensity; and v) linking prevention and treatment services.

I. Key elements of Case 1: APHIA-II - Kenya:

• Context - AIDS in Kenya (source: 2007 Kenyan AIDS Indicator Survey): Prevalence (adults 15-49) is 7.8%, with some populations at higher risk (e.g., sex workers' prevalence is 27%, and young women are experiencing higher prevalence rates than men).
• Development of field activities was evidence-based, and local communities were involved in programme development.
• Behavioural activities include: ABC messages (abstinence education, be faithful to one partner or limited partners, and use condoms), prevention of opportunistic infections for HIV-positive people, and behaviour communication change (BCC) materials specific to particular audiences (e.g., men who have sex with men, or MSM).
• Structural activities include: advocacy for change in social and cultural norms (i.e., female genital mutilation, early marriages, family planning); empowerment of women, people living with HIV (PLWH), and youth; income-generating activities; workplace policies; private sector involvement; adult education (literacy); political advocacy; collaborative arrangements with law enforcement; and stigma-reduction activities.
• Capacity building and systems strengthening involves: providing technical support and training to the Ministry of Health (MOH) and implementing partners (IPs); supporting supervision of service providers; widely publicising recognition of IP accomplishments; holding regular meetings of all stakeholders; and carrying out comprehensive recordkeeping.
• By September 2008, the project had reached: 1,008,967 people with education to increase their skills in remaining abstinent or faithful; 1,487,288 people with education and skills-building regarding other prevention strategies; 328,860 people with voluntary counselling and testing (VCT) services; 12,133 PLWH with antiretroviral therapy (ART); 19,216 PLWH with home-based palliative care; and 29,239 orphans and vulnerable children (OVC) with life-saving services and support; and 166,158 pregnant women with counseling and testing for HIV at preventing mother-to-child transmission (PMTCT) sites.
  

II. Key elements of Case 2: International HIV/AIDS Alliance in Ukraine

• Context (source: United Nations Programme on HIV/AIDS (UNAIDS) Epidemiological Fact Sheet on HIV and AIDS, 2008): Prevalence (adults 15-49): 1.6% (440,000). The epidemic is largely concentrated, with most affected groups injecting drug users (IDUs), sex workers, and MSM.
• Alliance programmes represent majority of HIV-prevention activities in Ukraine. Working through 101 local non-governmental organisations (NGOs), they operate in all 24 Oblasts and the Autonomous Republic of Crimea to reach 300,000 members of groups most vulnerable to HIV.
• Peer-driven interventions were central, and involved gaining access to most hard-to-reach populations (e.g., young, female, and/or stimulant users) and educating peers in community and sharing information about available services. This approach has been piloted for IDUs in 17 sites; the model is being applied to sex workers.
• A high importance is placed on use of data to inform activities and approaches. There is a strong emphasis on community involvement (e.g., bringing government healthcare workers to community centres fosters ties between two sectors) and a major role of advocacy for supportive policies (e.g., trainings and "summer schools" on policy and advocacy).
• In 2008, prevention services reached 195,379 IDUs, 33,449 female sex workers, 19,749 MSM, and 57,558 prisoners. Also, substitution maintenance therapy was provided to 2,202 individuals with opioid dependency; ART was provided to 6,070 PLWH and to 9,875 HIV-positive mothers. Evidence is emerging that harm reduction programmes for IDUs are stabilising the HIV epidemic in this risk group.
  

III. Key elements of Case 3: Avahan-India AIDS Initiative in India

• Context (source: UNAIDS Epidemiological Fact Sheet on HIV and AIDS, 2008): prevalence in adults 15-49: 0.36% (2,400,000). The epidemic is a concentrated in 4 southern and 2 northeastern states, and most affected groups are IDUs, sex workers, MSM, truck drivers. It is estimated that 80% of HIV-infected people do not know their status.
• The programme operates in 605 towns in 83 districts in 6 states, working through 134 local NGOs and 7,500 peer educators. Activities reach over 80% of high-risk people in the 6 states.
• Programme elements include: targeted prevention activities with at-risk groups; increased access to STI management services, condoms, and behavioural change messages; reduction in stigma and discrimination; development of peer education messages; and capacity building for community ownership.
• Strong emphasis is placed on building community ownership. Peer educators are drawn from female and male sex workers, transgender people, IDUs, and long-distance truck drivers. Each educator is responsible for individually mapping then maintaining contact with 40-50 peers. They promote behaviour change, condom usage, and treatment-seeking for STIs and other health conditions. They are trained to maintain records, analyse results, conduct advocacy with peers and power structures (such as police and government service providers). Responsibilities include basic tuberculosis (TB) screening with peers, referrals for opportunistic infections, and emotional and prevention counselling. "Micro-planning" enables peer educators to monitor contacts and identify on a weekly and monthly basis the most vulnerable individuals; these data are also used by state partners and Avahan managers.
• Achievements to date include: 412 programme-funded clinics that provide free STI diagnosis and treatment services have been set up; STI rates have been lowered; and 10 million free condoms are distributed monthly. The project also stimulated creation of support groups, committees, and community-based organisations (CBOs) in most sites at which it works.
  

Synthesis of initial findings from the 3 case studies: core components of combination prevention:

1. Know your epidemic - Track the epidemic, drivers, and underlying risk factors, changing the composition of the response - and the activities that compose it as the epidemic (or what we learn about it) changes. Conduct ongoing research to understand programmatic gaps, e.g., to learn more about risk groups that are not being adequately reached by the programmes and the behaviours that put them at risk. Local actors, e.g. peer educators, must understand data, why they are collecting it, and how to use it; workers must be vested in getting quality data.
2. A mix of activities that produces a maximum effect in a given setting - Add new activities, introducing innovative approaches to solve "old" problems and bringing in new areas of programming to tackle underlying factors that increase vulnerability. NGOs can take on new activities to change social norms, reduce stigma, and/or address gender dimensions. Plan locally using local data, then feed data to affect planning at other levels.
3. A core commitment to strengthening civil society and the local response - This involves strong implementing partners with their own mission and vision who integrate HIV into their own structure. The programme should engender confidence, skills, and commitment to community and pride in accomplishments among peers, staff, and participants. It should also promote a willingness to learn from mistakes and noneffective approaches and to change quickly, if necessary.
4. Policy engagement and advocacy at all levels - This involves a serious commitment to creating/nurturing an enabling environment, with continuously changing strategies, if needed, to get decision-makers on board at national, regional, local, and client levels.
   

AIDSTAR-One concludes that "A substantial amount of information can be gleaned from a systematic review of programmatic evidence and field observation toward the generation of operational approaches to combination prevention. This systematic review resulted in the identification of core programmatic components, tools for implementation and common challenges and solutions. The result is a more actionable description of how to implement combination prevention programs." The researchers plan to conduct 2 more case studies in southern Africa for a total of 5 case studies - with a comparative analysis summary expected to be published by December 2009.