HIV Update: Combination HIV prevention (Part 1)

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Meet the needs of populations through combination HIV prevention: Part 1 – overview This HIV update will form a chapter of the Alliance’s Good Practice Guide on Community-Based HIV Prevention, due out in June 2011.

The chapter gives an overview of combination HIV prevention -- an idea that focuses attention on the overall prevention needs of populations, and the total prevention response from all stakeholders. It also describes the contributions that community-based HIV prevention programmes can make to combination HIV prevention. The chapter also discusses combination HIV prevention that is available now, and changes in the future.

HIV Update No. 10 – part 1 Date:

April 2011

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MEET THE NEEDS OF POPULATIONS THROUGH COMBINATION HIV PREVENTION: PART 1 – OVERVIEW A simplified view Combination HIV prevention is a way of bringing together different interventions – behavioural, biomedical, and structural – as the necessary and complementary components of a total HIV prevention response. The combination of interventions should also be based on analysis of the HIV epidemic, the needs of priority populations, and current prevention efforts. A simplified view of the overall concept is shown in the diagram below.

A simplified view of combination HIV prevention

“Know your epidemic and know your response”

The combination of prevention interventions Behavioural interventions

Biomedical interventions

Environmental and structural interventions

Changes to determinants of risk and changes to prevention practices

Reduced HIV transmission

In practice, this means combination prevention needs people and organisations that specialise in different areas to play different contributing roles. These include work on: • behavioural prevention interventions that are aimed at individuals, peer groups and communities • biomedical interventions – quality clinical services that reach different people for a variety of specific purposes • creating a strong operating environment, including capacity to deliver quality interventions and reach the range of populations who are directly affected • addressing underlying vulnerabilities among populations – sometimes called structural drivers – that facilitate or block HIV prevention So this concept reinforces the notion that the overall prevention response requires a combination of efforts from different stakeholders and organisations. And therefore, combination prevention needs stakeholder collaboration to be effective.

A new term that helps us to focus on improvements Community-based efforts have contributed to combination HIV prevention since the beginning of the AIDS epidemic. And the prevention work supported by Alliance

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Linking Organisations almost always relies on a combination approach. This is true even though the term “combination prevention” is somewhat recent.

This fairly new term, though, helps us to better understand what we’re doing and how well we’re doing it. We can use it as a tool for improvement.

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It especially helps us to understand the connections between the objectives of individual interventions.

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It helps us understand if there are sufficient operational linkages between the efforts of different stakeholders who have shared priorities but are working in different sectors.

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It helps us understand our organisation’s contributions to the overall HIV response – what role are we playing?

Community-based efforts contribute to combination HIV prevention The following types of activities can give a better idea of the role of community-based contributions to the overall combination prevention effort, alongside other sectors in the AIDS response. This recognises that community action has a key role, but also needs to be linked up to clinical and other services, and involved in other aspects of improving the overall AIDS response – such as the enabling environment, and policy.

A rounded portfolio of community-based HIV prevention activities Behaviour change activities

Environmental and structural actions

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Prevention outreach in the field: targeted contact with people at risk, community mobilisation

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Increasing availability and acceptability of key commodities: condom and lubricant distribution and social marketing

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Peer group activities: safer sex education, skills building for prevention

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Increasing demand for services through community awareness and mobilisation

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Client-based services: face-toface information, counselling on specific topics

Community-based changes to social norms to integrate relevant issues – such as anti-AIDS stigma, gender norms – into targeted prevention activities, community awareness and mobilisation

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Community development for key populations: support meaningful involvement of people affected

by HIV, key population leadership, and development of peer organisations

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Responding to threats against people most affected: responding to exclusion, discrimination or violence; and working with authorities to reduce the incidence of these or to increase responses

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Outreach to key stakeholders and allies to increase ownership and engagement

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Advocacy and collaboration to prioritise underserved populations, increase access to key activities and services, improve resource allocation, and develop a stronger overall HIV response

Biomedical services •

Linkages between communitybased prevention projects and biomedical services providers

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Complementary activities delivered before and after biomedical services: counselling, follow-up, practical support

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Community-based provision of specific biomedical services in some settings – common examples are VCT, and STI diagnosis and treatment

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This table gives an example of a fairly complete programme – it is likely that many local or national community-based prevention efforts do not engage in all of these things.

However, a properly planned and fully resourced AIDS response should ensure that all these elements are considered in a “knowing your response” analysis. Where there are gaps, they need to be addressed. Where they are being worked on, the quality and effectiveness of this work needs to be understood.

We should also note that the table above reflects approaches that, so far, have been most commonly adopted. The environmental actions listed in the table do not include a very strong emphasis on interventions that address underlying socio-economic vulnerability factors – to date, these have not been implemented very often. (Some reasons for this are included in part 2, “a closer look.”)

For people working in community-based prevention, several planning and organising issues are important. Our organisations’ staff should have a common understanding of several points: • We have to ensure our prevention activities are of good quality and are reaching sufficient numbers of people in priority populations • Even if we recognise that our organisation plays a specific role alongside others in delivering combination prevention, we usually still need different types of capacities in diverse programming areas • We need to have functional partnerships and collaboration, and to be engaged in combination HIV prevention as a key stakeholder • We need to understand the complementary interventions undertaken by other sectors – what they are doing and why. We also need to decide what our organisation thinks about these efforts as part of the overall response, and advocate for changes if the actions of others are not appropriate • We need to understand our added value – notably what our organisation brings in terms of ensuring greater population access to prevention, how we support community-based responses, and how this contributes to broader health and development efforts Major inputs, approaches and expected outcomes UNAIDS defines combination prevention as an approach that seeks to achieve maximum impact on HIV prevention “by combining behavioural, biomedical, and structural strategies that are human rights-based and evidence-informed, in the context of a well-researched and understood local epidemic.” 1 So this definition incorporates some of the main points about how to make it happen.

A more rounded picture of combination prevention includes some of the main inputs and approaches that can be used to put it into practice. The diagram below also shows the main expected outcomes.

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UNAIDS (2011). UNAIDS Terminology Guidelines (January 2011)

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Major inputs, approaches and expected outcomes of combination HIV prevention “Know your epidemic and you’re your response” - Understand HIV epidemiology and transmission trends - Understand the realities and needs of priority populations - Understand the current HIV response and gaps

The combination of prevention interventions Evidence-based HIV prevention

Behavioural interventions

Changes to determinants of risk and prevention

Rights-based HIV prevention

Biomedical interventions

Environmental and structural interventions

- Determinants of individual behaviours - Access to quality activities, commodities and services

Partnerships and complementary action within the overall AIDS response

- Environment, stakeholders, good practice, policies and laws - Determinants of underlying vulnerabilities to HIV

In brief, some of the main points about inputs, approaches and expected outcomes of combination prevention include the following: Knowledge inputs These are the foundation of planning and implementing combination prevention.

First of all, “know your epidemic” is an extremely important approach that considers: •

epidemiology: where infections are occurring, and who is most affected

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transmission trends, and predictions about where the next infections are likely to occur

Understanding the realities and needs of priority populations includes: •

identifying populations where prevention efforts are most needed

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understanding major determinants of HIV risk and prevention for these populations, as well as their felt needs regarding sexual health

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understanding the feasibility of reaching priority populations in sufficient numbers with quality programming

Understanding the HIV response involves: •

mapping current prevention activities, commodities and services aimed at each priority population, and identifying the gaps

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Approaches There are several key approaches that are fundamental to ensuring effective combination prevention for priority populations: •

Evidence-based HIV prevention – prevention activities that have been shown to work by leading to behaviour change or reducing vulnerability to HIV infection

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Rights-based HIV prevention – prevention activities that are based on rights, including the sexual health rights of priority populations

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Partnerships and complementary action within the overall AIDS response, since combination prevention means that a single actor can rarely meet all the needs of even a single population

Expected outcomes HIV prevention programmes try to change the determinants of risk and prevention – by working with individuals, communities, systems, conditions and factors in the environment. The behavioural, biomedical and environmental / structural interventions seek to improve: − Determinants of behaviours at individual level − Population access to quality prevention activities, commodities and services that deliver behavioural or biomedical HIV prevention − Factors in the enabling environment that increase or decrease HIV transmission. − Determinants of underlying vulnerabilities to HIV The last two points are related to factors in the wider environment. These can be at the level of institutions, such as key stakeholders’ constructive involvement in the AIDS response – including communities, potential allies, gatekeepers and authorities.

A typical purpose of improving the enabling environment is to ensure start-up of new programming and greater access to prevention activities, commodities, and services.

Enabling environment actions can also include promoting better allocation of resources to meet priorities in the AIDS epidemic, as well as greater use of good practice in AIDS responses.

Environmental factors can also be at the level of society or a specific community, including social norms and economic drivers that can increase vulnerabilities of specific populations.

Among some of the most damaging social norms are attitudes that lead to HIVrelated prejudice, discrimination, and violations of human rights of people who are directly affected. Violence is another factor encountered by many. This includes intimate partner violence, most commonly violence against women performed by a

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husband or intimate male partner, 2 or hate crimes against key populations such as sex workers, injecting drug users, men who have sex with men, and transgender people.

For both improving the enabling environment and addressing underlying vulnerabilities, it is often important to also advocate for changes to policies and laws that are helpful or hindrances. These include laws that criminalise key populations and drive them underground (as well as hindering outreach efforts to them).

Enabling approaches to reduce risk through environmental interventions There is a distinction “between prevention approaches that aim to ‘persuade’ individuals to undertake behaviour change and those that ‘enable’ change to occur. The latter focus on the non-individual, or the social and environmental, determinants that facilitate or impede behavioural choice. Enabling approaches intend to remove barriers or constraints to protective action or, conversely, to erect barriers or constraints to risk-taking. In some cases, enabling approaches that remove barriers for some people, such as for women who may have little say in sexual matters, may actually erect barriers for others, such as for men who may find their traditional dominance constrained. An enabling approach that removes a barrier to change might be a policy that allows the purchase and possession of sterile injection equipment by drug users, while an example of an enabling approach that erects a barrier to continued risk taking might be a policy mandating condom use in commercial sex establishments.”

Source: Tawil, Verster and O’Reilly (1995) 3

Plan and evaluate prevention efforts using clear change frameworks Because combination prevention means a number of interventions for a given population are needed to get results, it is sometimes difficult to single out the effects of behaviour change efforts, biomedical services, or changes to the environment. To help overcome this, these interventions should be planned and assessed within an overall change framework for a given population.

The change framework should include: •

a programming hypothesis that states how all the interventions will produce changes for this specific population

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where possible, the evidence upon which the hypothesis is based

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information about how we will know that the overall change has happened

In addition, the change framework can help address a big problem: there is not enough routine evaluation of combination prevention, even in programmes that reach large numbers of people. Evaluation is especially important because priority populations, their contexts and prevention programmes can vary a great deal.

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World Health Organisation (2002). Intimate Partner Violence. Factsheet: http://www.who.int/violence_injury_prevention/violence/world_report/factsheets/en/ipvfacts.pdf 3 Tawil, O., Verster, A. and O’Reilly, K.R. (1995). Enabling approaches for HIV/AIDS Prevention: can we modify the environment and minimize the risk? AIDS: Vol. 9, Issue 12, p:1299-1306

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Basic change framework for combination HIV prevention

Prevention goal

E.g.

Contribute to reducing new infections among [specific population] by [amount] by [date]

Change needed

Interventions

How will the intervention make change happen?

How will we know the intervention has worked?

Possible challenges and risks in implementation

How to overcome or mitigate challenges

Determinants of individual behaviours Access to quality activities, commodities and services Environment, stakeholders, good practice, policies and laws Determinants of underlying vulnerabilities to HIV -

Of course, evaluation has to be feasible. Using a change framework and evaluating its hypothesis do not always have to be at the sophisticated level of randomised controlled trials. However, it should move beyond the current universal standard – which is counting the numbers of people reached for the purposes of donor reporting.

At the moment, combination HIV prevention rarely includes plans to produce programmatic evidence, and show whether prevention objectives for a specific population are being achieved.

Combination prevention today, combination prevention in the future Combination prevention is an important concept for analysing AIDS responses and helping ensure their effectiveness. Some of the main issues are: understanding connections between the desired effects of individual interventions for each population, ensuring operational linkages between stakeholders and their prevention efforts, and understanding our own organisation’s contributions to the overall effort.

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So is there a single formula that will work in different contexts and with different populations? And will there be changes to combination prevention in the future?

The answers need a bit of explanation.

Right now, there is a body of evidence-based prevention interventions that need to be used more widely. In addition, we know that there is a need to adapt packages of prevention interventions for different situations: •

Behavioural interventions are often specific to populations. In addition, they often need to be tailored to the realities of specific sub-groups in populations

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Biomedical interventions requiring services are both population-specific, based on population needs, and provider-specific, dependent on service provider priorities, as well as their capacities and resources to meet these needs

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Environmental and structural interventions are context-specific – the issues vary depending on the specific factors in the environment that influence HIV risk and prevention

That is why it is important to base programmes on the best possible understanding of the population and situation – looking at determinants of risk and prevention, and designing packages of multiple interventions for each priority population.

In future, new prevention interventions are likely to be introduced. For the most part, these will be biomedical approaches. For example, in the past few years male circumcision has become important in countries with high rates of HIV, especially those with more than 15% of adults living with HIV, and low rates of male circumcision. AIDS vaccines are in development, as are ARV-based interventions such as microbicides and pre-exposure prophylaxis (PrEP). These new technologies are still several years away from becoming major tools in HIV prevention. (For more information, see the second part of this HIV update – “a closer look.”)

Future prevention options, especially new biomedical interventions, could have a major impact on the epidemic. Their development needs continuing support. At the moment, however, there is also a lack of investment in scaling up tailored, targeted and evidence-based combination prevention for people who are at risk.

In sum: better planning efforts and funding are needed for combination prevention that can be scaled up now, alongside investments to shape technologies that will have a major role in future HIV prevention efforts.

PART 2 – A CLOSER LOOK Go to part 2 of this HIV update for an overview of the range of behavioural, biomedical, environmental and structural approaches within combination prevention.

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GOOD PRACTICE STANDARDS FOR COMMUNITY-BASED HIV PREVENTION This explanation of combination prevention is an integral part of the Alliance’s good programming standards on community-based HIV prevention. These are summarised below.

1. Effective HIV prevention that is rooted in community action

2. Rights-based HIV prevention

3. “Know your epidemic, know your response,” and focus on prevention activities that work

4. Meet the needs of populations through combination HIV prevention

5. A positive approach to sexual health

6. Gendertransformative HIV prevention

8. Ensure access to quality activities, commodities and services

7. Positive health, dignity and prevention for people living with HIV

9. Partnerships and complementary action within the overall AIDS response

For further information please contact: Kevin Orr, Senior Advisor: HIV Prevention e-mail: korr@aidsalliance.org International HIV/AIDS Alliance (International secretariat) Telephone: +44(0)1273 718900 Fax: +44(0)1273 718901 mail@aidsalliance.org www.aidsalliance.org Registered British charity number: 1038860