Centers for Disease Control and Prevention

Global AIDS Program

Prevention Interventions for People Living

with HIV: 5 HIV Prevention Steps
and Tools for Implementation
Pamela Bachanas, PhD
Washington, DC
August, 2008

Prevention for People Living with HIV

Scale up of care and treatment programs
in SSA have been an extraordinary
success 2.5 million people on ARVs
However, in 2007 alone, 2.5 million people
were newly infected with HIV, most of whom
will eventually need ARVs
Effective and efficient HIV prevention
interventions are critically needed

Prevention for People Living with HIV

Traditional focus of prevention efforts
have been on preventing acquisition
among HIV- individuals
To have a significant impact on slowing
the spread of the epidemic, prevention
efforts must also be directed toward
individuals living with HIV who can
transmit the virus

Only HIV+ individuals

can transmit HIV
HIV
prevalence,
Kenya, 2006

HIV positive, 6%

HIV negative, 94%

Focusing on ~1.3m HIV-infected people

rather than ~21.6m uninfected people is an
efficient, targeted prevention approach

HIV Prevention in
Care and Treatment
Due to increasing availability of HIV treatment, many
HIV+ persons are accessing health care settings and
clinics, providing an opportunity to reach a large
number of infected persons with prevention messages
and interventions
Health care providers in HIV clinic settings meet with
patients regularly and can deliver consistent, targeted
prevention messages and strategies during routine
visits
Providers are considered authority figures and trusted
sources of health information

HIV Prevention in
Care and Treatment
For any disease, preventive information on infection
control is regarded as quality standard of care
Health care providers can also address biomedical
prevention strategies, such as reproductive health and
STI management
Given clinic burden and complexity of patients needs,
many patients need more in-depth counseling on
prevention issues (e.g. disclosure, alcohol use).
Incorporating counselors (including PLWHA) into clinic
settings is essential for a comprehensive prevention
program

Prevention for People Living with HIV

Multiple approaches to prevention are
needed; integration of prevention into care
and treatment settings is critical
Integrating prevention services into care and
treatment can be overwhelming and can
require a great deal of effort and resources
However, we cant afford not to do it

ART Need in Namibia Assuming

Immediate End to Transmission

ART Need in Namibia Assuming

Ongoing Transmission

Prevention for People Living with HIV

The question isnt can we do prevention in
care and treatment
The question is how do
we do prevention in care
and treatment
What are the specific interventions
How can they be implemented most efficiently
(task shifting, etc,)

Step 1 Give prevention

recommendations to every
patient at every visit

Critical Need for Prevention

Interventions with PLWHA
Vast majority of PLWHA are married in Kenya (70%),
Malawi (82%), & Uganda (57%) [DHS & AIS data]
Rates of partner testing among PLWHA very low
Rates of disclosure of serostatus to partner(s) low
and challenging
Condom use in stable relationships very low

HIV status of spouses of HIV-infected

persons in Kenya, DHS, 2003
HIV DISCORDANT:
CONCORDANT POSITIVE:

One partner positive, one

partner negative: 50%

Both partners HIV-infected:

50%

In Kenya, 50% of married HIV+ persons

(450,000) have an HIV-negative spouse

NatureofIncidentInfection,Uganda
SerobehavioralSurvey,20045

Note:among79couples

CONDOM USE IN REGULAR PARTNERSHIPS

Discordant Couple Interventions:

Couple Counseling and Testing
963 discordant couples in
Lusaka (Allen et al., 2003)

Self-reported condom use

increased from 3% to 80% after
1 year

53 discordant couples in Kigali

(Allen et al., 1992)

Self-reported condom use

increased from 4% to 57% after
1 year

149 discordant couples in

Kinshasa (Kamenga et al.,
1991)

Self-reported condom use

increased from <5% to 77%
after 1 year

Step 1 Give prevention

recommendations to every patient
at every visit
Providers and counselors must assess
whether each patients partner has been
tested; test or refer to counselor for testing
Provider- and/or counselor-assisted
disclosure
Counselor who can conduct rapid testing
available in clinic and community settings
Children of HIV+ moms tested

Step 1 Give prevention

recommendations to every patient
at every visit
Discordant couples identified and counseled
Positive partners linked to care and treatment
Negative partners counseled on prevention practices to stay
negative (condoms!)

Provider delivers brief messages on patient selfprotection & partner protection

Consequences of unprotected sex

Provider assesses patient for alcohol use that affects

adherence or risky behavior
Refer drinkers to counselor

HIV Acquisition among Male Partners of

HIV + Female Partners By Circumcision
Status In Rakai

Female viral load

Quinn et al; NEJM 2000; 342:921-9

Step 2 Assess adherence to

ARVs
Provide adherence support or refer to
counselor for support

Step 3 STI Management

Integrated into HIV Clinics

STI Management Integrated

into HIV Care
In HIV+ individuals, STIs have been shown to increase
genital HIV shedding, increasing likelihood of HIV
transmission.
STIs have been associated with increased genital HIV
shedding in persons on ARVs with suppressed plasma viral
loads.
Genital ulcer disease has the strongest association with HIV
transmission; high rates of HIV/HSV co-infection.
Urethritis, vaginitis, and bacterial vaginosis have also been
associated with transmission and acqusition.

STI Management
Integrated into HIV Care
Assess for signs and symptoms of STIs at every visit
and treat as indicated
Treating STIs in HIV+ persons is important for care, as
STIs can be more severe and more difficult to treat in
immunocompromised individuals
Treating STIs in HIV+ persons is important for
prevention; may reduce chances of transmission of HIV
Treating partners of patients with STIs may reduce
reinfection and stop the spread of the STI

Step 4 - Family Planning Services

and Safer Pregnancy Counseling in
Care and Treatment
(through Wrap-Around Programs)

Family Planning
Many women on ARVs resume sexual activity and have
unintended pregnancies (Bunnell et al., 2006)
Preventing unintended pregnancy in HIV+ women who do
not want children can avert the need for and costs
associated with (Sweat et al., 2004)
PMTCT
care for HIV+ children
support for orphans
Other HIV+ women on treatment desire children (Nakayiwa
et al., 2006); they require counseling on safe timing of
pregnancy and referrals to PMTCT

Unmet need for family planning

among HIV-infected women

(Bunnell, 2007)

Kenya Malawi Uganda

Last pregnancy
unplanned/unwanted

54%

40%

HIV-infected women who do

not want more children

41%

50%

Unmet need for

contraception among those
who do not want more
children

64%

49%

79%

Step 4 Assess pregnancy

status & intentions
Inquire about pregnancy status/intentions every visit
Through wrap-around funding:
Provide basic contraceptives in HIV clinic (pills,
injectables) and refer to FP for other contraceptives
Provide basic counseling on safer conception,
pregnancy, and delivery for HIV+ women desiring
pregnancy in the HIV care and treatment setting

Step 5 Give patient

condoms at every visit!!

Lay Counselors in Care and

Treatment Clinics

Lay Counselors
Given clinic burden and complexity of patients
needs, many patients need more in-depth counseling
on prevention issues than providers can manage
Task shifting some responsibilities to lay counselors
may be a cost-effective and supportive way to meet
clinic and patient needs for services
Training lay counselors to expand and reinforce
prevention messages delivered by providers and to
provide more in-depth counseling on specific
prevention issues is critical for prevention efforts

HIV Prevention for People Living with HIV/AIDS:

An Intervention Toolkit for HIV Care and Treatment Settings

Overhead 5-10

The 5 HIV Prevention Steps

Intervention
1-day Provider Training
Sensitizes providers to their
critical role in influencing
patients risk behaviors
Teaches them skills for
delivering behavioral
prevention messages
Provides overview and
rationale for biomedical
interventions
Allows providers to practice
delivering prevention
messages to patients

Family Planning and Safer

Pregnancy Counseling
2 day provider training
Trains providers to integrate FP services into
routine care and treatment of HIV+ women
and partners of male patients
Pills, injectables
Safer pregnancy counseling
Flip chart for health care providers technical
resource

Management of Sexually
Transmitted Infections in People
Living with HIV/AIDS
2 day provider training
Management of STIs in PLWHA as part
of routine care
Assessment questions, exams, syndromic
management

Partner management

HIV Prevention and Adherence

Counseling for PLWHA
2 week training on prevention and adherence
counseling for lay counselors (many of whom
are PLWHA)
2 week training on counseling and testing for
lay counselors (where permitted by national
guidelines
Flip chart for group education on prevention
and adherence topics
Individual counseling guide

Prevention for People Living with HIV in

Care and Treatment Settings

Kenya
Namibia
Nigeria
Haiti
Ethiopia

Tanzania
Rwanda
Cote d Ivoire
Botswana
South Africa (?)

Integrating HIV Prevention into

Clinic Settings
Family Planning

CCC

Prevention
for PLWHA
TB

Primary Care

PMTCT/
ANC

Male Circumcision
Testing and
counseling

Integrating HIV Prevention into

Community Settings
PLWHA support
networks

VCT

FBO services

Community counseling
centers

Prevention
for PLWHA

Home-based
Care

Community Health
Workers

Thank you!

Discussion Questions
How can Track 1 partners assist MOH and
USG in developing and scaling up national
programs?
How can Track 1 partners strengthen role as
technical leaders and TA providers in this area?
How can efforts be coordinated to reduce
duplication of program development and
increase implementation efforts?
What are challenges and barriers to
implementation and scale-up?