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Prevention Trials in the Region Behavioral Trials*

Prevention Trials in the Region Behavioral Trials*. *Limited to interventions evaluated by randomized controlled designs with HIV incidence as an outcome. Prevention Trials in the Region Microcredit Trials*.

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Prevention Trials in the Region Behavioral Trials*

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  1. Prevention Trials in the Region Behavioral Trials* *Limited to interventions evaluated by randomized controlled designs with HIV incidence as an outcome

  2. Prevention Trials in the Region Microcredit Trials* *Limited to interventions evaluated by randomized controlled designs with HIV incidence as an outcome

  3. Prevention Trials in the Region MaleCircumcision Trials* *Limited to interventions evaluated by randomized controlled designs with HIV incidence as an outcome

  4. Male Circumcision • Reduces FM transmission by ~ 58% • Challenge for reduction in MF is ensuring sufficient time for wound healing before resumption of sexual activity • Little evidence of risk compensation in RCTs: critical consideration for scale-up

  5. Prevention Trials in the Region Microbicide Trials* *Limited to interventions evaluated by randomized controlled designs with HIV incidence as an outcome

  6. Microbicide evolution: Non-specific  ARV-containing products • Holds more promise • Topical, vaginal PREP • To prevent transmission (reduce infectiousness)? • Shift from original concept of low-tech, low-cost product • Challenges with resistance • Use during pregnancy • Not effective on other STI outcomes • Not a contraceptive

  7. Prevention Trials in the Region Cervical Barrier Trials* *Limited to interventions evaluated by randomized controlled designs with HIV incidence as an outcome

  8. Prevention Trials in the Region STI Treatment Trials* *Limited to interventions evaluated by randomized controlled designs with HIV incidence as an outcome

  9. Prevention Trials in the Region STI Treatment Trials* (con’t) *Limited to interventions evaluated by randomized controlled designs with HIV incidence as an outcome

  10. Epidemic Phase: A Guide in Designing HIV Prevention Strategy HIV Epidemic Pattern Mature/Generalized Nascent  Concentrated EpidemicPhase Hyperendemic Decline Growth Endemic Modified from: Wasserheit & Aral. JID 1996;174:S201-213

  11. Prevention Trials in the Region Vaccine Trials* *Limited to interventions evaluated by randomized controlled designs with HIV incidence as an outcome

  12. What works? • No HIV vaccine or topical prophylaxis will be available in the foreseeable future • For now: male condoms (condom promotion, distribution & IES); VCT and peer-based programs; male circumcision; and the prophylactic use of ARVs to reduce MTCT or contraception to prevent unwanted pregnancy • Treatment of sexually transmitted infections, a strong public health intervention in its own right, has had mixed results • Might be more effective if focused on reducing infectiousness than acquisition

  13. Levels of evidence for HIV prevention • Abstinence • Male circumcision • Male condom • Female condom • Reducing # of sex partners (absolute and concurrent) • STD tx for HIV • Abstinence promotion, • with or without • Postponing sexual debut More evidence Less evidence

  14. What we need to do: Combination prevention packages • No single magic bullet • + behavior: Essential to maintain adherence, to avoid sexual dis-inhibition (risk compensation) • + structural: Essential for addressing mechanisms that are necessary for scale-up to optimize effects • + biological: (e.g. male circumcision plus condoms; cervical barrier plus vaginal antimicrobial or antiretroviral gel)

  15. Whom to target Prioritization/targeting/tailoring Universalistic Dilution Equality Equal access Tipping point for social norms • Precision with or without diffusion • Potential for greater yet limited impact • Stigma • Restricted benefits • Restricted effects

  16. Relevant issues • UNAIDS guidelines for planning purposes useful first step • Epidemics: low-level, concentrated, generalized or hyper-endemic • Key steps: • “know epidemic and current response” • “match and prioritize response” • “set ambitious, realistic and measurable prevention targets” • “tailor prevention plans” • “utilize and analyze strategic information” • Guidelinesmay not accurately reflect real setting complexities, no specifics on how to choose optimal sets of interventions by situation, no focus on best-buys  • Academic studies have serious limitations

  17. Challenges for decision makers Finding the optimal balance between treatment, prevention, and palliative interventions Few good tools to choose sets of interventions that yield optimal results for specific settings (demographics, epidemic characteristics, economic context, etc.) and financing levels. Political and social considerations affect decision making: some cost-effective interventions hard to promote

  18. Levels of outcomes/impact Environmental e.g. Changes in social and sexual norms Cognitive, attitudinal, affectivee.g. fear of stigma Behavioral e.g. Condom use Biological HIV STI Pregnancy

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