Download US Global HIV Policy: Combination Prevention

POLICY BRIEF
U.S. Global HIV Policy:
Combination Prevention
Center for Health and Gender Equity (CHANGE)
INTRODUCTION
Since 2003, the U.S. government has been a leader in the global fight against HIV/
AIDS. The Obama administration has improved the U.S. approach, particularly
for women, by shifting U.S. efforts toward combination prevention—using a
variety of tools to combat the spread of HIV. As women are now more than
half of people living with HIV worldwide, the administration must prioritize
interventions that give women the ability to protect themselves.
This paper outlines the reasons why the Office of the Global AIDS Coordinator
(OGAC) and Congress must support a true combination prevention strategy, one
that both scales up proven biomedical prevention tools and integrates sexual and
reproductive health services into HIV prevention, while also pursuing structural
attacks on barriers to HIV prevention. This paper views the situation through the
lens of women’s needs.
U.S. POLICY AND HIV
In 2009, The Lancet called the President’s Emergency Plan for AIDS Relief
(PEPFAR), the “largest and most successful bilateral HIV/AIDS program
worldwide.”1 Launched in 2003, PEPFAR is credited with helping raise the
number of people in low- and middle-income countries receiving anti-retroviral
treatment (ART) more than 16-fold, from 400,000 in 20032 to 6.65 million in
2010,3 according to the World Health Organization (WHO). More than half those
people accessed ART through U.S.-funded programs, most in sub-Saharan Africa.4
Despite this remarkable progress, fewer than half of those needing ARVs in that
region5 are receiving them.
PEPFAR is now guided by President Obama’s Global Health Initiative (GHI)
of 2009. The GHI seeks to strengthen and increase the efficiency of U.S. global
health programs, including those promoting maternal and child health and family
planning, and combating HIV/AIDS, tuberculosis, malaria and neglected tropical
diseases.6 Together, PEPFAR and GFATM budgets were 70 percent of GHI-guided
funding in FY 2011.
Secretary of State Hillary Clinton, in a November 2011 speech, described a new
vision of an AIDS-free generation: one in which virtually no vertical (motherto-child) HIV transmission occurs; HIV-free children have more and better
prevention options, making them less likely to acquire HIV as they mature; and
those that do acquire HIV have assured access to ART, which benefits their own
health and greatly reduces their risk of transmitting HIV to anyone else.7
Clinton then outlined recent scientific breakthroughs underlying this vision. The
first step expands access to the strategy of preventing vertical transmission by
administering ART to pregnant women, new mothers and newborns. The second
step involves advances in developing HIV microbicides and vaccine candidates,
and evidence that medication before exposure (pre-exposure prophylaxis, or PrEP)
and male circumcision are both effective in reducing HIV infections. The latest
breakthrough is evidence that treatment-as-prevention (TasP) can almost eliminate
the risk that an HIV-positive person will transmit HIV to someone else.
“Now of course,” Clinton added, “interventions like these can’t be successful in
isolation. They work best when combined with condoms, counseling and testing,
and other effective prevention interventions. And they rely on strong systems
and personnel, including trained community health workers. They depend on
institutional and social changes like ending stigma; reducing discrimination
against women and girls; stopping gender-based violence and exploitation, which
continue to put women and girls at higher risk of HIV infection; and repealing
laws that make people criminals simply because of their sexual orientation.”
The most promising biomedical tools cannot realize their potential in the absence
of attention to these other components, because people’s HIV-prevention decisions
occur in the context of the rest of their lives. Male circumcision is less successful
in communities where its purpose is not fully understood and embraced, for
example.8 In the microbicide trial known as FEM-PrEP, the gel appeared to
be ineffective because many participants did not use it regularly or perceive
themselves to be at risk.9
2 Center for Health and Gender Equity (CHANGE)
REMOVING THE SILOS
In her November speech, Secretary Clinton implied the value of integrating sexual
and reproductive health services with HIV prevention. PEPFAR, she said, is “one
of the strong platforms upon which the Obama administration is building our
Global Health Initiative, which supports one-stop clinics offering an array of
health services while driving down costs, driving up impact, and saving more
lives.”
Creating these “one-stop shops” is vital because women tend to put children
and family needs before their own11,12,13 and they are therefore more likely to
access HIV services when those are readily available at sites they already visit
for other needs—sexual, reproductive, maternal and pediatric care, and financial
and/or food assistance.14 Such integration saves time and money (child care
and transport) and offers women HIV services in non-stigmatizing settings they
already find comfortable.
Conversely, trained providers of HIV services are well-situated to help clients
identify their care needs and initiate access to such services. Two of the four
pillars UNAIDS calls essential to preventing vertical transmission are preventing
HIV infection in women and providing family planning to prevent unintended
pregnancies.15 These steps are closely related and can best be achieved with
integration of sexual and reproductive health (SRH) care and HIV services:
through cross-training, co-location of services and referral systems.
Experts find that the best ways of keeping women healthy also keep their
infants and partners healthy. The World Health Organization has recommended “Option B+,” a protocol for treating HIV-positive pregnant women
during pregnancy and the rest of their lives, regardless of viral load. This
means women don’t start and stop treatment depending on their childbearing or breastfeeding status or CD4 count.16
“If option B+ can be supported, funded, scaled up at the primary care level
and sustained,” WHO said, “it will also likely provide the best protection for
the mother’s health, and it offers a promising new approach to preventing
sexual transmission and new HIV infections in the general population.”17
To make this work, service providers should have current data on potential
drug interactions and be able to assist women in making informed choices.
Last year, one study suggested that injectable hormonal contraceptives might
increase a woman’s risk of acquiring or transmitting HIV.18 But major health
institutions including the Centers for Disease Control and WHO concluded that
the evidence was not strong enough to justify advising women to switch birth
control methods. Providers who focus only on family planning to the exclusion of
HIV may not receive this message, or may not communicate it effectively. Family
planning providers must fully understand implications of the available data about
hormonal contraceptives and HIV risk.
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U.S. Global HIV Policy: Combination Prevention
Integrating, rather than siloing, HIV/AIDS care, treatment, and support with the
other health and social services women use routinely is cost-effective, for three
reasons:
1. Women are usually the primary caregivers for their children and often the
unpaid caregivers for other ill or elderly family and community members.
Enabling women to protect their own health protects their ability to fulfill
this function.
2. Integration of SRH and HIV care makes efficient use of providers’ time
and lowers infrastructure costs.19 It does require investment in crosstraining and thoughtful use of providers’ skills. Providers of SRH care,
for example, often need additional training to address the unique needs of
women living with HIV. All staff also need training that counters stigma
so that patients feel respected and comfortable discussing their needs,
HIV status and sexual issues.
3. Without removal of barriers to women’s access to HIV services,
treatment-as-prevention (TasP) cannot work. Much effort is required to
improve current rates at which women living with HIV are enrolled and
retained in care and adhere to treatment regimens.
SOME STRUCTURAL IMPERATIVES
In 2010, U.S. Global AIDS Coordinator Eric Goosby reported to Congress that
structural factors influencing HIV acquisition included “gender-based violence
(GBV); economic and educational constraints; inferior legal protection and rights
to property and inheritance; and lack of leadership roles for women.” He added,
“PEPFAR’s new strategy emphasizes programs to combat GBV.”20
Cultural acceptance of GBV is a structural factor that cannot be ameliorated
without structural interventions. Consultant Judith Auerbach defines such
interventions as those designed to “modify social arrangements and social
conditions, or both, to promote health and reduce risk in specific contexts. They
include efforts to change social norms, laws, and policies; institutional and cultural
practices; and economic and financial circumstances.”21
PEPFAR has made significant commitments along these lines, including an initiative
to “expand its work on the links between GBV and HIV, with $30 million in
funding to support the scale-up of GBV prevention and response programmes”22 in
three focus countries. Among other goals, this initiative proposes to “demonstrate
that GBV programs can be brought to scale at the national or regional level.”23
The link between GBV and HIV risk has been clearly established24,25,26,27 so the
need to scale up such programming can hardly be overstated. In FY 2010, PEPFAR
also spent some $38 million to support mainstreaming GBV components into
existing HIV programs in 28 countries. U.S. investment in this area should not be
curtailed.
Another vital component of PEPFAR’s gender strategy is increasing access to
income, productive resources and education for women and girls. It works because
completing secondary school reduces a girl’s risk of HIV infection and increases the
likelihood that she will practice safe sex.28 Thus, HIV prevention and sexual and
reproductive health are both advanced by removing barriers to education for girls.
4 Center for Health and Gender Equity (CHANGE)
FEMALE CONDOMS
The White House 2011 World AIDS Day Fact sheet cited vertical transmission,
voluntary medical male circumcision, treatment-as-prevention and female and male
condoms as priority areas for expanded efforts that “will dramatically reduce new
HIV infections and save lives.”29
The condom reference was a critical addition to the three priorities Secretary
Clinton had listed in November. Female condoms are particularly important,
because the other interventions do not allow women to initiate their own protection.
Research shows that female condoms are acceptable to diverse users across a variety
of settings, and are effective in preventing pregnancy and HIV and other sexually
transmitted infections when used correctly and consistently. Female condoms also
offer unique benefits. When promoted and programmed alongside male condoms,
they increase the total number of protected sex acts, because they are sometimes used
when unprotected sex would otherwise occur. Studies also show that women view the
female condom as helping their ability to negotiate safer sex.30 Some men who object
to male condoms find female condoms acceptable, and even desirable, because they do
not affect penile erection or interrupt pleasure if they are inserted in advance.31
The White House plans to distribute more than 1 billion male and female condoms
over the next two years, which is laudable, but there must also be an effort to ensure
access to the condoms and training for their use. Although female condoms are
now in theory available in 90 countries, they are only 1.3 percent of all condoms
distributed worldwide.32 That puts the overall odds against being able to obtain a
female condom at almost 99 to one.
Lack of investment also stymies efforts to educate and promote female condoms to
potential users. But such efforts pay off. For example, Zimbabwe’s National Female
Condom Strategy, supported by the United Nations Population Fund (UNFPA),
ensured affordable access to female condoms, social marketing, and training of
more than 1,500 service providers. It resulted in an increase from 500,000 female
condoms distributed in 2005 to over 2.5 million in 2009.33
Cost has been another limiting factor. In PEPFAR focus countries, the female
condom price is US$0.55 versus US$.04 for male condoms.34 Decision-makers
who balk at this fail to see that male and female condoms are not interchangeable:
female condoms are the only alternative for women whose male partners refuse to
use male condoms.
In 2011, USAID released its first guidance to PEPFAR grantees on female condoms,
referring to them as a “largely untapped resource for HIV prevention.”35 Most
health care providers have still not been active in educating people about female
condoms and many are skeptical themselves about the tool’s benefit. Pilot projects
in Zimbabwe, South Africa, Nigeria and the United States, however, verify that
training can overcome these gatekeepers’ negative perceptions and encourage them
to promote female condoms in a positive, supportive way.36,37
More than half of all people living with HIV/AIDS are female. HIV transmission
from male to female during sex occurs more easily than from female to male,40 and
vulnerability is increased by gender-related social, political, and economic factors. It
is self-evident that the United States needs federal priorities that reflect these facts.
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U.S. Global HIV Policy: Combination Prevention
A program that distributes free female condoms in Washington, D.C.
prevented enough HIV infections during its first year to save $8 million in
future medical costs, according to a study by Johns Hopkins University.38
The benefit was nearly $20 saved for every dollar spent. “This study
really says you ought to include female condoms as one element of a
comprehensive program because it’s acceptable, effective and costsaving,” said David Holtgrave, study co-author and chairman of the
Department of Health Behavior and Society at Johns Hopkins Bloomberg
School of Public Health.39
CONCLUSION
While celebrating the “full toolbox of effective HIV prevention interventions,”
the White House World AIDS Day Fact Sheet notes that “not all interventions are
equally effective, can be taken to scale, or are appropriate for all populations.”41
And as Clinton stated, they work best when combined with other measures,
and depend on ending stigma and discrimination against women and girls. For
example, circumcision can lower a man’s risk of acquiring HIV by more than
60 percent,42 and this eventually lowers HIV risk for women by reducing the
likelihood that their partners have HIV. But on its own, circumcision offers no
immediate protection for women—unless programs also motivate men to use
condoms and stop gender-based violence. Expanding treatment-as-prevention
and efforts against vertical transmission will also benefit women, although not
immediately without the lifelong treatment of Option B+ (see text box, page 3).
The “take-home” implication of the four World AIDS Day priorities, along with
Secretary Clinton’s AIDS-free Generation speech, is that that woman-centered
interventions need continued investment. Thanks to PEPFAR, the GFATM and
other funders, we know what works: integrating HIV and SRH services, programs
to counter gender-based violence, and greater investment in educating girls, as well
as income generation initiatives for women.43
These largely structural interventions change the global environment that has fed
the steady growth of women’s HIV risk for the last 30 years. A White House recommitment to structural change is just as vital as continued biomedical research
to prevent and eventually cure HIV/AIDS. It creates an environment in which HIV
is not transmitted because people, especially women, have the right to protect
themselves and can choose when and with whom they have sex. Ending AIDS
means ending the constraints that deprive women of this right.
6 Center for Health and Gender Equity (CHANGE)
RECOMMENDATIONS
The U.S. government could take three steps in the near term that would improve
health outcomes for women, strengthen U.S. HIV programs, and signal a shift in
HIV policy.
FIRST AND FOREMOST, WOMEN’S RIGHTS AND NEEDS MUST GUIDE HIV POLICY. The
pandemic thrives on gender inequalities that keep women from controlling their
own sexual activity. Women’s rights must be recognized and respected so they can
negotiate condom use and achieve financial independence. Women’s rights must
also be the basis of structural interventions to address social risk factors such as
child marriage, rape, and gender-based violence.
SECONDLY, INCREASED U.S. FUNDING AND POLICY SUPPORT FOR PROCUREMENT,
DISTRIBUTION AND PROGRAMMING OF FEMALE AND MALE CONDOMS IS CRITICAL. These
are the only existing dual-protection methods that, when used correctly and
consistently, protect against HIV and allow women to plan their families. They
have to be part of every program to prevent and treat HIV/AIDS.
FINALLY, SEXUAL AND REPRODUCTIVE HEALTH SERVICES MUST BE INTEGRATED. The two
are inextricably linked; addressing them independently causes critical health gaps
that fuel the pandemic. Women living with HIV may go untreated because their
family planning provider does not test for HIV. Others may receive treatment at
an HIV clinic, yet face stigma if they seek contraception or prenatal care because
of perceptions that women living with HIV should not have sex.
Combination prevention protects everyone. It can provide both short- and longterm prevention and treatment, and it recognizes the root causes that have made
HIV/AIDS a global pandemic. It also addresses the new shape of the pandemic:
women are the majority of people living with HIV.
Comprehensive combination prevention should be the next step in the U.S. legacy
as a leader in HIV prevention and treatment. It is the only way to truly turn the
tide and create an AIDS-free generation.
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U.S. Global HIV Policy: Combination Prevention
NOTES
1 The Lancet. Appointment of PEPFAR head should be merit based [editorial]. The Lancet. 2009;
373:354.
2 World Health Organization. “Global HIV/AIDS Response—Epidemic update and health sector
progress towards Universal Access—Progress Report 2011. Geneva: WHO. www.who.int/hiv/
pub/progress_report2011/summary_en.pdf
3 Ibid.
4 The White House, Office of the Press Secretary. Press Release, “Fact Sheet: The Beginning of the
End of AIDS.” 1 December 2011. www.whitehouse.gov/the-press-office/2011/12/01/fact-sheetbeginning-end-aids
5 World Health Organization. “Key facts on HIV epidemic and progress in regions and countries
in 2010.” Geneva: World Health Organization. www.who.int/hiv/pub/progress_report2011/
regional_facts/en/index.html
6 White House Office of the Press Secretary. “Statement by the President on Global Health
Initiative.” 5 May 2009. www.whitehouse.gov/the_press_office/Statement-by-the-President-onGlobal-Health-Initiative
7 Henry J. Kaiser Family Foundation. “The U.S. Global Health Initiative.” U.S. Global Health
Policy Fact Sheet. Menlo Park, CA. February 2011. www.kff.org/globalhealth/upload/8116.pdf
8 Clinton HR. “Remarks on Creating an ‘AIDS-Free Generation’.” 8 November 2011, U.S.
Department of State. www.state.gov/secretary/rm/2011/11/176810.htm
9 IRIN PlusNews. “Kenya: Male Circumcision Programme Suffers Setback.” 2 March 2012. IRIN
PlusNews. available online at www.plusnews.org/report.aspx?ReportID=94992
10 van Damme L. The FEM-PrEP Trial of Emtricitabine/Tenofovir Disoproxil Fumarate (Truvada)
among African Women. Paper presented at the Conference on Retroviruses and Opportunistic
Infections. 6 March 2012. Seattle.
11 Merenstein D, Schneider MF, Cox C, et al. (2009). Association of Child Care Burden and
Household Composition with Adherence to Highly Active Antiretroviral Therapy in the Women’s
Interagency HIV Study. AIDS Patient Care STDs; 23(4), 289–296. doi:10.1089/apc.2008.0161
12 Vyavaharkar M, Moneyham L, Tavakoli A, et al. (2007). Social Support, Coping, and
Medication Adherence among HIV Positive Women with Depression Living in Rural Areas
of the Southeastern United States. AIDS Patient Care STDs; 21(9), 667–680. doi:10.1089/
apc.2006.0131.
13 Hackl KL, Somlai AM, Kelly JA, & Kalichman SC. (1997). Women Living with HIV/AIDS: The
Dual Challenge of Being a Patient and Caregiver. Health & Social Work; 22, 53–62.
14 Gay J., Hardee, K., Croce-Galis M., Kowalski S., Gutari C., Wingfield C., Rovin K., Berzins, K.
(2010). What Works for Women and Girls: Evidence for HIV/AIDS Interventions. New York,
NY: Open Society Institute.
15 UNAIDS. “Global Plan Toward the Elimination of New HIV Infections among Children by 2015
and Keeping Their Mothers Alive.” 2011. Geneva: UNAIDS. www.unaids.org/en/media/unaids/
contentassets/documents/unaidspublication/2011/20110609_JC2137_Global-Plan-EliminationHIV-Children_en.pdf
16 Mazzota, Meridith. “WHO updates HIV treatment guidance for pregnant women and preventing
HIV infection in babies.” sciencespeaksblog.org/2012/04/09/who-updates-hiv-treatmentguidance-for-pregnant-women-and-preventing-hiv-infection-in-babies/#ixzz1zkE6YHQx
17 World Health Organization. Programmatic Update: Use of Antiretroviral Drugs for Treating
Pregnancy Women and Preventing HIV Infection in Infants. April 2012. 4.
18 Heffron R et.al. (January 2012). Use of hormonal contraceptives and risk of HIV-1 transmission:
a prospective cohort study. Lancet Infectious Diseases: 12(1):19-26.
19 Stover J, Dougherty L, Hamilton M. ” Are Cost Savings Incurred by Offering Family Planning
Services At Emergency Plan HIV/AIDS Care And Treatment Facilities?.” January 2006.
USAID Report. Washington DC, www.policyproject.com/pubs/generalreport/FP-HIV%20
Integration%20Costs%20and%20Savings%20Final.pdf
20 Ibid.
21 Auerbach J. Transforming social structures and environments to help in HIV prevention. 2008.
Health Affairs, 28 (6), 1655-1665
8 Center for Health and Gender Equity (CHANGE)
22 Fleischman J. Dialog with Development Partners: New U.S. Policy Approach to Women and
Girls in PEPFAR and the Global Health Initiative. 2010. Geneva: Global Coalition on Women
and AIDS, UNAIDS
23 Office of the Global AIDS Coordinator. ”PEPFAR:Addressing Gender and HIV/AIDS’ (March
2011) www.pepfar.gov/press/2011/157860.htm
24 Ellsberg M, Jansen HA, Heise L, et al. Intimate Partner Violence and Women’s Physical and
Mental Health in the WHO Multi-Country Study on Women’s Health and Domestic Violence: an
observational study. 2008. The Lancet, 371(9619): 1165–1172.
25 Silverman J.G., Decker M.R., Saggurti N, Balaiah D, Raj A. Intimate Partner Violence and HIV
Infection Among Married Indian Women. 2008. JAMA, 300(6): 703–710.
26 Dude A.M., Spousal Intimate Partner Violence is Associated with HIV and other STIs Among
Married Rwandan Women. 2009. AIDS and Behavior, 15(1); 142-152. doi:10.1007/s10461-0099526-1
27 Dunkle K.L., Jewkes R.K., Brown H.C., Gray G.E., McIntryre J.A., Harlow S.D. Gender-Based
Violence, Relationship Power, and Risk of HIV Infection in Women Attending Antenatal Clinics
in South Africa. 2004. The Lancet, 363(9419):1415–1421.
28 Hargreaves, J. and T. Boler, T. Girl Power: The Impact of Girls’ Education on HIV and Sexual
Behaviour. 2006. London: ActionAid International.
29 The White House, Office of the Press Secretary. Press Release, “Fact Sheet: The Beginning of the
End of AIDS.” 1 December 2011. www.whitehouse.gov/the-press-office/2011/12/01/fact-sheetbeginning-end-aids
30 Center for Health and Gender Equity. Female Condoms and U.S, Foreign Assistance: An
Unfinished Imperative for Women’s Health. Washington DC: Center for Health and Gender
Equity, 2011.
31 Mack N. et al. “Formative Research on Female Condom Promotion in Central America.” 2008.
Washington DC: USAID.
32 USAID. Technical Guidance: “The Female Condom.” 2011. transition.usaid.gov/our_work/
global_health/aids/TechAreas/prevention/femalecondom.html
33 UNFPA Zimbabwe. “Promoting evidence based HIV Prevention Services.” 30 March 2011.
countryoffice.unfpa.org/zimbabwe/2010/12/02/2921/prevention_evidence_based_hiv_prevention_
services
34 Center for Health and Gender Equity. Female Condoms and U.S. Foreign Assistance: An
Unfinished Imperative for Women’s Health. Washington DC: Center for Health and Gender
Equity, 2011.
35 USAID. Technical Guidance: “The Female Condom.” 2011. transition.usaid.gov/our_work/
global_health/aids/TechAreas/prevention/femalecondom.html
36 Mantell J.E., Hoffman S., Weiss E., et al. The acceptability of the female condom: perspectives of
family planning providers in New York City, South Africa, and Nigeria. Journal of Urban Health:
Bulletin of the New York Academy of Medicine. 2001 Dec; 78(4):658-668.
37 PreventionNow.net. Country Profile: “Female Condoms: Lessons from Zimbabwe.” July 2010.
www.genderhealth.org/files/uploads/prevention_now/publications/Zimbabwe_Female_Condom_
Country_Profile_2010.pdf
38 Holtgrave D.R., Maulsby C., Kharfen M., et al. Cost-utility analysis of a female condom
promotion program in Washington DC. AIDS and Behavior 2012; 16:1115-1120.
39 The Washington Post. “Study credits D.C. female condom program with reducing HIV and
associated costs.” 26 March 2012 Washington DC, The Washington Post Company. www.
washingtonpost.com/national/health-science/dc-female-condom-program-prevents-hivinfections/2012/03/25/gIQAvknpbS_story.html
40 Avert.org. “Women, HIV and AIDS.” www.avert.org/women-hiv-aids.htm
41 The White House, Office of the Press Secretary. Press Release, “Fact Sheet: The Beginning of the
End of AIDS.” 1 December 2011. www.whitehouse.gov/the-press-office/2011/12/01/fact-sheetbeginning-end-aids
42 Ibid.
43 Gay J., Hardee, K., Croce-Galis M., Kowalski S., Gutari C., Wingfield C., Rovin K., Berzins, K.
(2010). What Works for Women and Girls: Evidence for HIV/AIDS Interventions. New York,
NY: Open Society Institute.
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U.S. Global HIV Policy: Combination Prevention
ABOUT CHANGE
The Center for Health and Gender Equity (CHANGE) is a U.S.-based
nongovernmental organization that promotes the sexual and reproductive
health and human rights of women and girls globally by shaping rightsbased and just U.S. policies. CHANGE advocates for effective, evidencebased policies and increased funding for critical programs. CHANGE
believes that every individual has the right to basic information,
technologies, and services needed to enjoy a healthy and safe sexual and
reproductive life free from coercion and preventable illness.
This brief was written by Anna Forbes, MSS.
© 2012, Center for Health and Gender Equity.
CENTER FOR HEALTH AND GENDER EQUITY (CHANGE)
1317 F Street NW, Suite 400
Washington, DC 20004 USA
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Email: [email protected]
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