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Tuesday, 25 July 2017 21:08

Reality check!

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Advancing combination prevention

What does it take to build a comprehensive national HIV prevention programme? Good evidence about the epidemic, for a start.

At a Tuesday session at IAS 2017, Jpiego’s Daniel Were presented Kenya’s approach to a national scaled-up programme that is based on the latest epidemiological data. The evidence shows that young people count for 46% of Kenya’s new infections and key populations experience a disproportionate burden of HIV, with 29.3% of sex workers and 18% of MSM 18% being infected.

Kenya’s national HIV combination prevention strategy therefore prioritises these population groups that are most at risk, as well as geographical areas of high transmission. These groups are targeted with high impact interventions which combine behavioural, biomedical and structural elements. Awareness, risk perception, and self-efficacy have been identified as necessary behavioural interventions; treatment as prevention, male circumcision, PrEP, condoms and STI reduction are selected as key biomedical interventions, and structural interventions are aimed at reducing the vulnerability of young women. Different groups will receive different combinations of these interventions based on evidence from the past. PrEP is particularly targeted at groups at greatest risk, and VMMC is targeted to the western region of Kenya where there has been lower uptake. Behavioural programmes, however, will have a much broader reach.

In the same session modelling boffin John Stover explained that cost (and cost-effectiveness) of interventions is another dimension that may shape national programmes. Countries with a fixed, and even shrinking budget, must prioritise their programmes to meet an ever-growing pool of need. Cost effectiveness is essentially the art of doing more with existing resources, and involves reducing implementation costs, selecting the most effective programmes and improving reach by evidence-based targeting. A modelling tool that plots number of infections averted against cost of each infection averted is a useful tool for this exercise.

However, this approach is not without challenges and there are still many questions to answer. For example: how to find the groups at highest risk, how to balance prevention and treatment and how to value structural interventions, to name just a few. In addition, many interventions, such as behaviour change communication, are hard to assess, and impact is difficult to measure. Another challenge is keeping up with the growing population – particularly the “youth bulge” which means ever larger cohorts of vulnerable young people.



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