Prevention with Positives (October 2007)

President George W. Bush's Emergency Plan for AIDS Relief is the largest commitment ever by any nation for an international health initiative dedicated to a single disease-- a five-year, $15 billion, comprehensive approach to combating the disease around the world. U.S. Department of State U.S. Agency for International Development U.S. Department of Defense U.S. Department of Commerce U.S. Department of Labor U.S. Department of Health and Human Services Peace Corps Mailing address: SA-29, 2nd Floor 2201 C Street, NW Washington, DC 20522-2920 www.PEPFAR.gov

Prevention with Positives  Recent efforts by the President’s Emergency Plan for AIDS Relief (Emergency Plan/PEPFAR) to prevent new HIV infections have expanded from a focus on HIV-negative individuals to also include interventions with people who are living with HIV/AIDS (PLWHA). The adoption of healthy living and reduction in risk behaviors among HIV-positive people leads to a substantial improvement in the quality of life and a reduction in HIV transmission rates. These prevention efforts aim to mitigate the spread of HIV to sex partners, injecting drug use partners, and infants born to HIV-infected mothers, as well as protect the health of infected individuals. PEPFAR Supports Prevention for People Living with HIV/AIDS by: Providing HIV-positive individuals with information about ways they can protect their own health. This is done through the active involvement of PLWHA in the planning, delivering and monitoring of prevention, treatment and care services (see Issue Brief on Meaningful Involvement of PLWHA). It also ensures that interventions address comprehensive needs in an environment free from stigma and discrimination.   Encouraging and counseling HIV-positive persons to prevent transmission of HIV. In order to protect the health of PLWHA and to reduce the number of people exposed to HIV, every medical and/or counseling visit should include discussion of behavioral interventions to reduce the likelihood of HIV transmission. Counseling may include support for: sexual abstinence, reduction of the number and concurrency of sexual partners, and correct and consistent use of condoms. In addition to protecting HIV-infected individuals from acquiring sexually transmitted infections (STIs) or other strains of HIV that may be difficult to treat, these interventions also can help to prevent unintended pregnancies.   Promoting and providing condoms to sexually active HIV-positive individuals. Condom use is an essential component of prevention strategies for PLWHA to prevent transmission to HIV-negative sex partners, and reduce the risk of acquiring other STIs.   Developing strategies to increase adherence to PMTCT and therapeutic treatment regimens. Ensuring good adherence will facilitate maximum viral suppression, thus reducing HIV transmission risk. Interventions such as adherence counseling, use of pill boxes, and medication companions can be provided in clinical, community or home settings.   Providing all HIV-positive women and young people with support to prevent mother- to-child transmission. For HIV-positive women and couples who desire children, it is important to discuss strategies to reduce the likelihood of transmission to sex partners and infants. HIV-positive women who become pregnant are referred to PMTCT services as early as possible. Condoms are provided through PEPFAR funds; U.S. family planning programs may provide other contraceptives.   Discussing with all HIV-positive persons strategies for disclosing one’s HIV status to sex partners and offering confidential HIV testing to the sex partners of and children born to all individuals who are living with HIV/AIDS. Provider- and/or counselor- mediated disclosure are options for those who do not feel comfortable disclosing on their own.

Providing diagnosis and treatment of STIs as part of routine HIV care. Because the presence of active STIs can increase chances of HIV transmission, particular care should be paid to the syndromic management, diagnosis and treatment of genital herpes and other STIs in HIV-positive persons and their partners.   Giving HIV-positive individuals information about the risks of alcohol abuse. Heavy drinking can cause serious health risks for many PLWHA, including poor adherence to medications and increased disease progression. Under the influence of alcohol, individuals may be more likely to engage in risky behaviors, placing themselves at increased risk for acquiring STIs and placing their negative partners at risk for infection.   Incorporating prevention interventions with HIV-positive individuals in community-based settings and home-based care programs. Prevention messages and strategies can be included in counseling, support groups or peer-led interventions, or through home-based care providers. Drawing upon the leadership of PLWHA strengthens these interventions and provides further support for HIV-positive individuals. Interventions that include components such as income-generation activities or empowerment of women and girls increase the likelihood that individuals will have the means to change high-risk behaviors. The Emergency Plan at Work: The following examples highlight innovative PEPFAR-supported prevention interventions for people living with HIV/AIDS: In Kenya, a clinic-based, provider-delivered prevention intervention for HIV-infected individuals was piloted. HIV Prevention in Care and Treatment Settings is a 3-5 minute intervention that gives providers the tools and skills to deliver targeted prevention messages to HIV-positive patients at the end of every routine clinic visit. Messages focus on disclosure of HIV status, partner testing, reduction of transmission to others, and prevention of other STIs.   In Uganda, a collaborative provider training initiative involving non-profit organizations, community groups, and the Uganda Ministry of Health was developed to build capacity of service providers to deliver effective HIV counseling. Service providers and networks of PLWHA worked together to create prevention messages on a variety of topics, including: partner testing, status disclosure, socio-cultural barriers to prevention, HIV discordance, condom use, and managing the “new lease on life” challenges after antiretroviral therapy (ART), including dating, marriage and child bearing.   In Thailand, a collaboration with national and local government partners supported the design and implementation of programs for routine HIV testing in antenatal care and provision of life-saving antiretroviral drugs to HIV-infected pregnant women and their infants. A curriculum also was designed to facilitate delivery of PMTCT intervention nationwide. Expert regional trainers and consultants teach the curriculum throughout the country to provincial program managers, hospital staff and clinicians. This cascading training model has resulted in the rapid integration of PMTCT protocols into routine mother and child health services, with a high degree of acceptance from both providers and clients.   In Zambia, the purpose of the Stay Healthy program is to provide counselors, communities and clinics with an integrated program for training HIV-positive people in both maintaining their health and preventing the spread of HIV to others. The “Staying Healthy” portion of the training was developed from training provided by the Naval Medical Center in San Diego, California since the mid-1980’s and nutrition training adapted from the Regional Centre for Quality and Health Care (RCQHC) by the Zambia National Food and Nutrition Commission (ZNFNC), among others. The “Prevention for Positives” segments are based on a clinician training program currently in development by the U.S. Department of Health and Human Services and the Centers for Disease Control and Prevention (HHS/CDC) adapted from “Partnerships for Health.” The goal of this four day training is to teach counselors to educate their clients to be part of their own health process and to be a part of the efforts to reduce the spread of the HIV epidemic by making conscious and safe choices when it comes to their own behavior.