Technical brief: Biomedical and structural prevention: STRIVE in the era of 'cascades'

Technical brief - Biomedical and structural prevention.pdf

Despite advances, an unmet need remains for HIV prevention, both through primary prevention through treatment for HIV negative individuals and secondary prevention through treatment for HIV positive individuals. This need is urgent in key populations such as sex workers, men who have sex with me, prisoners and people who use drugs, transgender people and adolescent girls and young women in sub-Saharan Africa.

A number of direct biomedical mechanisms have proven efficacy in preventing transmission at the biological level:

  • condoms: 90 to 95%
  • voluntary medical male circumcision: 60 to 75%
  • pre-exposure prophylaxis (PrEP): 95 - 99%
  • dapivirine vaginal ring: 30 to 35%
  • antiretroviral treatment (ART) as secondary prevention: 96%

The advances in antiretroviral (ARV)-based primary and secondary prevention offer real promise for reducing HIV incidence at a population-level, if sufficient coverage is achieved. However, the impact at population level of treatment as prevention, for example, has been constrained by the realities of people's lives. In the past, interventions to overcome barriers to the uptake of prevention methods focused on behaviour change. Increasingly, though, the field has come to acknowledge that individual choices are shaped at the structural level.

"Prevention strategies must address the structural factors that inhibit or enhance the uptake of direct mechanisms of HIV prevention to achieve a population-level impact."

Key points

This brief presents conceptual thinking, synthesis and analysis of evidence to show that:

  • biomedical interventions will not achieve ambitious targets to end AIDS without addressing structural factors that shape HIV risk and undermine uptake and effective use of prevention options
  • structural factors can be addressed within programmatic time frames with evidence based interventions
  • we can and must integrate strategies to address structural factors within biomedical prevention, and evaluate this at scale

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