1. Prevention Trials in the Region Behavioral Trials*
Author (Year)
Location
Intervention
Findings (Rate ratio (RR))
Ross (2007)
Tanzania
MEMA kwa Vijana, adolescent sexual health education in primary school, condoms, health services
RR=0.75 (0.34, 1.66) (Girls only)
Corbett (2007)
Zimbabwe
Workplace onsite VCT vs. standard VCT at external provider
RR=1.49 (0.79, 2.80)
Jewkes (2008)
South Africa
Stepping Stones, 50-hr participatory learning approach vs. 3-hr standard intervention on safer sex and HIV
RR=0.95 (0.67, 1.35)
Pequagnat (2008)
Community popular opinion leader
To be announced
*Limited to interventions evaluated by randomized controlled designs with HIV incidence as an outcome

2. Prevention Trials in the Region Microcredit Trials*
Author (Year)
Location
Intervention
Findings (Risk ratio (RR))
Pronyk (2006)
South Africa
IMAGE Intervention, poverty-focused microfinance, month Sisters for Life gender and HIV training program
RR=1.06 (0.66, 1.69)
*Limited to interventions evaluated by randomized controlled designs with HIV incidence as an outcome

3. Prevention Trials in the Region Male Circumcision Trials*
Author (Year)
Location
Intervention
Findings (Rate ratio (RR))
Auvert (2005)
South Africa
Male circumcision vs. delayed circumcision
RR=0.40 ( )
Bailey (2007)
Kenya
RR=0.47 (0.28, 0.78) (Risk Ratio)
Gray (2007)
Uganda
RR=0.49 (0.28, 0.84)
*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*
Author (Year)
Location
Intervention
Findings (Hazard ratio (HR))
Kreiss (1992)
Kenya
Nonoxynol-9 sponge vs. placebo
HR=1.7 (0.9, 3.0)
Richardson (2001)
Nonoxynol-9 vaginal gel vs. placebo
RR=0.7 (0.3, 1.5) (Risk Ratio)
VanDamme (2002)
South Africa
HR=1.5 (1.0, 2.2)
VanDamme (2008)
South Africa, Uganda
Cellulose sulfate vs. placebo
HR=1.61 (0.86, 3.01)
Skoler-Karpoff (2008)
Carraguard vs. methylcellulose
HR=0.87 (0.69, 1.09)
*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*
Author (Year)
Location
Intervention
Findings (Hazard ratio (HR))
Padian (2007)
South Africa, Zimbabwe
Latex diaphragm, lubricant gel, and condoms vs. condoms alone
HR=1.05 ( )
*Limited to interventions evaluated by randomized controlled designs with HIV incidence as an outcome

8. Prevention Trials in the Region STI Treatment Trials*
Author (Year)
Location
Intervention
Findings (Rate ratio (RR))
Grosskurth (1995)
Tanzania
Improved STD case management at primary health care level
0.58 (0.42, 0.79)
Wawer (1999)
Uganda
Intensive STD control, via home-based mass antibiotic treatment
0.97 (0.81, 1.16)
Kaul (2004)
Kenya
Monthly administration of 1 g of azithromycin or identical placebo
1.2 (0.6, 2.5)
Gregson (2007)
Zimbabwe
community-based peer education, condom distribution, income-generating projects, and clinic-based STI treatment and counseling
1.27 (0.92, 1.75)
*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)
Author (Year)
Location
Intervention
Findings (Rate ratio (RR))
Watson-Jones (2008)
Tanzania
HSV-2 suppressive treatment with 400mg vs. placebo
1.08 (0.64, 1.83)
Kamali (2003)
Uganda
Behavioral interventions alone (A), behavioral and STI interventions (B), or routine government health services and community development activities (C)
RR=0.94 (0.60, 1.45) Group A vs. C
RR= 1.00 (0.63, 1.58) Group B vs. C
*Limited to interventions evaluated by randomized controlled designs with HIV incidence as an outcome

10. Epidemic Phase: A Guide in Designing HIV Prevention Strategy
Key Strategy Considerations
HIV+ partners
Rare
Common
Sub-pop’n distribution of HIV
Concentrated in
core groups
Majority in stable partnerships
Acute/early HIV inf’n (Incidence:Prevalence)
Higher I:P ratio
Lower I:P ratio
Biological & behavioral susceptibility
High
Lower
Behavior change at
individual & societal levels
(e.g. condoms, #sp, ART)
Low
Increasing
STDs
Bacterial GUD & other STDs common in core groups
Bacterial GUD replaced by HSV-2; Other
bacterial STDs falling
HIV Epidemic Pattern
Mature/Generalized
Nascent  Concentrated
EpidemicPhase
Hyperendemic
Growth
Decline
Endemic
Modified from: Wasserheit & Aral. JID 1996;174:S

11. Prevention Trials in the Region Vaccine Trials*
Author (Year)
Location
Intervention
Findings (Hazard ratio (HR))
HVTN 503
South Africa
HVTN 503: Phambili MRKAd5 HIV-1 gag/pol/nef
Enrolling
*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 Universalistic Prioritization/targeting/tailoring
Precision with or without diffusion
Potential for greater yet limited impact
Stigma
Restricted benefits
Restricted effects
Dilution
Equality
Equal access
Tipping point for social norms

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”
Guidelines may 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, affective e.g. fear of stigma
Behavioral
e.g. Condom use
Biological
HIV
STI
Pregnancy