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Geoffrey Setswe DrPH , MPH

Contextualizing HIV prevention interventions that work: Translation of evidence-based research into policies and practices. Geoffrey Setswe DrPH , MPH Symposium 1: Accelerating the uptake of evidence-based practices globally Georgetown East, Concourse Level April 28, 2011; 08:45 – 10:15.

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Geoffrey Setswe DrPH , MPH

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  1. Contextualizing HIV prevention interventions that work: Translation of evidence-based research into policies and practices Geoffrey Setswe DrPH, MPH Symposium 1: Accelerating the uptake of evidence-based practices globally Georgetown East, ConcourseLevel April 28, 2011; 08:45 – 10:15

  2. Introduction • >33m people have been infected by HIV and over 25m people have died in the past 30 years! • Over the years, we developed evidence on HIV prevention interventions that work • A myriad of policies were developed to respond to the epidemic • Describe the translation of evidence-based research on HIV/AIDS into policies and practices and give a context of why some HIV prevention interventions do not work

  3. Translation of research on PMTCT into policy and practice Research evidence: providing two ARV drugs to a pregnant HIV+ mother can reduce MTCT by up to 92%. Policy: WHO recommended single dose Nevirapine in 2001 and dual therapy later. Practice:15 countries, including Botswana, Guyana, and South Africa, were able to provide more than 80% of HIV positive pregnant women with ARVs to prevent transmission to their babies. 53% of pregnant women in poorer countries who needed services for PMTCT received them in 2009 • . Global Partners Forum (2007).

  4. Translation of HAART policiesCase of WHO’s “3 by 5” campaign Evidence: providing ART to a patient with AIDS reduces mortality and morbidity by 60-80%. Policy: Triple therapy for HIV+ patients with CD4 <350 with opportunistic infection. Policy reforms to expand treatment access to “3 m patients by 2005”. Policy response: Dramatically reduce the price of ARVs or offer them for free at public health services. . Global Partners Forum (2007).

  5. Current practice and context on ART • Practice: ART therapy coverage increased from 7% (2003) to 12% (2004) and 20% (2005). The # of people receiving ART in LMICs grew rapidly from 100,000 in 2001 to 4m in 2008, > 40% of all those in need… • 8 LMICs achieved the goal of 80% coverage of patients in need of antiretrovirals: Botswana (83%), Cambodia (94%), Croatia (80%), Cuba (95%), Guyana (>95%), Oman (>95%), Romania (81%), and Rwanda (88%).

  6. Translation of research to policy in Zambia:The case of Co-trimoxazole Preventative Therapy (CPT) for HIV/TB Research Policy Implementation Source: Evidence For Action Working Paper Issue 02, August 2009. Available at http://www.evidence4action.org/images/stories/documents/researchtopolicyzambia.pdf

  7. Translation of MC evidence into policy and programs Policy recommendations 2007 2011 Scientific evidence 1986-2007 Implementation (very few countries are implementing MC policies) WHO/UNAIDS Technical Consultation Male Circumcision and HIV Prevention: Research Implications for Policy and Programming Montreux, 6- 8 March 2007

  8. Evidence on Male and Female Condoms Evidence: A meta-analysis by UNAIDS* = male condom use is 90% effective in preventing HIV transmission. Based on laboratory and clinical evidence, the US FDA approved the female condom as 94-97% effective in reducing the risk of HIV infection, if used correctly and consistently**. *Hearst N and Chen S, Condom promotion for AIDS prevention in the developing world: is it working? Studies in Family Planning, 2004, 35(1):39–47. http://www.usp.br/nepaids/condom.pdf **AVERT, “The Female Condom” fact sheet, available online at http://www.avert.org/femcond.htm

  9. Policy and practice on condoms Policy: 100% condom use policies (CUP) for high risk sex and national condom policies for the general population Practice: Several Asian countries like Thailand, Indonesia implemented the 100% condom use Programs. Several African countries are implementing national condom programs for the general population e.g. Kenya, South Africa, Zimbabwe, Botswana, etc.

  10. Translation of research on ABC to policy and practice Evidence: There is mixed evidence on whether ABC works. In the US, abstinence-only interventions have failed. However, Uganda attributes its success in reducing HIV prevalence to ABC Policy position: Many African countries say their HIV prevention policy is based on ABC. Practice: The ABC approach has been adopted in many African countries, included in school curricula and in youth interventions Expert opinion: Scientists criticize/trash ABC

  11. Translation of MCP research into policy and practice Evidence: There is mixed evidence. • Concurrent sexual partnerships and the HIV epidemics in Africa: Evidence to move forward (Mah and Halperin, 2008). • The evidence that concurrency is driving Africa AIDS epidemics is not conclusive (Lurie and Rosenthal , 2009) . Policy: Maseru Declaration (2006) recommended policy on reducing number of partners in SADC Practice: FBOs support Abstinence for unmarried and Fidelity for married. NGOs support reduce number of partners or R in DRC *Coates TJ, Richter L,Caceres C (2008) Behavioural strategies to reduce HIV transmission: how to make them work better. Lancet , Aug 2008 AIDS and Behavior 2008 and 2009

  12. Research evidence on HIV Counseling and Testing (HCT) • Meta-analysis of 11 studies of the impact of counseling and testing for PLWH/A* • 68% reduction in high risk sexual behaviors with partners not already HIV+ (95% CI: 59% - 76%) • Very similar findings for men and women • Examining pool of 27 studies, a meta-analysis** found no significant impact of “counseling and testing” bundle on behavior relative to the untested. Goodevidence Weak or No evidence *Marks G et al. JAIDS 2005;39:446-453. **Weinhardt LS et al. Am J Public Health. 1999;89:1397-1405.

  13. Translation of HCT policySouth Africa’s HCT and mobilization campaign • Research assumptions: Testing increases health-seeking behaviors; equips those who test for HIV- with ways of ensuring that they don’t get HIV; and creates a quick and easy entry point to accessing wellness and treatment services for those who test HIV+ • Policy: 2001 policy on VCT was replaced with a new policy including VCT and Provider-initiated Counseling and Testing • Practice: President tested publicly to show political will and support the campaign. Launched campaign in all provinces in Apr 2010 . Aim: to test 15 million people by June 2011. >5 m people were tested by Feb 2011. Source: South African National AIDS Council (2010) Launch of the new HCT campaign. April 2010

  14. The AIDS epidemic has taught us to be innovative and to invent, test and implement new interventions. We now have evidence of HIV prevention strategies that work! Picture source: Naidoo D (2007). Science, Technological and Innovation – A Strategic Imperative for South Africa

  15. However, despite the evidence and myriad of policies, it has been difficult to implement effective strategies. People still get infected and die from HIV/AIDS! Picture source: Naidoo D (2007). Science, Technological and Innovation – A Strategic Imperative for South Africa

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