1. Coordination of care, treatment, and prevention services at the planning and operational levels
Donors and Governments should be encouraged and assisted to more effectively integrate appropriate aspects of HIV prevention with HIV care and treatment. Ultimately, there is a need to expand the types of services delivered to HIV-infected individuals on the ground. Systems and operational research are critically important to understanding how this can be achieved in diverse countries based on the characteristics of their health care services. Although the goal of coordinated HIV services at the community level is the same across countries, each country’s planners will need to assess existing health systems and the burden and characteristics of their nation’s epidemic to develop an appropriate blend of linkages, co-location or totally integrated services. Donor funding should encourage flexibility and nurture the establishment of creative models of integrated programs. As an example, Brazil’s long term commitment to the integrated delivery of prevention and care to people living HIV/AIDS has been documented [14
] and has demonstrated how the implementation of comprehensive prevention strategies can be successfully accomplished in a middle-income country. Further, a well-integrated and far-reaching system of monitoring and evaluation has been recently established in the country [54
], paving the way for similar initiatives in other middle and hopefully low-income countries. This type of approach is compatible with the recommendation made by the Institute of Medicine regarding focus on integrated prevention and treatment efforts and support for behavioral prevention efforts [55
2. Development of programs focused on women’s needs that integrate reproductive health and HIV services through co-location and/or effective linkages
Across countries, women come into contact more often with the health care system and are better positioned to help other family members access health care services (ref). Orienting services to the particular needs of women, which include care of their partners and children when appropriate, is a strategic way to improve adherence to care and treatment programs. Because of the disproportionate impact of the HIV epidemic on women (in both social and biomedical terms), the separation of prevention and care/treatment services is likely to exacerbate the negative consequences of HIV disease for women. Specifically, the triad of HIV care/treatment, pMTCT, and reproductive health care, should be coordinated at the policy, planning and operational levels as a seamless continuum. Integrated services would provide opportunities to deliver interventions across the spectrum of needs of HIV-infected women
3. Development of guidelines for safer reproductive strategies for HIV-infected women and men with training of health care workers on the sexual and reproductive rights of the patient
In order to better support informed and appropriate sexual partnering and reproductive choices among HIV-positive individuals, and facilitate effective prevention interventions within care and treatment programs, interventions are required at two discrete points. First, at a policy level, clear and explicit statements are required to underscore the importance of free and informed sexual and reproductive choices among HIV-infected women and men (as among all individuals). For individuals considering whether to have a child, clear messages are required regarding the potential risks involved (including vertical transmission of HIV to the child, and possibly horizontal HIV transmission in the case of serodiscordant partnerships), as well as the magnitude of these risks relative to that of a safe pregnancy. Second, policies that support informed choice must be supported by services that allow individual choices to be enacted as safely as possible. Individuals who have decided to have a child require information regarding safe conception and childbearing; individuals who decide to not have a child require access to effective contraception, along with information on sexual risk reduction. Specific interventions for health care providers are needed as they often act as the principle ‘gatekeepers’ to health related information. Health care providers (including nurses, doctors and counselors) require relevant biomedical information on fertility and HIV infection. Many providers may benefit from values clarification interventions, which seek to distinguish between providers’ professional responsibilities and their personal beliefs. Also, standards of care guidelines are needed for routine sexual behavior assessments for all people living with HIV, in conjunction with HIV care and treatment, as well as routine screening for, and treatment of, all STIs.
4. Human right advocacy for changes in policy and law and their implementation to ensure access to services for all HIV-infected individuals, including high-risk marginalized populations
Since international human rights law prohibits discrimination on the basis of HIV status all countries must ensure that no laws, policies or practices discriminate in access to prevention, care, treatment as well as reproductive and sexual health information and services on the grounds of HIV status, as well as race, color, gender, or national or social origin, [56
]. While law reform is a time-consuming political process requiring broad consensus among policy makers, law enforcement practitioners, healthcare professionals, and communities, there are specific policies that can be implemented to improve public health in terms of HIV. Safe access is needed to prevention strategies including sexual and reproductive health and HIV-related services for all people including adolescents and those with minority status such as sex workers, men who have sex with men, substance users (including IDUs), and undocumented immigrants and migrants. Availability of confidential youth-friendly health services for adolescents without legal and policy constraints is critical. In addition, programs are also needed to address the needs of minority and marginalized populations with HIV.
5. “Scale-up” of effective behavioral interventions and training of staff to provide these interventions
Various sexual risk reduction behavioral interventions have been shown to be effective among HIV-infected men, women, and adolescents [8
], although these studies have been conducted primarily in the U.S. and have not included evaluated their effect on HIV transmission or other biological outcomes. Thus, more research is needed that evaluates the effectiveness of various interventions on HIV acquisition as well as studies of effectiveness of the behavioral interventions that have been shown to be effective in the US in resource-limited countries. Even with limited data on the effectiveness of the behavioral interventions on HIV transmission and lack of data on their impact when implemented in a programmatic setting, offering prevention services to HIV-infected individuals is now recommended as an important approach to control of the HIV epidemic in the United States [60
]. Both the Institute of Medicine (IOM) and the Centers for Disease Control and Prevention (CDC) have advocated for the inclusion of “Prevention with Positives” programs in a coordinated national prevention strategy [55
The development and dissemination of innovative tools is needed in order to assist in their use by a broad range of counselors and healthcare providers. For example, multimedia technology, such as use of laptops and pre-programmed psycho-educational materials as well as standardized training and tools have been used effectively in other health related interventions in resource poor settings, showing improvements in health behaviors among patients and enhanced cost-effectiveness when implemented by community health workers [62
]. Such tools may have the advantage of: (1) use of videos and pictures to teach memorable lessons to patients, including those with poor literacy, about HIV care, adherence, and sexual practices, (2) improving quality control and consistency of delivery of intervention content, (3) and necessitating limited supervision and training
6. Provision of mental health and substance use services to HIV-infected individuals who need it
It is important to find ways to provide and sustain much needed mental health services for all individuals and families living with HIV, both in resource poor countries with limited mental health infrastructure, as well as in settings that already have the capacity and means. HIV treatment guidelines should include routine screening for mental illness as part of regular assessments and the provision of management for individuals with such conditions including appropriate medications and counseling interventions. Creative approaches are needed for provision of mental health services in settings where such services may be perceived as unfamiliar to the culture and the local capacity of health care system. For example, psychological support, particularly around issues such as disclosure, adherence, and sex can be provided by peer counselors, trained nursing staff, and lay counselors from the community. At other times we may need to build more formal mental health infrastructure (i.e., for treatment of psychiatric disorders). Innovative partnerships between community based organizations and clinical settings can assist in enhancing available resources. While it may be difficult for some to justify the provision of mental health or other psychosocial services when there are pressing physical needs (e.g., physical symptoms, food, shelter), to ignore the former may severely limit the ability to control transmission of HIV and to enable individuals and families to remain engaged in treatment programs. Similarly, due to its direct link to HIV transmission, there is a specific need to implement and sustain NSEPs as HIV prevention strategies, as well as ensuring availability of pharmacological and behavioral treatments for PLWHA coping with substance use disorders.
7. Building on the lessons of the ART Scale-Up “3×5”
The rapid expansion of HIV treatment programs over the past five years has important lessons for all sectors of the global AIDS community. It has demonstrated that dramatic advances can be achieved by setting clear goals and numerical targets, by increased funding, and by exceptionally hard work by a broad coalition of stakeholders. It has also clarified the need for a global commitment to strengthening weak health care systems across the world. The evaluation of 3×5 done by the WHO, as well as the evaluation of PEPFAR done by the U.S. Institute of Medicine, should be disseminated and discussed as the HIV community plans for the IAS conference in Mexico City, in 2008. If commitments to universal access by 2010 are to be achieved, they must build on a critical assessment of successes and shortfalls of current efforts. This must include a discussion of how access to treatment can advance prevention endeavors. It is the responsibility of the global AIDS community, professionals, PLWHA and advocates, to develop a plan of action with clear timelines for achievement of an integrated approach to HIV prevention linked to care and treatment. While the demand made by activists at the Durban AIDS conference in 2000 that effective HIV treatment be made available to every person who needs it was dismissed by many as utopian, it may now be seen as visionary. The progress since that meeting has clarified the obstacles that must be overcome over the next decade at the international, governmental and community levels in order to fulfill this vision. If this momentum continues, it should serve as a catalyst for a new and more comprehensive approach that aims at control of spread of HIV through effective integration of HIV prevention with care and treatment. There is a need to learn the lessons from the past, renew and broaden the current vision, and set future concrete targets that link prevention with treatment efforts. As WHO Director-General Margaret Chan has said, “What gets measured, get’s done”.