Making HIV prevention programmes work

Summary

Even after 25 years of experience, HIV prevention programming remains largely deficient. We identify four areas that managers of national HIV prevention programmes should reassess and hence refocus their efforts—improvement of targeting, selection, and delivery of prevention interventions, and optimisation of funding. Although each area is not wholly independent from one another, and because each country and epidemic context will require a different balance of time and funding allocation in each area, we present the current state of each dimension in the global HIV prevention arena and propose practical ways to remedy present deficiencies. Insufficient data for intervention effectiveness and country-specific epidemiology has meant that programme managers have operated, and continue to operate, in a fog of uncertainty. Although priority must be given to the improvement of prevention methods and the capacity for the generation and use of evidence to improve programme planning and implementation, uncertainty will remain. In the meantime, however, we argue that prevention programming can be made much more effective by use of information that is readily available.

Introduction

The preceding papers in this Series have reviewed the state-of-the-art of knowledge in biomedical,¹ behavioural,² and structural approaches³ to HIV prevention. Here, we ask how this information can be used and what additional information is needed to optimise national HIV prevention programmes. Optimisation of a national response to prevent the transmission of HIV requires not only information, but also knowledge of how to use the data to improve the response. Focusing on developing countries, we imagine how managers of national HIV prevention programmes could reassess and prioritise available resources to improve the performance of national prevention efforts. We identify four key areas on which time and attention should be focused: improvement of targeting, selection, and delivery of prevention efforts, and optimisation of funding.

In no country will the benefits of a programme manager allocating additional time to any one of the areas identified be the same. Typically, the greatest benefit of additional time invested will result from improving the dimension that is currently furthest from optimum. However, the costs and feasibility of improving performance in that dimension will also affect the decision. For example, in a country where the current level of funding represents only a small fraction of the budget needed, focus should be given primarily to securing additional funds. Similarly, in a country with adequate funding but gross inefficiency in the delivery of services, focus should be placed on improving management and monitoring.