HIV can’t be prevented by one intervention alone. Different prevention interventions are needed for different people and for different countries.
There are three categories of prevention interventions:
biomedical interventions: a mix of clinical and medical approaches to reduce the risk of HIV
behavioural interventions: addressing risky behaviours to reduce the risk of HIV
structural interventions: addressing social, economic, political or environmental factors that make people vulnerable to HIV.
These can be combined to create effective prevention programmes. Below we describe some of the most common types of HIV prevention interventions.
Prevention of mother-to-child transmission (PMTCT) of HIV
PMTCT services aim to protect the health of a pregnant woman with HIV and prevent her baby getting HIV. This includes:
preventing unintended pregnancies among women living with HIV
preventing HIV transmission from a woman living with HIV to her baby
providing appropriate treatment, care and support to mothers living with HIV and their children and families.
These services should be offered before conception, and throughout pregnancy, labour and breastfeeding. It is especially important that women stay in PMTCT services after delivery: most HIV infections in babies occur during breastfeeding because the mother has left the service. The current global target is for 95% coverage of services for PMTCT by 2025.
When used correctly and consistently, condoms offer very high (about 98%) protection against HIV, sexually transmitted infections and unintended pregnancy. Condom programmes aim to get condoms to as many people as possible.
Condom programmes is more than just handing them out. It must include:
In countries where it is hard to access condoms, there are low levels of condom use. Conversely, countries that have supplies of condoms to match the demand have relatively higher levels of condom use.
Pre-exposure prophylaxis (PrEP)
PrEP is a course of antiretroviral drugs (ARVs) taken by HIV-negative people before exposure to HIV, to protect themselves from infection. PrEP is most commonly available in pill form, but a long-acting injection and a vaginal ring are also newly available in some countries. Evidence shows that, when taken consistently and correctly, oral PrEP reduces the chances of HIV infection to near-zero.
PrEP should be offered as a choice to people who are at substantial risk of HIV infection, for example HIV-negative people who have a HIV-positive partner with a detectable viral load, or people who don’t always use condoms. Currently, PrEP is not available in many countries; efforts need to be made to make PrEP available everywhere. The 2020 target of 3 million people in low- and middle-income countries being on PrEP was missed – only 28% of this target was reached.
Post-exposure prophylaxis (PEP)
PEP is a short course of HIV drugs taken after potential exposure to HIV, to prevent HIV infection. PEP is a combination of pills that must be taken every day for 4 weeks, at the same time each day. Taking PEP correctly will reduce a person’s risk of getting HIV to almost zero.
PEP must be started within 72 hours of possible exposure to HIV. For this to be an effective prevention method, people must know about PEP as an option, and they must be able to access it. Therefore, education about PEP needs to be heightened, as well as efforts to roll out PEP in more countries, as currently it isn’t available everywhere.
Treatment as prevention (TasP)
Treatment as prevention (TasP) refers to HIV prevention interventions that use antiretroviral treatment (ART) to decrease the risk of HIV transmission. People on effective ART with an undetectable viral load cannot transmit HIV to others. Therefore, TasP decreases community viral load and reduces the rate of new HIV infections.
WHO recommends the ‘test and treat’ or ‘treat all’ strategy. This means all people diagnosed with HIV should start antiretroviral treatment (ART) immediately, regardless of their CD4 count or viral load. The success of TasP is highly dependent upon people adhering to their treatment. The current global target is for 95% of all people diagnosed with HIV to be on ART by 2025.
Voluntary medical male circumcision (VMMC)
Voluntary medical male circumcision (VMMC) is the removal of the foreskin from the penis. It reduces the chance of a man getting HIV from having sex with a woman by 60%.
VMMC is recommended for adolescents 15 years and older and adult men in 15 priority countries where there is a high HIV prevalence among the general population. These are: Botswana, Eswatini, Ethiopia, Kenya, Lesotho, Malawi, Mozambique, Namibia, Rwanda, South Africa, South Sudan, Tanzania, Uganda, Zambia, and Zimbabwe.
Harm reduction programming
HIV can be transmitted when someone with HIV uses drug injecting equipment which is then used by someone else. Harm reduction programmes aim to prevent the spread of HIV and reduce other harms associated with drug use. Evidence shows harm reduction is extremely effective. Approaches include:
The basic premise of harm reduction programming is to support, rather than punish people who use drugs. Services should be provided with the safer use of drugs in mind rather than the promotion of abstinence. But many countries maintain punitive laws (the ‘war on drugs’) against people who use drugs, making it difficult to provide harm reduction services.
Behavioural interventions seek to reduce the risk of HIV transmission by addressing risky behaviours. As such, behaviour change communication is a big part of this strategy.
Effective behaviour interventions address the cultural contexts within which risk behaviours occur and aim to increase uptake of HIV prevention services. Examples of behavioural interventions include:
information provision (such as sex education)
counselling and other forms of psycho-social support
safe infant feeding guidelines
Structural interventions are those that look to address the social, economic, political or environmental factors that make people vulnerable to HIV. The 2025 targets emphasise the importance of enabling environments that are free of societal, political, legal and economic barriers.
Structural interventions need support from all levels of society – from the national governments making laws to individual members of society. Interventions might involve:
decriminalising sex work, homosexuality or drug use
implementing laws to protect the rights of people with HIV
increasing access to school education for girls.