a public health approach to combination prevention

Public Health
Transformation of HIV from pandemic to low-endemic
levels: a public health approach to combination prevention
Alexandra Jones, Ide Cremin, Fareed Abdullah, John Idoko, Peter Cherutich, Nduku Kilonzo, Helen Rees, Timothy Hallett, Kevin O’Reilly,
Florence Koechlin, Bernhard Schwartlander, Barbara de Zalduondo, Susan Kim, Jonathan Jay, Jacqueline Huh, Peter Piot, Mark Dybul
Large declines in HIV incidence have been reported since 2001, and scientiﬁc advances in HIV prevention provide
strong hope to reduce incidence further. Now is the time to replace the quest for so-called silver bullets with a public
health approach to combination prevention that understands that risk is not evenly distributed and that eﬀective
interventions can vary by risk proﬁle. Diﬀerent countries have diﬀerent microepidemics, with very diﬀerent levels of
transmission and risk groups, changing over time. Therefore, focus should be on high-transmission geographies,
people at highest risk for HIV, and the package of interventions that are most likely to have the largest eﬀect in each
diﬀerent microepidemic. Building on the backbone of behaviour change, condom use, and medical male circumcision,
as well as expanded use of antiretroviral drugs for infected people and pre-exposure prophylaxis for uninfected people
at high risk of infection, it is now possible to consider the prospect of what would be one of the most remarkable
achievements in the history of public health: reduction of HIV transmission from a pandemic to low-level endemicity.
Background
Between 2001 and 2012, 26 countries, 16 of them in subSaharan Africa, had at least a 50% reduction in new
infections.1,2 Despite these gains, there were an estimated
1·6 million new infections in sub-Saharan Africa and
2·3 million globally in 2012.1 Although scaling up of
antiretroviral treatment to the global goal of 15 million
people receiving treatment by 2015 is important both to
save lives and to contribute to prevention, recent
scientiﬁc and epidemiological advances provide further
support for a more comprehensive prevention strategy.
Combination prevention has been advocated by many
and is the application of several evidence-based
interventions to achieve maximum eﬀect on populationlevel HIV transmission in a speciﬁc setting. This
approach usually entails combination of biomedical,
behavioural, and structural strategies. There are no socalled silver bullets. With use of the interventions of
combination prevention and a highly focused public
health approach—ie, use of available resources for
highest population eﬀect rather than individual
outcome—a goal of reduction of new infections to move
from pandemic levels to low-endemic levels seems
within reach. At that level, even a partially eﬀective
vaccine, more feasible than the highly eﬀective
formulation being sought, could yield the potential to
contain the HIV epidemic.3 Achievement of this goal,
however, requires acknowledgment that every country
has diﬀerent microepidemics, with very diﬀerent levels
of transmission and risk groups or key populations,
changing over time. Thus, it is essential to become more
reﬁned, and to move beyond the use of global, national,
and even subnational averages in assessment of the HIV
epidemic and the path to its control.
We present an overview of the key elements of
combination prevention, including data limitations and
key issues related to implementation (panel). Additionally,
interest is increasing in the eﬀect of structural factors on
HIV and interventions to address them.66 For example, a
recent trial in Malawi showed a decreased HIV prevalence
in girls who received a cash transfer.67 We then outline key
principles of a public health approach to combination
prevention that can be used to drive towards control of the
HIV pandemic. It is not possible or our intention to
provide an exhaustive review of the literature in one article;
rather, we provide an overview of directional thinking
based on our interpretation of the available data with
greater emphasis on more recently studied interventions.
Principles of a public health approach to
combination prevention
Although scientiﬁc advances now provide a range of
interventions with proven clinical eﬃcacy, challenges
remain in translation of these advances to populationlevel eﬀectiveness. The concept of combination
implementation has been introduced to capture the need
for pragmatic, localised application of evidence-based
combination prevention strategies to enable high,
sustained uptake and quality of interventions in a realworld setting.68 The US President’s Emergency Plan for
AIDS Relief (PEPFAR) has also presented its blueprint to
create an AIDS-free generation.69 In addition to relevant
services and strategies already introduced elsewhere, we
oﬀer a set of key principles of a public health approach to
support policy makers in the complex business of
combination implementation—a process requiring
judgment and best guesses on what might work, or what
some might call the art of public health.
Epidemics are not uniform: focus on hightransmission geographies and key populations
Much heterogeneity exists in levels of HIV prevalence and
incidence between and within geographical regions, and
by age, sex, and risk-taking behaviours. These vast
variations suggest that a particular focus on high-incidence
locations will probably achieve the greatest gains.
The 12 countries with highest prevalence made up more
than 40% of estimated new infections globally in 2012.1
www.thelancet.com Published online April 14, 2014 http://dx.doi.org/10.1016/S0140-6736(13)62230-8
Published Online
April 14, 2014
http://dx.doi.org/10.1016/
S0140-6736(13)62230-8
O’Neill Institute for National
and Global Health Law,
Georgetown University Law
Center, Washington, DC, USA
(A Jones LLM, S Kim JD, J Jay JD,
J Huh BA, M Dybul MD); School
of Public Health, Imperial
College London, London, UK
(I Cremin PhD,
Prof T Hallett PhD); South Africa
National AIDS Council
(SANAC), Pretoria, South Africa
(F Abdullah FCPHM(SA));
National Agency for the
Control of AIDS, Abuja, Nigeria
(Prof J Idoko MD); National
AIDS/STD Control Programme
(NASCOP), Nairobi, Kenya
(P Cherutich MPH); Liverpool
Voluntary Counselling and
Testing, Care and Treatment,
Nairobi, Kenya (N Kilonzo PhD);
Wits Reproductive Health and
HIV Institute, University of
Witwatersrand,
Witwatersrand, South Africa
(Prof H Rees MB BCHIR);
Department of HIV/AIDS,
World Health Organization,
Geneva, Switzerland
(K O’Reilly PhD, F Koechlin MIA);
Department of Evidence,
Strategy and Results
(B Schwartlander PhD) and
Oﬃce of the Deputy Executive
Director for Programme
(B de Zalduondo PhD), UNAIDS,
Geneva, Switzerland; Director’s
Oﬃce, London School of
Hygiene and Tropical Medicine,
London, UK (Prof P Piot PhD);
and The Global Fund to Fight
AIDS, Tuberculosis and Malaria,
Geneva, Switzerland (M Dybul)
Correspondence to:
Dr Mark Dybul, The Global Fund
to Fight AIDS, Tuberculosis and
Malaria, Geneva Secretariat,
Chemin de Blandonnet 8,
1214 Vernier, Geneva,
Switzerland
mark.dybul@theglobalfund.
org
1
Public Health
Panel: Key elements of combination prevention
Behaviour change
Eﬃcacy and eﬀect
• Decreases in population-level prevalence and incidence
correlated with reductions in risk behaviour in several highly
aﬀected countries4–9
Key issues
• Diﬃcult to attribute population-level changes to speciﬁc
programmes
• Self-report bias limits interpretation of behavioural data10–13
• Reductions in risk among young people not replicated in
older cohorts8,14
• Overall population prevalence reductions can mask high
prevalence among key populations
Condoms
Eﬃcacy and eﬀect
• Consistent use reduces incidence by 80–95%5,15–18
• Condom promotion has been shown to be a successful
intervention to reduce transmission among key populations
such as sex workers19–21
Key issues
• Barriers remain to reaching high levels of condom use
• Use is often inconsistent and sporadic (eg, use at last sex
<20% in many high-prevalence countries22)
• Condom use can be particularly low in stable, long-term
partnerships23,24
• Diﬃcult for women to negotiate use; limited uptake of
female condoms with early designs25–27 but increased with
newer products and marketing26,27
Voluntary male medical circumcision
Eﬃcacy and eﬀect
• Reduces female-to-male sexual transmission by 60%
or more;28–30 protection increased over time31
• Life-long partial protection
• Estimated 3·4 million infections averted from 2011
to 2025, if coverage scaled up to 80% in 13 priority
countries32
• Nearly half of projected infections averted by 2025
are expected to be among women33
Key issues
• Low uptake in many countries despite reasonably high
acceptability1,24,34
• Human resources, cost, infrastructure, and political issues
remain34–36
• New non-surgical devices37 and traditional and political
leader support38 will be important
• Risk compensation could negate beneﬁts; however, no
evidence in initial studies39–41
• Observational studies in men who have sex with men are
inconsistent42,43
2
Antiretroviral therapy (ART)
Eﬃcacy and eﬀect
• 96% decrease in transmission among stable serodiscordant
couples with early initiation of ART44
• Strong empirical and modelled evidence that ART can
reduce transmission at a population level45
Key issues
• Decreases in prevalence in some countries predated scale-up
of ART1
• Increased prevention programmes limits sole attribution of
decreases in incidence to ART46,47
• Increasing incidence despite high ART coverage in some
settings (eg, Uganda,1 and men who have sex with men in
the USA48 and Amsterdam49)
• Eﬀect of ART in young people in whom infection rates
rapidly decreasing8,14 requires study
• Treatment cascade poses challenges—eg, average CD4
count at ART initiation is well below 350 T cells per μL in
high-income,50 middle-income, and low-income51,52
countries; 40% of serodiscordant couples decline early ART53
Pre-exposure prophylaxis (PrEP)
Eﬃcacy and eﬀect
• Eﬃcacy ranges from no eﬀect to 44% in men who have sex
with men,54 39% in women who used topical PrEP,55 and
75% in discordant couples56,57
Key issues
• Achieving and maintaining high levels of adherence is essential
• Potential for drug resistance is concerning;58 no evidence of
PrEP-induced resistance in trials;59 models predict lower rates
of resistance than from ART, because of prevention eﬀect60,61
• Many cost and implementation issues62
Prevention of mother-to-child transmission
Eﬃcacy and eﬀect
• Combination ART reduces cumulative transmission at 6 weeks
to 3·3%63
Key issues
• Need a focus on improvement of coverage, quality of services,
and monitoring
Harm reduction
Eﬃcacy and eﬀect
• A package of needle exchange, substitution therapy, and
ART decreases transmission in injecting drug users64
• Reduction of unmet need estimated to have large eﬀect—
eg, a decrease in HIV prevalence by 41% in Odessa (Ukraine),
43% in Karachi (Pakistan), and 30% in Nairobi (Kenya)65
Key issues
• Several political and policy issues remain in many settings
www.thelancet.com Published online April 14, 2014 http://dx.doi.org/10.1016/S0140-6736(13)62230-8
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Within countries HIV prevalence often varies greatly
between provinces or states, and even between districts.
In Kenya, for example, there is a 15-fold diﬀerence in
prevalence between the highest-prevalence and lowestprevalence province.70 Countries deﬁned as low prevalence
(<5%) often have areas with high prevalence (>10%).
Incidence can also be highly variable. For example,
incidence in young women aged 15–19 years in South
Africa’s KwaZulu-Natal region is 4·7 per 100 person-years,
compared with a national incidence of 1·49 per 100 personyears.71 Even within severely aﬀected areas of rural South
Africa one in three new infections can be attributed to
clustered so-called hot zones, comprising only 5·7% of the
area studied.72 In Lesotho, some such hot zones have a
prevalence among men of more than 35%, whereas other
areas in the same district have a prevalence of less than
6%.73 Despite an overall national adult prevalence of 3·1%
and incidence of 0·36 per 100 person-years, geographical
variation in incidence across Nigeria’s large population,
including ﬁve states with prevalence of about 10%,
contributed to an estimated 260 000 new infections, or
11·3% of global numbers in 2012.1
Drivers of each epidemic and microepidemic can diﬀer
greatly, even in the same country. In addition to data for
age-speciﬁc and sex-speciﬁc prevalence that remain
strikingly similar in countries with generalised
epidemics, drivers of a speciﬁc epidemic must be
examined to determine high-risk populations. In some
cases, there will be overlap between high-transmission
geographies and high-risk groups. In others, people at
high risk for HIV—eg, sex workers, men who have sex
with men (MSM), young women, or people who inject
drugs—can be dispersed throughout a region with a low
average rate of HIV incidence. In Kenya, for example,
serodiscordant couples contribute an estimated 44% of
new infections, but in Nairobi and on the Kenyan coast,
MSM, including those in prison, represent about a ﬁfth
of new infections and are emerging as a population in
need of urgent intervention.74 In South Africa, an
estimated 9·2% of all new infections are related to MSM,
and 19·8% are related to sex workers.71
Risk taking is not distributed equally in any population.
Those engaging in speciﬁc behaviours that put them or
their partners at risk for HIV infection cluster
geographically and socially. Because of this combination,
the individual behaviour alone does not determine the
extent of new infections, but the location and mixing
patterns also greatly increase—or reduce—the chance
that the virus will be transmitted.
Despite continued promotion of a “know your
epidemic, know your response” agenda by UNAIDS, and
previous calls for and emphasis on hot zones,75–77 focus on
high-transmission regions and populations most at-risk
of new infection remains challenging.78 Regular and
high-quality epidemiological data need to be collected
and reviewed, and people at high risk must be identiﬁed,
informed, given access to treatment, and remain
adherent to programmes. These challenges can be
compounded by marginalisation, stigmatisation, and
criminalisation of key populations.65,79,80 It can also be
diﬃcult for countries to commit resources and
programmes to speciﬁc geographical areas, particularly
in ethnically diverse countries. From a human rights
perspective, there is a solid case to be made for equitable
access for all interventions.
Notwithstanding these challenges, identiﬁcation of
people at high risk for HIV, providing them with access to
information and interventions, and maintenance of high
levels of adherence are essential for prevention strategies
to have an eﬀect. A focus on high-transmission regions
and key populations is essential for cost-eﬃcient use of
scarce health and community systems and ﬁnancial
resources, and can be the foundation to achieve suﬃcient
coverage of, and adherence to, intensive communitybased interventions with links to health delivery services
to substantially reduce incidence. Although care and
treatment must be equitably provided, prevention
interventions, including aggressive use of test and treat
(eg, in areas of very high transmission or for groups of
people most at risk, treating irrespective of CD4 T-cell
count) or treatment as prevention (TasP) where
appropriate, should be directed where they will have the
greatest eﬀect. Indeed, focused implementation might
advance equity and human rights for all by reducing the
overall risk of new infections. In some nations with small
populations and high rates of infection—eg, Botswana
and Swaziland—focus on geography and most vulnerable
population could include the entire country.
Design a package of interventions most likely to
reduce transmission in each microepidemic
Once high-transmission areas and key populations have
been identiﬁed, the elements of the prevention toolbox
with the greatest potential to be eﬀective, acceptable, and
deliverable can be chosen. Consistent with the approach
set out in the UNAIDS 2011 Strategic Investment
Framework,81 these considerations will span biomedical,
behavioural, and structural forms of intervention.
To maximise the prevention eﬀect of the interventions
delivered with the resources available, the programme
must be carefully calibrated to the local epidemic
conditions and take account of prevailing costs.
Mathematical modelling provides a precise way to
synthesise data for epidemiology, behaviours,
interventions, and costs to guide how this can be done.82
Generally, model analyses have suggested that, with the
prevention options available nowadays, greater ﬁnancial
resources can translate into greater eﬀect on the
epidemic.83–85 Thus in the highest incidence hotspots,
increased investment and the use of new prevention
technologies could yield substantial gains in reduction of
the level of the epidemic in a country overall.
For example, in a hotspot area where transmission
within stable serodiscordant couples is a key source of
www.thelancet.com Published online April 14, 2014 http://dx.doi.org/10.1016/S0140-6736(13)62230-8
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new infections,86,87 programmes might leverage existing
programmes for HIV testing and prevention of mother-tochild transmission (PMTCT) to identify discordant
couples and prioritise prevention services according to
their speciﬁc needs. In addition to condom promotion,
male circumcision could be oﬀered to the male partner if
he tests negative, and immediate initiation of antiretroviral
therapy (ART) can be oﬀered to the positive partner, and
pre-exposure prophylaxis (PrEP) to the negative partner if
ART is not initiated or until the positive partner achieves
complete viral suppression.88
By contrast, in settings where more transmission
occurs in young women in casual partnerships, screening
methods that identify and reach women at highest risk
(eg, those out of school or engaged in transactional sex)
can be packaged with use of PrEP for HIV-negative
women, increased access to ART—even including a test
and treat approach in areas of very high transmission—
and promotion of condoms and voluntary male medical
circumcision (VMMC) in men.83 When a key driver of
continued transmission seems to be the large age
diﬀerence between young women and older male
partners under circumstances of poverty, gender-based
violence, and lack of education, behaviour change
programmes must be customised to prioritise key
vulnerable subgroups of the young female population.89
Where they have increased negotiating capacity, sex
workers should be a group to promote condom use to, as
well as oﬀering access to PrEP and support for increased
access to ART including test and treat in areas of very
high transmission. In an MSM-driven epidemic, focus
on earlier identiﬁcation and access to treatment including
test and treat in areas of very high transmission, condom
promotion, and PrEP might be considered.90,91
Models have been an indispensable resource to shape
policy and planning programmes because they can show
how programme inputs can translate into eﬀect and
costs.82 But models alone are not suﬃcient. Sometimes,
the total cost and feasibility of a project will be more
important than whether or not a strategy is strictly the
most cost eﬀective. Planners can also identify synergies
and antagonisms between programmes relevant to their
communities that models do not capture. For example,
provision of a wide range of choice in prevention options
can, in itself, help to increase uptake of services in the
same way that increased method mix is now valued
within a family planning context globally.69 In other
settings, sharp discontinuities in the provision of services
between adjacent areas, although perhaps optimal, might
not be feasible.
Use a critical path to structure and evaluate
intervention programming
The use of a critical path, or the sequence of events
needed to achieve an outcome, with key performance
indicators, can help to streamline public health policy
making while promoting greater management eﬃciency
4
of programmes.92 For example, a critical path for a new
product analyses the key steps from clinical development,
regulatory approval, policy and advocacy, and delivery,
including structural or legal barriers that limit access and
ﬁnance across a predicted timeframe for rollout.
Development of a critical path for each intervention to
be used in each hyperendemic region or population could
be valuable for ministries of health and implementing
partners. As one looks across the pathways, some
common denominators will be identiﬁed. For example,
testing is necessary for PMTCT, PrEP, TasP or test and
treat, and even VMMC.93 Antiretroviral drugs are needed
for PMTCT, PrEP, and TasP or test and treat. One might
also begin to identify various common outlets for services.
For example, serodiscordant couples could be identiﬁed
in antenatal clinics, family planning clinics, and schools
(at an age that is culturally appropriate) that could then
also be used as entry points for intensive promotion of
condoms, partner reduction, VMMC, PrEP, and TasP or
test and treat. Similar outlets could be as, if not more,
useful to identify young women at risk.
Local epidemics require local solutions: use
feasibility studies and acceptability research
In recounting the eﬀort to eradicate smallpox, as much
weight has been put on understanding of local cultures
and norms to avoid mistakes and promote vaccination as
on the medical intervention itself.94 Uptake of any health
intervention, and particularly those involving both
intimate human behaviours such as sexual practices and
marginalised populations, is likely to be aﬀected by nonclinical factors rather than clinical trial results. In addition
to individuals who might access services, feasibility
studies and market research can help to understand the
views of key constituencies—eg, HIV-positive people,
health providers, faith leaders, tribal or other local leaders,
community-based organisations, and all segments of civil
society that can aﬀect uptake.95 Feasibility studies and
market research has been used successfully for condom
use, introduction of vaccines, and other areas.96 However,
they have not been used systematically, nor do they seem
to have gained currency as essential components of
successful combination prevention.
The success of any health intervention requires
engagement well beyond the traditional health sector,
and is even more important when stigma, discrimination,
sexual violence, and other societal norms play a
substantial part. To eﬀectively reach key populations and
control HIV, far more engagement of communities and
civil society is essential. Although advocacy and civil
society engagement have been essential elements of the
ﬁght against HIV, as biomedical interventions become
more prominent, there seems to be a tendency to focus
on a health system that ends at the clinic. For combination
prevention and implementation to succeed, we believe
that the health system should be viewed as extending
deep into the community.
www.thelancet.com Published online April 14, 2014 http://dx.doi.org/10.1016/S0140-6736(13)62230-8
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Feasibility studies to assess cultural issues and
acceptability related to interventions can include the
following: factors that could promote acceptance of HIV
testing; optimal delivery routes for various interventions;
preferences for and options to promote uptake, use, and
adherence of interventions; preferences and concerns
about various combination prevention interventions that
might be available; and potential for risk compensation
and ways to minimise it.
Acceptability studies help to gauge demand for
existing health interventions, but can also be forward
leaning. In studies of PrEP acceptability, questions
about longacting injectable or vaginal products were
included.97,98 Although results from clinical trials and
regulatory approvals are several years away,99
understanding of long-term preferences can assist
policy makers to begin planning for incorporation of
new products as they become available, potentially
shortening the timeline from clinical trial results to
real-world application. Combining acceptability studies
also saves time and money in duplicating this analysis
for each new product.
Situations change: regularly assess drivers of
epidemics and assess eﬀectiveness of
interventions
HIV epidemics are not stagnant. In eastern Europe, the
epidemic has begun to shift from intravenous drug users
to the wider population.100 Transmission hot spots—
within and between countries—can also shift, with some
areas achieving relative control while others are
recalcitrant or even increasing. The drivers and
geographies of epidemics in each country should be
regularly assessed to ensure that combination prevention
strategies can be maximally eﬀective. No one indicator or
data element might be suﬃcient. Case reports, surveys
(eg, prevalence of antenatal clinics, population surveys),
and special studies (eg, behavioural and treatment uptake
assessments) are all useful. The use of a critical path can
also assist to assess progress. Therefore, it is essential
that countries collect relevant data, and that UNAIDS
and WHO regularly report on subnational geographical
prevalence and incidence estimates as well as estimates
for those most vulnerable and key aﬀected populations.
Ultimately, it is necessary to assess the eﬀect of
interventions based on HIV incidence. The present gold
standard is the nationally representative Demographic
Health Survey (DHS). However, DHS can be undertaken
only every 3–5 years,101 and prevalence data collected can
only indirectly be used to calculate incidence from
successive surveys. Investments in HIV prevention
activities aiming to reduce incidence urgently need an
improved quick, easy, valid, and precise method to
estimate incidence in populations to guide prioritised
interventions.102 UNAIDS has suggested periodic
estimations of HIV incidence and modelled number of
infections averted by particular programmes.103 Others
have suggested use of trends in HIV prevalence among
young people as a proxy for incidence (but that addresses
only one risk cohort),104,105 or randomisation of diﬀerent
combination prevention strategies in diﬀerent areas to
assess eﬀect.106
Beyond development of an incidence assay, general
improvements in surveillance and evaluation are valuable
to guide a strategic response. PEPFAR has used public
health evaluations and an implementation science
framework—the study of methods to improve the uptake,
implementation, and translation of research ﬁndings
into common practice within its programmes to improve
their eﬃciency.107 This type of implementation science
can be used to assess the relative eﬃcacy and costeﬀectiveness of components—eg, the most cost-eﬀective
way to identify serodiscordant couples.108 Advances in
statistical analysis might help to evaluate the elements
of a package that are synergistic or antagonistic,
multiplicative or additive, and to establish the population
eﬀect of HIV interventions.109
Demonstration projects for new interventions can help
to assess eﬀect and maximise eﬃciencies before
expansion to larger implementation. Similarly, studies of
earlier identiﬁcation and access to treatment for key
populations at high risk are under development in some
countries in the hope of learning these lessons about
early treatment. This approach can be usefully
extrapolated to a broader combination prevention context
to gain better understanding of the eﬀective interplay of
various intervention components in priority populations
before national scale-up. Assessments are often viewed
as luxuries and are the ﬁrst to be cut. This view is shortsighted. The rapidly changing nature of HIV demands
regular assessment and adaptation to ensure maximally
eﬃcacious and cost-eﬀective combination prevention. At
the same time, collection of data for the sake of it is cost
ineﬃcient. It is necessary to identify the key areas for
assessment during the planning phase and to resist the
temptation to continually add indicators and increase the
frequency of collection. However, assessment must be
understood as an integral part of any combination
prevention strategy.
Data are powerful if collected and presented in ways that
policy makers understand, and if data are proactively
gathered to meet their needs. In our collective experience,
data following the principles presented would promote
eﬀective policy making at global, and more importantly,
national level. Strong leadership will be integral to make
diﬃcult decisions in both design and implementation
of combination HIV prevention programming in
resource-constrained settings.
Conclusion
In our view, scientiﬁc research has identiﬁed the methods
to develop combination programmes that could control
the HIV pandemic. But there is a short window of
opportunity that must be acted upon. As seen in the ﬁrst
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few years of the 21st century in sub-Saharan Africa as a
whole and the mature epidemic in Uganda, as well as in
key populations in the USA and Europe,100 decreases in
new infections can be ﬂeeting and incidence can rise
despite substantial increases in national ART coverage
rates. If we do not seize the opportunity now, and we see
recent progress reverse and HIV rates again on the rise,
control might be beyond our reach ﬁscally and
epidemiologically.
A focused public health approach that prioritises
hyperendemic and high-endemic hot zones and key
populations and individuals with the combination of
interventions that are most likely to have high eﬀect in the
most cost-eﬀective way could achieve one of the greatest
accomplishments in the history of global health—
conversion of the HIV pandemic, the deadliest of the
modern era, to a low-endemic level. Now is the time to act.
Contributors
AJ did the literature review, wrote the ﬁrst and subsequent drafts,
responded to reviewer comments, and prepared the ﬁnal draft. IC did
the literature review, reviewed the ﬁrst draft, provided reference
materials, contributed to writing subsequent drafts, and assisted in
responding to reviewer comments. FA and JI did the literature review
and contributed to writing drafts. PC, NK, and HR reviewed earlier
drafts and contributed to data interpretation. TH did the literature
review on modelling, reviewed drafts, contributed to writing, and
assisted in responding to reviewer comments. KO contributed to the
original idea behind this manuscript, provided reference materials,
reviewed drafts, and oﬀered speciﬁc text for inclusion. FK and BS
reviewed earlier drafts and contributed to writing. BdZ reviewed drafts,
contributed to writing and interpretation, and contributed to framing by
leading the UNAIDS initiative to deﬁne combination prevention. JJ and
SK did the literature review and reviewed drafts. JH did the literature
review and assisted in proofreading. PP contributed to the original idea
behind this manuscript, reviewed earlier drafts, and contributed to
writing subsequent drafts. MD conceived of the idea, reviewed the ﬁrst
draft and contributed to writing subsequent drafts, drafted and ﬁnalised
the response to reviewers, and ﬁnalised the manuscript.
Declaration of interests
We declare that we have no competing interests.
Acknowledgments
The Bill & Melinda Gates Foundation provided grant support for some of
the activities described in this paper. No funding bodies had any role in the
design, data collection and analysis, decision to publish, or preparation of
the manuscript. We thank Stephen Becker, Blair Hanewall, Salif Sow, and
Wilson Mok of the Bill & Melinda Gates Foundation for their support,
insights, review, and comment on early versions of the manuscript.
References
1
UNAIDS. UNAIDS report on the global AIDS epidemic 2013.
November, 2013. http://www.unaids.org/en/media/unaids/
contentassets/documents/epidemiology/2013/gr2013/UNAIDS_
Global_Report_2013_en.pdf (accessed Oct 8, 2013).
2
WHO. Global update on HIV treatment 2013: results,
impact and opportunities. June, 2013. http://apps.who.int/iris/
bitstream/10665/85326/1/9789241505734_eng.pdf (accessed
Aug 3, 2013).
3
Stover J, Hallett T, Wu Z, et al. How can we get to zero? The potential
contribution of biomedical prevention and the investment framework
towards an eﬀective response to HIV and AIDS. 17th International
Conference on AIDS and STIs in Africa; Cape Town, South Africa;
Dec 7–11, 2013. Oral abstract. http://www.icasa2013southafrica.org/
images/stories/ICASA_presentations/Sunday/Auditorium%20
1/12h45/Impact%20of %20Combined%20Prevention.pdf (accessed
Feb 4, 2014).
4
Gregson S, Garnett GP, Nyamukapa CA, et al. HIV decline associated
with behavior change in eastern Zimbabwe. Science 2006; 311: 664–66.
6
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
Gregson S, Gonese E, Hallett TB, et al. HIV decline in Zimbabwe
due to reductions in risky sex? Evidence from a comprehensive
epidemiological review. Int J Epidemiol 2010; 39: 1311–23.
Green EC, Halperin DT, Nantulya V, Hogle JA. Uganda’s HIV
prevention success: the role of sexual behavior change and the
national response. AIDS Behav 2006; 10: 335–46.
International Group on Analysis of Trends in HIV Prevalence and
Behaviours in Young People in Countries most Aﬀected by HIV.
Trends in HIV prevalence and sexual behaviour among young
people aged 15-24 years in countries most aﬀected by HIV.
Sex Transm Infect 2010; 86 (suppl 2): ii72–83.
Shisana O, Rehle T, Simbayi LC, et al. South African national
HIV prevalence, incidence, behaviour and communication
survey 2008: a turning tide among teenagers? Cape Town:
HSRC Press, 2009.
Central Statistics Oﬃce. 2008 Botswana AIDS Impact Survey III.
November, 2009. http://www.hiv.gov.bw/sites/default/ﬁles/
documents/baisiii_report%5B1%5D.pdf (accessed April 29, 2013).
Zenilman JM, Weisman CS, Rompalo AM, et al. Condom use to
prevent incident STDs: the validity of self-reported condom use.
Sex Transm Dis 1995; 22: 15–21.
Sigall H, Aronson E, Van Hoose T. The cooperative subject:
myth or reality? J Exp Soc Psychol 1970; 6: 1–10.
Weir SS, Roddy RE, Zekeng L, Ryan KA. Association between
condom use and HIV infection: a randomised study of self reported
condom use measures. J Epidemiol Community Health 1999;
53: 417–22.
Allen S, Meinzen-Derr J, Kautzman M, et al. Sexual behavior
of HIV discordant couples after HIV counseling and testing.
AIDS 2003; 17: 733–40.
Zaba B, Todd J, Biraro S, et al. Diverse age patterns of
HIV incidence rates in Africa. XVIIth International AIDS
Conference. Mexico; August, 2008. Oral abstract TUAC0201.
http://www.iasociety.org/Abstracts/A200720876.aspx (accessed
April 29, 2013).
UNAIDS. Condoms and HIV prevention: position statement by
UNAIDS, UNFPA and WHO. March 19, 2009. http://www.unaids.
org/en/resources/presscentre/featurestories/2009/march/20090319
preventionposition/ (accessed April 29, 2013).
Carey RF, Lytle CD, Cyr WH. Implications of laboratory tests of
condom integrity. Sex Transm Dis 1999; 26: 216–20.
Weller S, Davis K. Condom eﬀectiveness in reducing
heterosexual HIV transmission. Cochrane Database Syst Rev
2002; 1: CD00325.
Pinkerton SD, Abramson PR. Eﬀectiveness of condoms in
preventing HIV transmission. Soc Sci Med 1997; 44: 1303–12.
Ng M, Gakidou E, Levin-Rector A, Khera A, Murray CJ, Dandona L.
Assessment of population-level eﬀect of Avahan, an HIV-prevention
initiative in India. Lancet 2011; 378: 1643–52.
Ngugi EN, Plummer FA, Simonsen JN, et al. Prevention of
transmission of human immunodeﬁciency virus in Africa:
eﬀectiveness of condom promotion and health education
among prostitutes. Lancet 1988; 2: 887–90.
Rojanapithayakorn W. The 100% condom use programme in Asia.
Reprod Health Matters 2006; 14: 41–52.
UNAIDS. Global report: report on the global AIDS epidemic 2010.
http://www.unaids.org/globalreport/global_report.htm (accessed
April 29, 2013).
Foss AM, Watts CH, Vickerman P, Heise L. Condoms and
prevention of HIV. BMJ 2004; 329: 185–86.
Kenya National Bureau of Statistics. Kenya Demographic and
Health Survey 2008–2009. June, 2010. http://www.measuredhs.
com/pubs/pdf/FR229/FR229.pdf (accessed April 29, 2013).
Global Industry Analysts. Condoms: a global strategic business
report. October, 2012. http://www.researchandmarkets.com/
reports/338816/condoms_global_strategic_business_report
(accessed April 29, 2013).
Beksinska M, Smit J, Joanis C, Usher-Patel M, Potter W.
Female condom technology: new products and regulatory
issues. Contraception 2011; 83: 316–21.
Coﬀey PS, Kilbourne-Brook M, Austin G, Seamans Y, Cohen J.
Short-term acceptability of the PATH Woman’s Condom among
couples at three sites. Contraception 2006; 73: 588–93.
www.thelancet.com Published online April 14, 2014 http://dx.doi.org/10.1016/S0140-6736(13)62230-8
Public Health
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambekou J, Sitta R,
Puren A. Randomized, controlled intervention trial of male
circumcision for reduction of HIV infection risk: the ANRS 1265
Trial. PLoS Med 2005; 2: e298.
Gray RH, Kigozi G, Serwadda D, et al. Male circumcision for HIV
prevention in men in Rakai, Uganda: a randomised trial. Lancet
2007; 369: 657–66.
Bailey RC, Moses S, Parker CB, et al. Male circumcision for
HIV prevention in young men in Kisumu, Kenya: a randomised
controlled trial. Lancet 2007; 369: 643–56.
Gray R, Kigozi G, Kong X, et al. The eﬀectiveness of male
circumcision for HIV prevention and eﬀects on risk behaviors
in a posttrial follow-up study. AIDS 2012; 26: 609–15.
Njeuhmeli E, Forsythe S, Reed J, et al. Voluntary medical male
circumcision: modeling the impact and cost of expanding male
circumcision for HIV prevention in eastern and southern Africa.
PLoS Med 2011; 8: e1001132.
Hankins C, Forsythe S, Njeuhmeli E. Voluntary medical male
circumcision: an introduction to the cost, impact, and challenges
of accelerated scaling up. PLoS Med 2011; 8: e1001127.
Westercamp N, Bailey RC. Acceptability of male circumcision
for prevention of HIV/AIDS in sub-Saharan Africa: a review.
AIDS Behav 2007; 11: 341–55.
WHO. Country experiences in the scale-up of male circumcision
in the Eastern and Southern Africa Region: two years and counting.
July, 2009. http://www.who.int/hiv/pub/malecircumcision/
meetingreport_june09/en/index.html (accessed Feb 4, 2014).
Dickson KE, Tran NT, Samuelson JL, et al. Voluntary medical
male circumcision: a framework analysis of policy and program
implementation in eastern and southern Africa. PLoS Med 2011;
8: e1001133.
McIntyre JA. Can devices for adult male circumcision help
bridge the implementation gap for HIV prevention services?
J Acquir Immune Defic Syndr 2011; 58: 506–08.
Zimbabwean MPs to be circumcised as part of HIV/Aids campaign.
The Telegraph (London); May 20, 2012. http://www.telegraph.co.uk/
news/worldnews/africaandindianocean/zimbabwe/9278524/
Zimbabwean-MPs-to-be-circumcised-as-part-of-HIVAids-campaign.
html (accessed April 29, 2013).
Mattson CL, Campbell RT, Bailey RC, Agot K, Ndinya-Achola JO,
Moses S. Risk compensation is not associated with male
circumcision in Kisumu, Kenya: a multi-faceted assessment of men
enrolled in a randomized controlled trial. PLoS One 2008; 3: e2443.
Agot KE, Kiarie JN, Nguyen HQ, Odhiambo JO, Onyango TM,
Weiss NS. Male circumcision in Siaya and Bondo Districts, Kenya:
prospective cohort study to assess behavioral disinhibition following
circumcision. J Acquir Immune Defic Syndr 2007; 44: 66–70.
Kong X, Kigozi G, Nalugoda F, et al. Assessment of changes in risk
behaviors during 3 years of posttrial follow-up of male circumcision
trial participants uncircumcised at trial closure in Rakai, Uganda.
Am J Epidemiol 2012; 176: 875–85.
Grulich AE, Hendry O, Clark E, Kippax S, Kaldor JM. Circumcision
and male-to-male sexual transmission of HIV. AIDS 2001; 15: 1188–89.
Buchbinder SP, Vittinghoﬀ E, Heagerty PJ, et al. Sexual risk, nitrite
inhalant use, and lack of circumcision associated with HIV
seroconversion in men who have sex with men in the United States.
J Acquir Immune Defic Syndr 2005; 39: 82–89.
Cohen MS, Chen YQ, McCauley M, et al, and the HPTN 052 Study
Team. Prevention of HIV-1 infection with early antiretroviral
therapy. N Engl J Med 2011; 365: 493–505.
Tanser F, Bärnighausen T, Grapsa E, Zaidi J, Newell ML. High
coverage of ART associated with decline in risk of HIV acquisition
in rural KwaZulu-Natal, South Africa. Science 2013; 339: 966–71.
Johnson LF, Hallett TB, Rehle TM, Dorrington RE. The eﬀect of
changes in condom usage and antiretroviral treatment coverage
on human immunodeﬁciency virus incidence in South Africa:
a model-based analysis. J R Soc Interface 2012; 9: 1544–54.
Smith MK, Powers KA, Muessig KE, Miller WC, Cohen MS.
HIV treatment as prevention: the utility and limitations of ecological
observation. PLoS Med 2012; 9: e1001260.
Centers for Disease Control and Prevention. CDC fact sheet:
new infection in the United States. December, 2012. http://www.cdc.
gov/nchhstp/newsroom/docs/2012/hiv-infections-2007-2010.pdf
(accessed April 30, 2013).
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
Bezemer D, de Wolf F, Boerlijst MC, et al. A resurgent HIV-1
epidemic among men who have sex with men in the era of potent
antiretroviral therapy. AIDS 2008; 22: 1071–77.
Dybul M, Bolan R, Condoluci D, et al. Evaluation of initial CD4+
T cell counts in individuals with newly diagnosed human
immunodeﬁciency virus infection, by sex and race, in urban
settings. J Infect Dis 2002; 185: 1818–21.
Keiser O, Anastos K, Schechter M, et al, and the ART-LINC
Collaboration of International Databases to Evaluate AIDS (IeDEA).
Antiretroviral therapy in resource-limited settings 1996 to 2006: patient
characteristics, treatment regimens and monitoring in sub-Saharan
Africa, Asia and Latin America. Trop Med Int Health 2008; 13: 870–79.
Mugglin C, Althoﬀ K, Wools-Kaloustian K, et al. Immunodeﬁciency
at the start of ART: global view. 19th Conference on Retroviruses and
Opportunistic Infections. Seattle, WA, USA; March 5–8, 2012.
Abstract.
Heﬀron R, Ngure K, Mugo N, et al. Willingness of Kenyan HIV-1
serodiscordant couples to use antiretroviral-based HIV-1 prevention
strategies. J Acquir Immune Defic Syndr 2012; 61: 116–19.
Grant RM, Lama JR, Anderson PL, et al, and the iPrEx Study Team.
Preexposure chemoprophylaxis for HIV prevention in men who
have sex with men. N Engl J Med 2010; 363: 2587–99.
Abdool Karim Q, Abdool Karim SS, Frohlich JA, et al, and the
CAPRISA 004 Trial Group. Eﬀectiveness and safety of tenofovir gel,
an antiretroviral microbicide, for the prevention of HIV infection in
women. Science 2010; 329: 1168–74.
Baeten JM, Donnell D, Ndase P, et al, and the Partners PrEP Study
Team. Antiretroviral prophylaxis for HIV prevention in heterosexual
men and women. N Engl J Med 2012; 367: 399–410.
Haberer JE, Baeten JM, Campbell J, et al. Adherence to
Antiretroviral Prophylaxis for HIV Prevention: A Substudy Cohort
within a Clinical Trial of Serodiscordant Couples in East Africa.
PLoS Med 2013; 10: e1001511.
Marrazzo J, Ramjee G, Nair G, et al. Pre-exposure prophylaxis
for HIV in women: daily oral tenofovir, oral tenofovir/emtricitabine
or vaginal tenofovir gel in the VOICE study (MTN 003). 20th
Conference on Retroviruses and Opportunistic Infections. Atlanta,
GA, USA; March 3–6, 2013. Abstract 26LB.
Hurt CB, Eron JJ Jr, Cohen MS. Pre-exposure prophylaxis and
antiretroviral resistance: HIV prevention at a cost? Clin Infect Dis
2011; 53: 1265–70.
Parikh UM, Mellors JW. HIV-1 drug resistance resulting from
antiretroviral therapy far exceeds that from pre-exposure
prophylaxis. Clin Infect Dis 2012; 55: 303–04.
van de Vijver DA, Nichols BE, Abbas UL, et al. Preexposure
prophylaxis will have a limited impact on HIV-1 drug resistance
in sub-Saharan Africa: a comparison of mathematical models.
AIDS 2013; 27: 2943–51.
Pretorius C, Stover J, Bollinger L, Bacaër N, Williams B. Evaluating
the cost-eﬀectiveness of pre-exposure prophylaxis (PrEP) and its
impact on HIV-1 transmission in South Africa. PLoS One 2010;
5: e13646.
The Kesho Bora Study Group. Triple antiretroviral compared
with zidovudine and single-dose nevirapine prophylaxis during
pregnancy and breastfeeding for prevention of mother-to-child
transmission of HIV-1 (Kesho Bora study): a randomised controlled
trial. Lancet Infect Dis 2011 11: 171–80.
WHO. UNODC, UNAIDS. Technical guide for countries to set
targets for universal access to HIV prevention, treatment–2012
revision. Geneva: WHO, 2012.
Strathdee SA, Hallett TB, Bobrova N, et al. HIV and risk
environment for injecting drug users: the past, present, and future.
Lancet 2010; 376: 268–84.
Gupta GR, Parkhurst JO, Ogden JA, Aggleton P, Mahal A.
Structural approaches to HIV prevention. Lancet 2008;
372: 764–75.
Baird SJ, Garfein RS, McIntosh CT, Özler B. Eﬀect of a cash
transfer programme for schooling on prevalence of HIV and herpes
simplex type 2 in Malawi: a cluster randomised trial. Lancet 2012;
379: 1320–29.
Chang LW, Serwadda D, Quinn TC, Wawer MJ, Gray RH,
Reynolds SJ. Combination implementation for HIV prevention:
moving from clinical trial evidence to population-level eﬀects.
Lancet Infect Dis 2013; 13: 65–76.
www.thelancet.com Published online April 14, 2014 http://dx.doi.org/10.1016/S0140-6736(13)62230-8
7
Public Health
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
8
PEPFAR. PEPFAR blueprint: creating an AIDS free generation.
November, 2012. http://www.pepfar.gov/documents/
organization/201386.pdf (accessed Feb 4, 2014).
NACC and NASCOP. Kenya AIDS Epidemic update 2011.
Nairobi: NACC and NASCOP, 2012. http://www.unaids.org/en/
dataanalysis/knowyourresponse/countryprogressreports/2012count
ries/ce_KE_Narrative_Report.pdf (accessed April 29, 2013).
Bärnighausen T, Tanser F, Gqwede Z, Mbizana C, Herbst K,
Newell ML. High HIV incidence in a community with high HIV
prevalence in rural South Africa: ﬁndings from a prospective
population-based study. AIDS 2008; 22: 139–44.
Tanser F, Bärnighausen T, Newell ML. Identiﬁcation of localized
clusters of high HIV incidence in a widely disseminated rural
South African epidemic: a case for targeted intervention strategies.
18th Conference on Retroviruses and Opportunistic Infections;
Boston, MA, USA; Feb 27–March 2, 2011.
Cohen J. HIV prevention. Halting HIV/AIDS epidemics. Science
2011; 334: 1338–40.
Kenya National AIDS Control Council. Analysis of HIV prevention
response and modes of HIV transmission. Nairobi: National AIDS
Control Council, 2009. http://www.nacc.or.ke/images/stories/
Documents/KenyaMOT22March09Final.pdf (accessed April 29,
2013).
Bertozzi SM, Laga M, Bautista-Arredondo S, Coutinho A. Making
HIV prevention programmes work. Lancet 2008; 372: 831–44.
Piot P, Bartos M, Larson H, Zewdie D, Mane P. Coming to terms
with complexity: a call to action for HIV prevention. Lancet 2008;
372: 845–59.
Cuadros DF, Awad SF, Abu-Raddad LJ. Mapping HIV clustering:
a strategy for identifying populations at high risk of HIV infection
in sub-Saharan Africa. Int J Health Geogr 2013; 12: 28.
Buse K, Dickinson C, Sidibé M. HIV: know your epidemic, act on
its politics. J R Soc Med 2008; 101: 572–73.
The People Living with HIV Stigma Index. London: International
Planned Parenthood Federation, 2012. http://www.stigmaindex.org/
(accessed June 26, 2012).
Smith AD, Tapsoba P, Peshu N, Sanders EJ, Jaﬀe HW. Men who
have sex with men and HIV/AIDS in sub-Saharan Africa. Lancet
2009; 374: 416–22.
Schwartländer B, Stover J, Hallett T, et al, and the Investment
Framework Study Group. Towards an improved investment
approach for an eﬀective response to HIV/AIDS. Lancet 2011;
377: 2031–41.
Garnett GP, Cousens S, Hallett TB, Steketee R, Walker N.
Mathematical models in the evaluation of health programmes.
Lancet 2011; 378: 515–25.
Eaton JW, Johnson LF, Salomon JA, et al. HIV treatment as
prevention: systematic comparison of mathematical models
of the potential impact of antiretroviral therapy on HIV incidence
in South Africa. PLoS Med 2012; 9: e1001245.
Cremin I, Alsallaq R, Dybul M, Piot P, Garnett G, Hallett TB.
The new role of antiretrovirals in combination HIV prevention:
a mathematical modelling analysis. AIDS 2013; 27: 447–58.
Bärnighausen T, Bloom DE, Humair S. Economics of antiretroviral
treatment vs. circumcision for HIV prevention.
Proc Natl Acad Sci USA 2012; 109: 21271–76.
Shelton JD. A tale of two-component generalised HIV epidemics.
Lancet 2010; 375: 964–66.
Bellan SE, Fiorella KJ, Melesse DY, Getz WM, Williams BG,
Dushoﬀ J. Extra-couple HIV transmission in sub-Saharan Africa:
a mathematical modelling study of survey data. Lancet 2013;
381: 1561–69.
Hallett TB, Baeten JM, Heﬀron R, et al. Optimal uses of
antiretrovirals for prevention in HIV-1 serodiscordant heterosexual
couples in South Africa: a modelling study. PLoS Med 2011;
8: e1001123.
Hallett TB, Gregson S, Lewis JJC, Lopman BA, Garnett GP.
Behaviour change in generalised HIV epidemics: impact of
reducing cross-generational sex and delaying age at sexual debut.
Sex Transm Infect 2007; 83 (suppl 1): i50–54.
90
91
92
93
94
95
96
97
98
99
100
101
102
103
104
105
106
107
108
109
Sullivan PS, Carballo-Diéguez A, Coates T, et al. Successes and
challenges of HIV prevention in men who have sex with men.
Lancet 2012; 380: 388–99.
Gomez GB, Bórquez A, Caceres CF, et al. The potential impact of
pre-exposure prophylaxis for HIV prevention among men who have
sex with men and transwomen in Lima, Peru: a mathematical
modelling study. PLoS Med 2012; 9: e1001323.
Woosley RL, Cossman J. Drug development and the FDA’s Critical
Path Initiative. Clin Pharmacol Ther 2007; 81: 129–33.
WHO, UNAIDS. Operational guidance for scaling up male
circumcision services for HIV prevention. Geneva: World Health
Organization, 2008. http://whqlibdoc.who.int/publications/2008/
9789241597463_eng.pdf (accessed April 29, 2013).
Foege WH. House on ﬁre: the ﬁght to eradicate smallpox. Berkeley:
University of California Press, 2011.
Jegede AS. What led to the Nigerian boycott of the polio vaccination
campaign? PLoS Med 2007; 4: e73.
Wheelock A, Eisingerich AB, Gomez GB, et al. Views of
policymakers, healthcare workers and NGOs on HIV pre-exposure
prophylaxis (PrEP): a multinational qualitative study. BMJ Open
2012; 2: e001234.
Eisingerich AB, Wheelock A, Gomez GB, Garnett GP, Dybul MR,
Piot PK. Attitudes and acceptance of oral and parenteral HIV
preexposure prophylaxis among potential user groups:
a multinational study. PLoS One 2012; 7: e28238.
Nel AM, Mitchnick LB, Risha P, Muungo LT, Norick PM.
Acceptability of vaginal ﬁlm, soft-gel capsule, and tablet as
potential microbicide delivery methods among African women.
J Womens Health (Larchmt) 2011; 20: 1207–14.
International Partnership for Microbicides. The Ring Study.
Silver Springs: International Partnership for Microbicides.
http://www.ipmglobal.org/the-ring-study (accessed April 29, 2013).
UNAIDS. Together we will end AIDS. Geneva: World Health
Organization, 2012.
Measure DHS, International ICF. DHS overview. Calverton:
Measure DHS, ICF International. http://www.measuredhs.com/
What-We-Do/Survey-Types/DHS.cfm (accessed April 29, 2013).
Incidence Assay Critical Path Working Group. More and better
information to tackle HIV epidemics: towards improved HIV
incidence assays. PLoS Med 2011; 8: e1001045.
UNAIDS. Combination HIV prevention: tailoring and
coordinating biomedical, behavioural and structural strategies
to reduce new HIV infections. Geneva: Joint United Nations
Programme on HIV/AIDS, 2010. http://www.unaids.org/en/
media/unaids/contentassets/documents/unaidspublication/2011/
20111110_JC2007_Combination_Prevention_paper_en.pdf
(accessed April 29, 2013).
Ghys PD, Kufa E, George MV. Measuring trends in prevalence and
incidence of HIV infection in countries with generalised epidemics.
Sex Transm Infect 2006; 82 (suppl 1): i52–56.
Zaba B, Boerma T, White R. Monitoring the AIDS epidemic using
HIV prevalence data among young women attending antenatal
clinics: prospects and problems. AIDS 2000; 14: 1633–45.
Padian NS, McCoy SI, Manian S, Wilson D, Schwartländer B,
Bertozzi SM. Evaluation of large-scale combination HIV prevention
programs: essential issues. J Acquir Immune Defic Syndr 2011;
58: e23–28.
Padian NS, Holmes CB, McCoy SI, Lyerla R, Bouey PD, Goosby EP.
Implementation science for the US President’s Emergency Plan for
AIDS Relief (PEPFAR). J Acquir Immune Defic Syndr 2011;
56: 199–203.
Schackman BR. Implementation science for the prevention and
treatment of HIV/AIDS. J Acquir Immune Defic Syndr 2010;
55 (suppl 1): S27–31.
Kurth AE, Celum C, Baeten JM, Vermund SH, Wasserheit JN.
Combination HIV prevention: signiﬁcance, challenges, and
opportunities. Curr HIV/AIDS Rep 2011; 8: 62–72.
www.thelancet.com Published online April 14, 2014 http://dx.doi.org/10.1016/S0140-6736(13)62230-8

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