FHI - Comprehensive Programming

FHI's more than 15 years of experience in the HIV epidemic have produced many effective HIV prevention and care strategies. Many pilot projects and small-scale projects in several countries have shown that key technical approaches can reduce transmission. But to have the greatest impact on the epidemic, it is now time to go beyond pilot and demonstration projects to increase coverage and quality at local, regional and national levels.

HIV/AIDS interventions targeting individuals have achieved some success. But individual behavior is profoundly influenced by broader contextual factors, including social norms, service accessibility and public policy. To be successful and sustainable, interventions must take place at multiple levels so that they can best influence individual and societal norms, improve the health infrastructure and alleviate structural and environmental constraints to HIV prevention and care. The design and implementation of programs must be tailored to local conditions, appropriate to the stage of the epidemic, responsive to donor and host country needs, and targeted to meet strategic objectives.

The main technical elements of a comprehensive strategy are presented below:

Prevention	Care and support
Behavior change communication (BCC) Condom promotion and availability STI management Voluntary counseling and testing (VCT) for HIV Prevention of mother-to-child-transmission (MTCT) Blood Safety Harm reduction for injecting drug users Stigma reduction	Stigma reduction VCT Psychosocial support Clinical management of opportunistic infections and HIV-related illnesses Tuberculosis prevention and control Palliative care Home-based care Disease management with anti-retrovirals (ARV)	Interventions for orphans and other vulnerable children Micro-enterprise and income generation Educational support Legal support

Technical elements of comprehensive care and support cannot be implemented in isolation. Only by combining key technical strategies can the needs of the community be met and the greatest impact on the epidemic made. Depending on the goals of the program, various combinations of technical strategies will be used to address different segments of the population, since one component may be most effective when bolstered by another. The following offer examples of how some technical elements complement each other:

Voluntary counseling and testing (VCT) for HIV is recognized as an effective, pivotal strategy in AIDS prevention and care. VCT provides benefits for those who test positive as well as for those who remain negative. But quality programs and services must be in place before individuals can truly benefit from VCT. Promoting VCT for behavioral change as a prevention strategy alone will not work if services or referrals are unavailable for those found to be positive. Using VCT to identify HIV-positive individuals without then trying to promote behavior change for prevention — preventing MTCT, for example — does not make full use of the strategy.

Intervention	Program goal(s)	Necessary programs and services
VCT for HIV		High quality, accessible, acceptable, utilized VCT services
	Promote behavioral change (reduced risk behavior)	Behavior change communication Supportive environment and policies
		Availability of prevention tools (condoms, needles, syringes)
		Quality STI services
		Outreach to particularly vulnerable groups
		Post-test support groups
		Stigma alleviation
	Referral for care and support	Medical, nursing and home care services for managing common problems and providing nutritional support
		Providing ARVs as appropriate (e.g., stage of infection, MTCT program, etc)
		Prophylaxis for common infections (bacterial and tuberculosis)
		Social support for VCT client and family
		Post-test support groups
		Stigma alleviation

Managing Sexually Transmitted Infections (STI) is a key strategy in HIV prevention. STIs increase one's susceptibility to HIV infection — and the same behaviors that put individuals at risk for STIs put them at risk for HIV. The link between the two allows for a "care-prevention synergy," since people are more receptive to condom use and other prevention messages when they are delivered with quality, non-judgmental curative services.

Intervention	Program goal(s)	Necessary programs and services
STI control	Reduce STI prevalence	High quality, accessible, acceptable, utilized STI treatment services
		Behavior change communication
		Access to prevention tools (condoms)
		Outreach to high-risk and vulnerable groups
		Supportive environment and policies
		Referral to VCT for HIV
		Quality laboratory services for surveillance and guideline design
		Stigma alleviation

Resources

Lamptey P, Gayle H, eds. HIV/AIDS Prevention and Care in Resource-Constrained Settings: A Handbook for the Design and Management of Programs. Arlington, VA: Family Health International, 2002.
Hunter S, Williamson J. Children on the Brink 2000. Washington, DC: U.S. Agency for International Development, 2000.
O'Grady M, Miller NN. The Civil-Military Project on HIV/AIDS: An International Joint Venture for HIV/AIDS Prevention. In Bunmi M and O'Grady M, eds. FHI/UNAIDS Best Practices in HIV/AIDS Prevention Collection. UNAIDS and Family Health International, 2001.
Osborne CM, van Praag E, Jackson H. Models of care for patients with HIV/AIDS. AIDS 1997;11 (suppl B): S135-S141.
Gibney L, DiClemente R, Vermund S, eds. Preventing HIV in Developing Countries: Biomedical and Behavioral Approaches. New York: Plenum Publishers, 1999.
UNAIDS Best Practice series and Technical Update series. www.unaids.org.