Module 2: Technical Strategies

Overview

In the decades since HIV emerged, the global community has refined key technical strategies for preventing HIV/AIDS and caring for those who are living with it. These approaches can and do affect transmission and mitigation, as demonstrated by numerous pilot and small-scale demonstration projects and a few national-level programs. The next critical step in affecting the epidemic is to move beyond pilot and demonstration projects, increasing coverage at the local, regional and national levels. To accomplish this, program managers and planners must address the key questions listed above.

Module 2, Technical Strategies for ECR:

• Describes the synergy of interlocking technical interventions, including:
  • combining key technical interventions;
  • grouping interventions for targeted prevention; and
  • integrating technical interventions into other services and sectors.
• Discusses ECR issues in implementing technical strategies for prevention and for care and support.
• Presents key questions for different aspects of implementing ECR technical strategies.
• Provides references and resources for further reading.

The key technical elements for HIV prevention and care that have been implemented effectively over the last two decades. Interventions are grouped into two mutually reinforcing categories: prevention, and care and support.

Synergy of Interlinking Technical Interventions To Support ECR Goals

This section will examine three ways to support ECR goals by linking technical interventions: 1) combining key technical interventions; 2) grouping interventions for targeted prevention; and 3) integrating technical interventions into other services and sectors.

Synergy of Interlinking Technical Interventions for ECR: Combining Key Technical Interventions
Technical interventions for prevention, care and support programs cannot be implemented in isolation. Community needs typically are expressed for prevention, care and support at the same time and are best addressed with a comprehensive response of combined interventions. Additionally, combining technical interventions will likely have a greater impact on the overall epidemic. The multiplier effect of mutually reinforcing technical interventions can maximize benefits. Depending on program goals and the status of the epidemic, different population segments can be targeted with different combinations of technical interventions. Three examples of how key technical interventions are both interconnected and complementary for VCT, STI management and home-based care appear in the accompanying boxes.

Voluntary Counseling and Testing (VCT)
VCT is a critical strategy in HIV/AIDS prevention and care synergy, providing benefits to those who test HIV positive and those who test HIV negative. For VCT to be effective, high-quality counseling and testing services must be in place, and the community must perceive these services to be beneficial. Promoting VCT for behavioral change as a prevention strategy alone will have limited impact without quality services and/or referrals for individuals who test HIV positive. For example, using VCT to identify HIV-positive individuals to prevent MTCT without providing behavior change interventions does not use the VCT strategy fully and will have less impact. Similarly, counseling an HIV-positive individual on ways to prevent further spread of HIV without addressing the person's psychological and medical needs will have limited impact.

Management of Sexually Transmitted Infections (STIs)
STI management is a key strategy in HIV prevention because STIs increase individuals' susceptibility to HIV – and their infectiousness with it. The behaviors that put individuals at risk for STIs also put them at risk for HIV. A care/prevention synergy, where prevention messages such as condom use are delivered with quality, nonjudgmental treatment services, helps individuals become more receptive to prevention messages.

Home-Based Care
Home-based care is an intervention strategy that aims to relieve the burden of an already stretched health care system by providing care to persons living with HIV/AIDS (PLHAs) in the home and community. For PLHAs, there are clear psychological benefits to home care: It is a trusted environment and it provides opportunity for discussing care and prevention with the entire family. Home-based care volunteers are often respected in the community and can mobilize communities for prevention and care.

Different combinations of technical interventions can be selected when developing an ECR, depending on program goals and affected or targeted populations. It is important to consider the technical strategies most appropriate for different levels (individual, family, community and society), recognizing that at the center of all AIDS work is the individual and the family. Individual and family needs are not limited to one category of intervention; they require prevention programming, care and support, and strategies to mitigate the impact of the epidemic. All interventions must be integrated into existing health and social services systems and structures.

Synergy of Interlinking Technical Interventions for ECR: Grouping Technical Interventions for Targeted Prevention
Grouping technical interventions to meet the needs of individuals, families, communities and society around specific targeted populations has been successful. Concepts of targeted prevention are described at right.

Evidence increasingly suggests that the most efficient way to reduce the epidemic's spread is to reduce transmission among those who change partners most often. Preventing infection among those with the highest rates of partner change, either sexual or drug injecting, prevents many more subsequent, secondary infections.

Targeted interventions have led to successful risk reduction and decreased levels of HIV infection.

• A targeted intervention with sex workers in Abidjan, which combined BCC with condom promotion and STI services, reported condom use among sex workers with last client increased from 63 percent in 1991 to 91 percent in 1997 (Ghys et al. 1998).

• The Thai 100 percent condom program has been associated with an increase in condom use among sex workers from 14 percent to 94 percent (Hanenberg et al. 1994). This program created a policy incentive for brothels to insist on condom use by fining brothels whose female sex workers test positive for STIs. The policy was backed up by legal enforcement of regular STI screening and treatment, condom provision and a comprehensive communications campaign.

• In South Africa, condom sales remained low among women at high risk in a mining community, despite the introduction of a condom social marketing program. The women indicated they were tired of receiving condom messages while other health issues were ignored. With the introduction of STI services for the women, condom use began increasing among them (Steen et al. 2000).

As a result of these targeted interventions, fewer infections have been observed, not only in the targeted populations themselves, but also in the bridge and general populations.

To apply the concept of targeted prevention, the subpopulations where risk behavior is most concentrated and who are most vulnerable must be identified on a country, state or provincial basis. But sex workers and their clients, IDUs, and men who have sex with men (MSM) are more likely to predominate, so targeted subpopulations should be selected based on local data.

The above chart highlights examples of ways to combine technical strategies to meet specific program goals.

An urgent priority for countries, regardless of the state of the epidemic, is to rapidly expand and deliver prevention and care and support services to the majority of people at highest risk. Pilot projects have demonstrated the effectiveness of targeted interventions but, in most cases, coverage of the high-risk population has been low.

Linking Prevention and Care
As people infected with HIV progress to recurrent illnesses, the services they need change. Providing comprehensive care across a continuum, from home and community to institutional services and back, will ensure that the specific needs of clients and their families are met. Effective referral systems have been developed to ensure that people living with and affected by HIV/AIDS can benefit from the various community and institutional-level services available. These services provide comprehensive care and support throughout the course of infection and disease. The following chart highlights the technical strategies needed to meet the needs of a community affected by HIV/AIDS.

Synergy of Interlinking Technical Interventions for ECR Method 3: Integration of Targeted Prevention Into Other Services and Sectors
HIV/AIDS prevention efforts are more effective when programs and activities are integrated into existing large-scale infrastructures that operate across a range of sectors. Combining delivery of HIV/AIDS interventions with other sectors, rather than expanding HIV/AIDS interventions independently, helps reduce costs, improve efficiency and maintain sustainability. But the potential for integrating HIV/AIDS programs into other services, such as education, reproductive health, family planning or sex education, has not always been exploited fully by countries (Watts and Kumaranayake 1999). In addition to the public sector, integration is needed for civil society groups as well, such as trade unions and youth and women's associations.

The chart shows how some HIV efforts have been integrated into existing programs, systems and structures.

ECR Issues in Implementing Technical Prevention Strategies

Eight technical prevention strategies are presented and discussed in this section as they relate to ECR: BCC; condom promotion; sexual health services; blood safety; VCT; MTCT; harm reduction; and stigma reduction.

Technical Prevention Strategy 1: Behavior Change Communication (BCC)
Changing individual and community behaviors is key to HIV prevention. BCC plays five different but related roles in HIV/AIDS and STI programming:

• Community dialogue. Stimulates community and national discussions on the factors that contribute to HIV/AIDS, such as risk behaviors and the environment that creates them, and demand for information and for prevention, care and support services.

• Advocacy. Ensures that policy makers and key opinion leaders stay informed on the epidemic. Advocacy takes place at national and community levels.

• Provision of information and education. Provides individuals basic facts in language and visual and media formats they can understand, and motivates positive behavior change.

• Stigma. Conveys the issue of stigma and attempts to influence the social response in all communications as it relates to prevention and care. This is a particularly critical component of BCC.

• Promotion of services and products. Communicates promotional information on HIV/AIDS and STI programs and services. Services can include STI treatment, VCT, support groups, PLHA networks, OVC, MTCT, clinical care for OIs, ARV therapy and social and economic support.

Consistent messages from a variety of legitimate sources must be disseminated in an interactive fashion to affect behavior change. The graphic highlights the behavior change process as it relates to communication.

HIV prevention interventions aim to change individual behavior, but community- and societal-level interventions have been developed to change norms and behaviors at the group level. It is critical to support and promote BCC at both the individual and group levels.

Experience has shown that while HIV risk may grow quickly in a community or country, attitudes favoring prevention and preventive behaviors are likely to lag far behind. Mass media play an important role in promoting attitude changes and popularizing safer behaviors. When behaviors lag behind knowledge, mass communication can be used to stimulate dialogue about risk behaviors and risk settings particular to a community.

BCC campaigns are developed using behavior change methods and are tailored to address different stages of the epidemic, since population subgroups (target audiences) may be at different stages in the behavior change continuum. Target audiences must be segmented and BCC campaigns developed for each group. For an ECR to be effective, a national BCC campaign must target specific groups with quality messages and interventions.

Stigma is a critical issue to address when developing BCC campaigns. Stigma is defined as a mark of shame or discredit on a person or group. In HIV/AIDS, stigma affects PLHAs, men who have sex with men, commercial sex workers, intravenous drug users, migrant populations and other marginalized groups. Stigma often presumes a negative behavior on the part of those individuals stigmatizing others, and manifests itself in a range of ways, from ignoring the needs of a person or group to psychologically or physically harming the stigmatized. The importance of addressing stigma in BCC campaigns transcends questions of compassion and humane treatment for programs. BCC programs that address stigma can benefit from motivated persons or groups, such as PLHAs, CSWs and MSM, who can work effectively for change as policy advocates and serve as caregivers and peer educators.

Technical Prevention Strategy 2: Condom Programming

The male condom is the only widely available, effective protection against HIV and other STIs. Access to male condoms is essential in prevention strategies targeting sex workers, their clients, and non-client partners. Condom social marketing programs have been deployed successfully in developing countries and are one of the most effective HIV prevention interventions.

Social marketing and distribution of condoms to targeted populations can take multiple approaches, such as free, targeted distribution, community-based distribution programs, and dissemination via health facilities, pharmacies and village stores. The distribution strategy can be coordinated among the different outlets to achieve maximum availability of condoms.

For an ECR, it is important to improve the access and availability of condoms to all communities (urban and rural) and for specific groups.

People must also know how to use them correctly. A successful condom promotion program should ensure that condoms are used often and consistently in most high-risk sexual encounters. A condom social marketing program that reaches primarily the lower-risk general population may not have a significant impact on reducing HIV transmission.

The female condom has been the subject of extensive studies in effectiveness, acceptability, cost-effectiveness, training, and gender dynamics for the past decade. Study results have been positive. WHO and UNAIDS have encouraged introducing the female condom as a new method of preventing pregnancy and HIV infection. The female condom can be a vital component of reproductive health and HIV/AIDS programs. It should be introduced strategically to have the strongest, most cost-effective public health impact. When trying to expand the response to the epidemic, all potential methods must be used strategically to increase safer sexual behaviors.

Technical Prevention Strategy 3: STI Management

There have been several large-scale interventions that demonstrate the potential impact of STI control on HIV transmission. Thailand reduced the incidence of curable STIs by more than 80 percent in less than five years through a comprehensive effort that included improved STI treatment and targeted promotion of condom use in commercial sex establishments (100 percent condom policy). During this period, HIV prevalence, which had been increasing rapidly, began to fall. Through sustained application of these interventions, Thailand stabilized HIV transmission early and averted a more extensive epidemic. There is also evidence that more limited STI interventions can reduce HIV transmission. In rural Mwanza, Tanzania, improving the case management of STI through the syndromic approach in clinics reduced the incidence of new HIV infections by 40 percent. But in nearby Rakai, Uganda, mass antibiotic treatment of the sexually active population at nine-month intervals resulted in no drop in most curable STIs or in HIV transmission.

Experience in STI control programming shows that reducing high rates of STI requires a comprehensive strategy for prevention and treatment. This type of strategy includes well-known aspects of STI control programs, such as ensuring effective diagnosis and treatment, encouraging treatment adherence and partner treatment and avoiding reinfection. Equally important, however, is who uses existing clinical services and who does not. Even the most technologically advanced services will have little impact on STI prevalence if access to those services is poor. One of the most important challenges in STI control is orienting effective services to reach the people who are exposed to infection most frequently and who have the most opportunities to pass infection on to others.

Though important, STI case management is not the sole component of an STI control approach. The syndromic approach endorsed by WHO/UNAIDS has become the standard of care for managing the most common STI syndromes in many countries. By directing treatment against the common causes of easily identified syndromes, high cure rates can be achieved by primary health care workers without the delay and cost involved in laboratory workups. Syndrome algorithms can reduce treatment failures and reinfection by stressing the importance of treatment adherence, condom use and partner treatment. Syndromic management is best suited for syndromes such as urethral discharge and genital ulcer disease. Current approaches to managing vaginal discharge syndromes in women are less accurate, and better combinations of syndrome and laboratory diagnosis and screening are needed. For the present, more sensitive and costly approaches can be adapted for populations where prevalence and exposure are relatively high. In lower-risk populations, treating the more common vaginal pathogens may be more cost effective. As simpler, more affordable and accurate diagnostics become available, STI case management guidelines that recommend combinations of syndrome and laboratory diagnostic methods will become feasible under field conditions.

Technical Prevention Strategy 4: Blood Safety

Key Implementation Questions for Blood Safety

Is there a national blood transfusion service? Are there additional services in the private and non-governmental sector? If so, are they coordinated under a guiding national policy? Do blood transfusion service staff have adequate capacity to deliver and maintain high quality? Is a quality assurance system in place? Is there a voluntary blood donation program? Are there "professional" blood donors? If so, are there any programs in place to decrease their number?

Designing strategies and interventions to promote blood safety in developing countries requires planners and program managers to understand the many factors influencing behavioral practices that present challenges to

change. Factors to consider include:

• Level of awareness of basic principles and concepts, such as voluntary blood donation
• Impact of HIV, hepatitis C virus (HCV) on donor selection
• Need for appropriate technology
• Societal perceptions and behavior concerning blood donation
• Political will
• Organization of blood transfusion services
• Behavior change within the delivery system, such as reducing unnecessary blood transfusions
• Need for new training methods
• Need for system-wide health care training
• Linking VCT to blood safety

A reliable and safe blood supply is still out of reach for many countries. Blood-borne transmission of HIV accounts for up to 10 percent of HIV infections in countries with limited resources. The vast majority of these infections can be prevented by:

• reducing unnecessary transfusions by effective clinical use of blood;
• educating, motivating, recruiting and retaining low-risk blood donors; and
• screening all donated blood for infectious agents.

Many countries have made progress, often with limited resources, toward securing an adequate and safe supply of blood.

Technical Prevention Strategy 5: Voluntary HIV Counseling and Testing (VCT)
See Section on "ECR Issues in Implementing Technical Care and Support Strategies."

Technical Prevention Strategy 6: Prevention of Mother-to-Child Transmission (MTCT)
Strategies to reduce MTCT include primary prevention of HIV infection among women, family planning, antiretroviral intervention, restricted use of invasive obstetric procedures during vaginal delivery, and provision of infant feeding options.

A number of ARV regimens, including long- and short-course zidovudine and nevirapine, have been shown to be effective and safe in MTCT. UNAIDS, WHO and UNICEF have recommended that MTCT prevention be included in the minimum package of care for women living with HIV/AIDS, with the choice of ARV regimen determined according to local circumstances (UNAIDS 2000).

But ARV therapy in MTCT prevention can be challenging for countries because of: limited availability of antenatal care and maternal health infrastructures and services; lack of awareness of HIV transmission and personal HIV infection in pregnant women; and underdevelopment of VCT services, including limited integration into MTCT sites, compliance in taking longer-course ARV, maintaining infant feeding options, and inconsistent care and for mothers living with HIV/AIDS.

Expanding access to counseling, testing, family planning services and antenatal and postnatal care, along with adapting obstetrical practices and introducing antiretroviral therapy (ART), can result in a heavy demand on existing antenatal clinics (ANCs) and maternity facilities. Prenatal care will be the area first affected, followed by postnatal care, because infants born to mothers living with HIV/AIDS need extra care. Further effects will be felt in HIV testing and monitoring of HIV infection and ART, and extra work will be required of laboratories. Countries must consider the cost-effectiveness of this intervention based on prevalence levels.

Determining whether to implement MTCT prevention on a large scale is complex. The following considerations can help program managers and planners make decisions about MTCT interventions:

• Cost-effectiveness of the intervention based on the prevalence level (cost-effectiveness has been questioned at HIV prevalence levels of less than 10 percent).
• State of the existing health system and maternal child health services.
• Consideration of the risks associated with various infant-feeding options.
• Community attitudes toward women living with HIV/AIDS.
• Cultural beliefs about childbearing, breastfeeding and family planning.

Technical Prevention Strategy 7: Harm Reduction

There is evidence that HIV epidemics among IDUs can be prevented, slowed and even reversed in developing and developed countries by implementing specific harm-reduction strategies, including:

• community-based peer outreach;
• increasing access to sterile injecting equipment; and
• increasing access to drug dependence treatment, particularly methadone (Ball 1998).

Where effective action has been taken to stem HIV epidemics among IDUs, no single element has been found to be effective on its own. Comprehensive programs, based on community development principles and operating in supportive environments that include access to social welfare and primary health care (including drug treatment/rehabilitation programs), are key components of successful approaches. Increasing access to sterile needles and syringes is critical to a successful HIV prevention program for IDUs.

HIV prevention targeting IDUs is more effective and less costly the earlier it is implemented, ideally before HIV is introduced into the population or before it spreads widely – i.e., exceeding 5 percent (Rhodes et al. 1999). Once HIV prevalence reaches 10 percent, it can surpass 50 percent in just one to four years. When high prevalence is established, it may be sustained for several years, although there are some examples of epidemics being reversed (Strathdee et al. 1998).

Technical Prevention Strategy 8: Stigma Reduction

HIV/AIDS-related stigma continues to inform perceptions and shape the behavior of PLHAs, which can hamper prevention interventions. Developing policies to combat discrimination is crucial to any HIV prevention program. Stigma reduction is both a human rights and a public health issue. Stigma has effects at many different levels:

• Prevention. On the social level, stigma can cause target audiences to view those with or at risk of HIV/AIDS as the other or them, perpetuating notions that such an epidemic "could not happen to me." BCC programs can result in audiences rejecting AIDS prevention messages when stigma is not addressed. On the individual level, ignoring stigma can cause people to decide not to seek VCT or other medical care, including care regarding MTCT.
• Quality of care. Stigma can perpetuate negative practices among health care providers, such as secrecy, neglect and poor treatment of PLHAs. A BCC campaign aimed at increasing demand for a facility's services might not be effective, due in part to poor quality of care encountered by PLHAs.
• Policy. It is important to address stigma to facilitate enforcement of existing laws and end discriminatory laws and practices.

ECR Issues in Implementing Technical Care and Support Strategies

Four interrelated needs of PLHAs and their families have been identified: 1) medical needs – e.g., treatment information and treatment; 2) psychological needs – e.g., emotional support; 3) socioeconomic needs – e.g., helping hands and orphan support; and 4) human rights and legal needs – e.g., access to care, protection against violence and discrimination. As HIV infection progresses, the services needed change. Providing comprehensive care across a continuum – from home and community to institutional services and back – will ensure that the needs of clients and their families are met.

In the chart, care and support needs are outlined for the different stages of HIV/AIDS. As an individual enters the system for care, it is also essential that an active and effective referral system is in place, as depicted in the chart at bottom.

Eight documented, cost-effective care and support interventions are explored in this section: VCT; psychosocial support; palliative care; clinical management of opportunistic infections (OIs); tuberculosis (TB); home-based care; care for orphans and vulnerable children (OVC); and antiretroviral therapy (ART).

Technical Care and Support Strategy 1: Voluntary HIV Counseling and Testing (VCT)
Voluntary counseling and testing (VCT) for HIV is recognized internationally as an effective and pivotal strategy for both prevention and care. Research in Kenya, Tanzania and Trinidad by FHI, in collaboration with UNAIDS, WHO and the Center for AIDS Prevention Studies at the University of California at San Francisco, provides strong evidence that VCT is an effective and cost-effective strategy for facilitating behavior change. VCT was also identified as an important entry point to care and support. These findings have raised interest and support for VCT as a valuable component of comprehensive HIV/AIDS programs among international organizations as well as the national AIDS programs of many countries and donors.

The major barrier to VCT is fear of stigma; women in particular can face violence and loss of security in the form of shelter, food and relationships. It is particularly important with this population to ensure that testing is performed and results given without breaches in confidentiality. Other barriers are the lack of available drug therapies, psychological support and clinical care for individuals who test HIV positive. Counseling itself is labor intensive and requires training and supervision to assure high quality.

As an entry point for prevention and care, VCT must be made available on a much larger scale. The use of simple, rapid HIV tests can decrease loss of follow-up in VCT. Lessons learned from VCT programming to date include:

• VCT can be offered by government, non-government, community and private sectors.

• The gold standard for VCT follows a regimen of pretest counseling, testing (as desired by the client and after informed consent is provided), and post-test counseling (involving one or more sessions, depending on the client's needs). Individual risk assessment, risk reduction planning, and preparing for and coping with test results are integral components of pre- and post-test counseling.

• A range of innovative service delivery models can be applied, depending on the context. These include variations on integration within the existing health facilities, freestanding and mobile services.

• The model of choice should address cost considerations to guarantee sustainability of services. Service sustainability remains a challenge in many settings, especially within non-integrated sites where initial start-up costs are provided by external international donors.

• VCT must be accessible and affordable for those at highest risk of HIV infection or those suspected to have HIV-related illness. VCT should be available to the range of clients who may benefit from knowing their HIV serostatus, including couples, individuals and young people.

• VCT sites need to be adequately staffed by individuals with high-quality training in counseling and testing practices.

• VCT site managers must help staff sustain high-quality service provision, retain skilled staff and prevent burnout among counselors.

• VCT for couples must be widely encouraged and promoted. Couples' pre- and post-test counseling has significant benefits for addressing risk assessment and risk reduction planning, particularly for women in countries where there is substantial gender inequity. Targeting couples for VCT is also cost efficient.

• VCT design needs to address service promotion within the planning and establishment of high-quality VCT services. This includes identifying or strengthening other care and support services, community and hospital referral networks.

• VCT services must to be tailored to the unique epidemiological, behavioral and socioeconomic context of each country and/or setting. The designs also can take into account stigma reduction and demand creation interventions.

• In scaling-up VCT or developing new VCT sites, a coordinated response by all stakeholders – including partnerships among donors, government and non-governmental organizations – is crucial to ensure standardization of services in terms of quality of care and support offered to clients and to avoid duplication of services within regions.

• Monitoring and evaluation systems must be established from the onset for both counseling and testing components. Counseling and testing protocols may vary from one program to another based on the goals and objectives of the program. Whatever approach is taken, the VCT intervention must be evaluated regularly to determine whether it is being provided in accordance with the predetermined protocol and is satisfying client needs.

• Innovative approaches to VCT should be responsive to the specific needs of a country. These include VCT services for adolescents and integration of VCT practices within antenatal sites that can employ group pretest information sessions in settings with high client load/volume, as part of a comprehensive strategy for prevention of MTCT.

• VCT is a public health intervention. Governments and donors will need to assume some of the associated costs of VCT to ensure the widest possible access.

• National HIV/AIDS policies and strategies need to ensure adequate coverage of VCT services and set national VCT service provision standards.

Technical Care and Support Strategy 2: Psychosocial Support

Ongoing counseling helps individuals to accept their HIV status and develop a positive attitude. It can facilitate information sharing with partners or close family members who may also participate in counseling. In Uganda, for example, a study of 730 patients who received long-term counseling found that 90 percent revealed their serostatus to another person and 85.3 percent told relatives. Disclosure, however, is still a very difficult process. Another study found a high level of acceptance of HIV-positive people in families (79 percent) and communities (76 percent) (Coates et al. 2000). Psychosocial support can be provided at clinics, schools or community support groups.

Caregivers also need psychosocial support. Caring for someone with a serious chronic illness is a physical and emotional challenge, even for the most dedicated caregiver. This is particularly true for nurses, counselors and caregivers in the home who provide the bulk of care for PLHAs. These caregivers also need support to help them do their jobs well, avoid "burnout" and keep going, free of HIV infection.

Technical Care and Support Strategy 3: Palliative Care

Palliative care is defined as controlling symptoms, relieving distress, promoting quality of life, and attending to the psychosocial aspects of illness. These are appropriate in all stages of all diseases, not just during a terminal illness. In the case of HIV/AIDS, as the disease progresses, symptom relief, pain management and attention to psychosocial needs will require increased attention. Many infected persons currently lack access to palliative care services and medications. Palliative care can be provided in hospitals and in the home environment.

Technical Care and Support Strategy 4: Clinical Management of Opportunistic Infections (OIs) and HIV-related Illnesses
Most OIs are treatable with prompt diagnosis and appropriate management. TB is the leading HIV-associated opportunistic disease in developing countries and causes 30 percent to 40 percent of deaths in PLHAs. Other causes of AIDS-related mortality and morbidity include pneumonia, candidiasis, cryptococci infections, toxoplasmosis, herpes, and common infections. Effective interventions against OIs require not only the appropriate drug and other medications, but also the infrastructure necessary to diagnose the condition, monitor the intervention and counsel PLHAs.

In addition to access to appropriate drugs, treatment of OIs requires clinic facilities for outpatient care and hospital facilities for serious illness. Laboratory requirements are needed for diagnosis and follow-up of certain OIs, such as TB, parasitic and bacterial infections. The potential to expand clinical management relies heavily on existing capacity constraints, both for inpatient and outpatient care. These capacity limits may already be reached in some countries, given the current evidence that 50 percent to 70 percent of beds in some African countries are being used to treat HIV-related illnesses (World Bank 1997).

Interventions to prevent OIs can result in significant gains in life expectancy and quality of life for PLHAs. Cotrimoxazole has been recommended for preventive use in HIV-symptomatic persons as part of a minimum package of care (UNAIDS, April 5, 2000). It is widely used in developing countries, listed as an essential drug and inexpensive. In two randomized controlled trials in Côte d'Ivoire, Cotrimoxazole prophylaxis resulted in fewer hospitalizations, enteritis, pneumonia, isosporiasis, nontyphoidal salmonella, and septicemia than a placebo. In one of the studies there was decreased mortality (Anglaret et al. 1999). While recommended, the feasibility of widespread implementation of TB treatment is still in the early stages in many countries, given the required intensive collaboration between TB and HIV clinical staff. VCT is seen as an entry point for providing TB prophylaxis, but few individuals have access to these services or the incentive to be tested.

Highly active antiretroviral therapy (HAART) remains the most effective strategy for reducing OI-related morbidity and mortality, but the treatment is complex and not widely available in many countries.

The WHO estimates that more than one-third of the world's population lacks access to essential drugs because of high prices or inadequate supply and distribution systems. With HIV, essential drugs are required to provide adequate care for a number of OIs and malignancies. On a basic level, these drugs include anti-infective agents and palliative drugs. Issues to consider with regard to expanding access to drugs are found in Module 7, Managing the Supply of Drugs and Commodities.

Technical Care and Support Strategy 5: Tuberculosis
Tuberculosis is an important disease to target in areas severely affected by HIV because TB is curable. Although it is fueled by the HIV epidemic, TB is an infectious disease that does not remain confined to HIV-positive individuals. As one of the first opportunistic infections to appear in PLHAs, TB may be the earliest sign of HIV infection. Addressing TB offers the opportunity for early HIV intervention.

Coordinating TB and HIV services is important when targeting TB in countries with high HIV prevalence. This can be accomplished by maximizing the directly observed treatment, short-course (DOTS) strategy, establishing HIV services in TB service points, incorporating TB-control activities within HIV services, and advocating for greater coordination of TB and HIV programs.

Studies in resource-scarce countries suggest that TB prophylaxis can be both cost effective and operational (Brewer 1999). Preventive therapy for TB with isoniazid is recommended as a health-preserving measure for HIV-infected persons at risk of TB, such as those with a positive TB skin test or living in areas of endemic TB (WHO 1999).

Technical Care and Support Strategy 6: Home-based Care
Home-based care is defined as any care given to PLHAs in the home or community environment. This can involve people at different stages – for example, people who are chronically ill at an early stage or those at the terminal stage of illness. Care can be provided by family caregivers, trained volunteers or health and social/support care providers. Home-based care has emerged over the past decade as a valuable strategy to alleviate the strain on hospitals, families and communities, and provide PLHAs with a better quality of life.

Home-based care models generally take two forms – hospital/clinic-based outreach and community-based programs. Programs can benefit by developing both hospital and community-based components. These services are intended to provide comprehensive care for clients in the home and reduce the need for hospital admission.

While home care has many benefits, it often can be limited because it is time- and resource-intensive. As a result, home care programs and family caregivers may not be supported fully. Outreach workers may be challenged to meet client needs as caseloads escalate, reducing the frequency and duration of visits. Other difficulties include travel costs and travel time. Outreach work is demanding and workers require appropriate training and support. In some areas, trained community volunteers have been used extensively as a link between family caregivers and outreach staff. For the family, caring for the PLHA can be challenging. Individuals may be cared for in overcrowded and impoverished conditions. This raises important issues regarding the potential to expand home care services. Alternatives to home care, such as hospice care or day care centers, have not been explored in many countries. Some faith-based organizations can also play a vital role in providing care to PLHAs.

Technical Care and Support Strategy 7: Care for Orphans and Vulnerable Children (OVC)
Experience indicates that multi-sectoral, collaborative and coordinated responses are essential for the care of orphans and vulnerable children. While there are a number of successful but relatively small and localized responses to OVC care, capacity building in NGOs and CBOs is needed to develop a broader vision and engage more organizations in caring for OVCs.

To date, the response to OVC care has come mostly from women who respond by visiting orphan households, establishing income-generating projects and sending children back to school. Adapting and replicating many of these initiatives can help protect and support greater numbers of vulnerable children.

While more resources are needed, their timing and manner of provision need careful consideration. Funding assistance must be in response to community action undertaken with local resources. This type of targeted assistance goes hand-in-hand with community capacity building.

Efforts to strengthen the social safety net that supports orphans and vulnerable children require a complex range of social development interventions. These interventions increase access to resources and promote optimal use of resources. Interventions include social/support services, health services, education and food security. Target populations include child-headed households, widows, grandparents, orphans and youths. The goal is to develop the ability to be self-supporting.

Key social sectors for OVC programs include:

• Social Welfare/Community Development. Identify vulnerable families and assess material and other support needs and local and external resources. Special attention must be paid to child-headed households; families with young children headed by the elderly; families with young children headed by adolescents; and abandoned newborns. Appropriate counseling services should be aimed at encouraging families to care for HIV/AIDS-affected children (in cooperation with the health sector).

• Micro-finance. Expand access to micro-finance services to improve the capacity of households and communities to support PLHAs and affected households.

• Labor. Strengthen efforts to eliminate child labor as a preventive strategy to protect orphans and children without adequate family care from being exploited economically. Pay special attention to training labor inspectors and revising national laws and policies in accordance with the international conventions on child labor.

• Education. Consider accelerating action to ensure that universal primary education is available to all children regardless of their social situation. Assess the impact of the pandemic on the number and quality of teachers and the possible reduction in enrollment levels.

• Health. Build capacity to reach HIV-positive children with adequate medical attention to alleviate their suffering and reach adolescents with information about infection prevention and actions they can take to manage their HIV.

• Agriculture. Assess the impact of the pandemic on the productivity of farm families; develop outreach programs aimed at supporting young farmers; provide human resources and technical assistance to families identified as taking care of orphans and headed by children and adolescents (in cooperation with social welfare).

Technical Care and Support Strategy 8: Antiretroviral Therapy (ART)
With antiretroviral drugs (ARV), AIDS may become a manageable chronic illness resulting in restoration of economic productivity and social functioning. These effects, however, have only occurred where resources are available to make the drugs affordable and health service capacities exist to enable sustained, safe and effective use. Successful implementation of ART requires the drugs, the client and the health care system.

Specific services and facilities must be in place before considering introducing ART into any setting, because of the high cost of ARV drugs, complexity of drug regimens and need for careful monitoring. These services include:

• Access to VCT
• Capacity to diagnose and monitor common HIV-related illnesses and infections
• Laboratory monitoring services, including routine hematological and biochemical tests for detection of drug toxicity and monitoring immunologic and virologic parameters
• Resources to pay for long-term treatments
• Information and training for health professionals on safe and effective use of ART
• Regulatory mechanisms to ensure that drugs are being used appropriately

Lessons learned from large-scale programming include:

• HIV/AIDS care must be planned and implemented with significant involvement of PLHAs
• Efforts to address stigma and discrimination are integral parts of successful mitigation
• Community ownership of care and support is key
• Successful responses are ones that are coordinated and planned across sectors

Further Reading

1. Anglaret X, Chene G, Attia A et al. 1999. Early chemoprophylaxis with trimethoprim-sulphamethoxazole for HIV-1 infected adults in Abidjan, Cote d'Ivoire: a randomized trial. Lancet; 353:1463-1468.
2. Ball A. 1998. Overview: Policies and Interventions to Stem HIV-1 Epidemics Associated with Injecting Drug Use. In G. Stimson, D. DesJarlais and A. Ball (eds.). Drug Injecting and HIV Infection. Geneva: World Health Organization.
3. Brewer TF. 1999. Preventive therapy for tuberculosis in HIV infection. JAMA, March 10, 1999; 281(10): 485-486.
4. Coates T, Grinstead O, Gregorich S et al. 2000. Efficacy of Voluntary HIV-1 Counseling and Testing in Individuals and Couples in Kenya, Tanzania and Trinidad: A Randomised Trial. Lancet; 356 (9224): 103.
5. Ghys P, Mah-Bi Guessman, Traore M et al. 1998. Trends in condom use between 1991 and 1997 and obstacles to 100% condom use in female sex workers in Abidjan, Cote d'Ivoire. 12th World AIDS Conference, Geneva, June 28-July 3, 1998. Abstract 33101.
6. Gilks C, Floyd K, Haran D, Kemp J, Squire B, Wilkinson D. 1998. Sexual Health and Health Care: Care and Support for People with HIV/AIDS in Resource-Poor Settings. London: Department for International Development.
7. Hanenberg RS, Rojanapithayakorn W, Kunasol P. 1994. Impact of Thailand's HIV-control programme as indicated by the decline of sexually transmitted diseases. Lancet, 1994. 344: 243–245.
8. Marlink R, Ramanathan K, Coll-Seck A. November 12, 2000. Treatment now: For HIV/AIDS in sub-Saharan Africa. Paper presented at Africa Now! A leadership summit to define African priorities for HIV/AIDS. Addis Ababa, Ethiopia.
9. Osborne CM, van Praag E, Jackson H. 1997. Models of Care for Patients with HIV/AIDS. AIDS 11 (Suppl. B): S135—41.
10. Rhodes T, Simson G, Crofts N, Ball A, Dehne K, Khodakevich L. 1999. Drug Injecting, Rapid HIV Spread, and the "Risk Environment." Implications for Assessment and Response. AIDS 13 (Suppl. A): S259—69.
11. Steen R et al. Evidence of declining STD prevalence in a South African mining community following a core group intervention. Sex Trans Dis 2000. 1:1-8.
12. Strathdee SA, van Amerijden EJC, Mesquita F, Wodak A, Rana S, Vlahow D. 1998. Can HIV epidemics among injection drug users be prevented? AIDS, 12 (Suppl A): S71-S79.
13. UNAIDS. November 1997. Counseling and HIV/AIDS, Best Practice Collection-Technical Update.
14. UNAIDS. 2000. Use of antiretroviral treatments in adults with particular reference to resource limited settings. 
15. UNAIDS. September 8, 2000. Key elements in HIV/AIDS care and support. Draft working document. Geneva: WHO/UNAIDS.
16. UNAIDS. October 25, 2000. Preventing Mother to Child HIV Transmission. Technical experts recommend use of antiretroviral regimens beyond pilot projects. UNAIDS press release, Geneva.
17. UNAIDS. April 5, 2000. UNAIDS/WHO Hail consensus on use of cotrimoxazole for prevention of HIV-related infections in Africa. UNAIDS press release, Geneva.
18. UNAIDS/Ministry of Public Health, Thailand. 2001. Going to Scale: From Pilot Project of National Responses. Report from the 5th Asian Workshop, Bangkok, February 12—16, 2001. UNAIDS Asia Pacific Regional Program, Bangkok, Thailand.
19. Watts C, Kumaranayake L. 1999. Thinking big, scaling-up HIV-1 interventions in Sub-Saharan Africa. Lancet 354: 1492.
20. World Bank. 1977. Confronting AIDS: Public Priorities in a Global Epidemic. New York: Oxford University Press.
21. WHO. 1999. Policy Statement on Preventive Therapy Against Tuberculosis in People Living with HIV. WHO/TB/98.225; UNAIDS 98.34. Geneva: WHO.
22. WHO. 2000. Use of antiretroviral treatments in adults with particular reference to resource limited settings.

OVC References

1. Bruce J, Lloyd C, Leonard A. 1995. Families in Focus: New Perspectives on Mothers, Fathers, and Children. New York: Population Council.
2. Budlender D (ed.). 1996. The Women's Budget. Cape Town: Institute for Democracy in South Africa.
3. Community Mobilization and AIDS. 1997. Technical Update. Geneva: UNAIDS.
4. Donahue J, Williamson J. 1996. Developing Interventions to Benefit Children and Families Affected by HIV/AIDS: A Review of the COPE Program in Malawi. Washington: USAID, Displaced Children and Orphans Fund.
5. Donahue J, Williamson J. 1999. Community Mobilization to Mitigate the Impacts of HIV/AIDS. Washington: USAID Displaced Children and Orphans Fund.
6. Hunter S. 1999. Building a Future for Families and Children Affected by HIV/AIDS: Report on a Two-Year Project for Care and Protection Programs for Children Affected by HIV/AIDS. New York: UNICEF/Child Protection Division.
7. Hunter S, Williamson J. 1997. Children on the Brink: Strategies to Support Children Isolated by HIV/AIDS. Washington: USAID.
8. Hunter S. and Williamson J. 2000. Children on the Brink 2000. Washington: USAID.
9. Mutangadura G, Mukurazita D, Jackson H. 1999. A Review of Household and Community Responses to the HIV/AIDS Epidemic in the Rural Areas of Sub-Saharan Africa. Geneva: UNAIDS.
10. UNAIDS, UNICEF. 1999. Children Orphaned by AIDS: Front-line Responses from Eastern and Southern Africa. Geneva: UNAIDS.
11. UNICEF. 2001. Principles to Guide Programming for Orphans and Other Vulnerable Children, draft 3. New York: UNICEF.
12. Williamson J, Armstrong S. Action for Children Affected by AIDS: Programme Profiles and Lessons Learned. New York and Geneva: UNICEF and WHO.