Abstract

Combination prevention: four promising approaches

S. Stash¹, H. Begman², P. Okaalet³, B. Rau⁴, L. Romocki<sup>5

1</sup>John Snow Inc., AIDSTAR-One, Arlington, United States, ²John Snow Inc., Arlington, United States, ³MAP, Nairobi, Kenya, ⁴EnCompass LL, Washington DC, United States, ⁵AIDSTAR-One, Yaoundé, Cameroon

Background: Considerable international momentum has gathered in support of combination prevention programming. Although developed earlier, combination prevention came to the forefront at the IAS Conference in Mexico City and in the 2008 Lancet Prevention series. Combination prevention was the focus of a recent UNAIDS Prevention Reference Group meeting and featured in the PEPFAR II Strategy. This paper describes the elements of combination prevention as implemented by four very different programs: Avahan, India; APHIA, Kenya; Alliance, Ukraine; and a national consultation in Namibia.
Methods: In 2009-2010, AIDSTAR-One completed a series of case studies on combination prevention (Romocki and Okaalet, 2010; Rau, 2010; Stash and Bergmann, 2010; Stash, 2010). Four exemplary programs were selected using a common definition. Case studies were systematically developed based on observational site visits, key informant interviews, and programmatic data.
Results: Local organizations developed the optimal mix of services through commitment to local ownership, application of data, adaptive planning, and empowered local-level advocacy. Community-level workers serve as the critical link between people and a full-range of prevention services. Programs determined the right mix of services using timely applications of “best-available” data. Organizations encouraged planning from the community-level up and understood the local context of risk. Strong, adaptive management structures and partnerships enabled programs to be responsive. Programs exemplified concern for issues in the social and economic context and structural elements were key.
Conclusions: Because epidemics are dynamic, as is the environment of risk, programs must empower local learning and decentralized decisionmaking. Complexity can be managed but it takes serious program commitment to developing management structures that support it. Coordination and linkages are essential since no one organization or sector can support all the functions that are required. Approaches are needed to determine the optimal mix of services, elaborate costs, and understand the effectiveness of programs.