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Commentary & Opinion

HIV Combination Prevention Programs Should Be Evidence-Based, Lancet Opinion Piece Says

February 13, 2009

"Effective public health must be grounded in evidence and prioritize what is most effective," Daniel Halperin of the Harvard School of Public Health writes in a Lancet opinion piece. Halperin discusses a November 2008 Lancet opinion piece, written by Michael Merson of the Duke Global Health Institute and colleagues, that argued that HIV prevention cannot be limited to "just one or two stand-alone interventions." Halperin agrees that HIV prevention can include many diverse interventions such as "harm reduction for injecti[on] drug users, consistent condom use, empowerment of sex workers, and the need to address sexual coercion, gender-based violence and homophobia," In addition, there is "strong evidence" that partner reduction and male circumcision are effective HIV interventions, although these strategies are not "magic bullet solutions," Halperin writes.

Although Halperin agrees with some of Merson and colleagues' claims, he writes that their emphasis on combination HIV prevention methods is "problematic." He adds that although the "general notion of 'comprehensive prevention' is appealing, the specific elements of the mix are essential." He continues that the "assumption that merely combining different strategies -- whose individual effectiveness is often 'insufficiently proven' -- will somehow result in a substantial population-level effect is dubious." Halperin writes, "As with HIV treatment regimens, prevention elements should be combined, but their combined effectiveness must be demonstrated." According to Halperin, "Trials of standard combination prevention approaches in Africa have thus far been unsuccessful." He concludes that "Like treatment, prevention must be deployed with scientific rigor" to curb the spread of HIV effectively (Halperin, Lancet, 2/13).

Online An extract of the opinion piece is available online.

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