Across the 18 studies with behavioral or biologic outcomes, PfP interventions continue to be effective, with all but 3 reducing targeted sexual and/or drug-related risk behaviors; Table 1 provides specifics of relevant studies. Most of the interventions contained elements consistent with those identified earlier as contributing to effective outcomes.11,12 For example, most were developed using one10,37,46-48,50 or more34,38,40-42,45,49 health-behavior theories and were delivered in either an HIV clinic10,35,36,38,39,42,43,45,48,49 or another HIV service venue40,44 and by professional counselors/therapists40,41,43,44,48,50 or HIV care providers/other medical staff.1,35,39,49 A relatively small number of interventions targeted multiple HIV risk-related behaviors (eg, increasing disclosure, reducing heavy drinking or drug use, or enhancing coping skills36,37,40-45,48,50) and targeted biologic transmission risk factors (eg, increased adherence to ART, reduced viral load37,40,42-45). Compared with previous reviews,1,11,33 we note an increase in the number of PfP interventions tailored to risk dynamics unique to specific subpopulations of PLWHA (eg, decreasing sexual risk in substance-using seropositive MSM).34,40,41,45-47,50,76 Future meta-analysis should evaluate the effectiveness of emerging efforts to use multicomponent and more tailored intervention approaches to reduce overall transmission risk.
We believe that a synergistic package of PfP interventions at the intersection of behavior and biology will have optimal impact on limiting HIV transmission and maintaining PLWHA health.1-4,77 In Figure 1, we identify vital components and linkages of a comprehensive behavioral-biomedical conceptualization of next-generation PfP interventions (with an alphanumeric system denoting the various components and paths as well as “movement” within the model, eg, to component C from component B via path i).
All components and linkages need to be copresent and integrated in such an approach. To date, these elements remain separate unintegrated components of HIV prevention and of treatment science for PLWHA. Finally, we emphasize that the model must be evaluated and supported over the disease course of PLWHA (component A), understanding that what is needed to optimize the effect of each component and path may vary by disease stages78 and subpopulations (eg, PLWHA who are MSM vs injection drug user; young vs older PLWHA; incarcerated vs unincarcerated PLWHA; PLWHA with different comorbid conditions38,39,43,48,57,77,79-81).
Due to space limitations, our discussion of a comprehensive behavioral-biomedical approach to PfP addresses model components and their links in a somewhat arbitrary linear fashion. We recognize that the need for any component and relevant linkages could occur along paths not discussed. The next generation of PfP interventions must attend to reducing both behavioral and biologic risk factors across the components in Figure 1 and ensure the linkages among them. Fortunately, some emerging PfP interventions are beginning to incorporate elements of behavioral and biologic risk reduction, but they are not comprehensive and the links are not always fleshed out.37,43,45 Future PfP intervention development needs to ensure that the linkages among these components are maintained, enhanced, and evaluated.
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