Historically, efforts to prevent human immunodeficiency virus (HIV) infection have focused on reducing HIV infection risk among individuals with HIV-negative (HIV-) or unknown serostatus. Initially, this reflected concerns over stigmatization and discrimination associated with interventions targeting HIV-infected (HIV+) individuals and limited availability of HIV testing services. (1) Recently, however, there has been a dramatic scale-up of HIV testing, antiretroviral therapy (ART) availability and associated care worldwide. Consequently, many more people living with HIV now know their serostatus and are living longer and healthier lives. (2)
Today, programme planners recognize that continued reliance on general HIV prevention messages may limit the effectiveness and sophistication of prevention strategies. (3) It may be more efficient to change behaviour among fewer HIV+ individuals than many HIV- individuals. (4) Recent data show that in many sub-Saharan African countries, most new cases of HIV infection occur in HIV-serodiscordant couples, and rates of HIV disclosure and condom use in such couples remain low. (45) Focusing attention on HIV-serodiscordant couples may therefore be one of the most effective ways of reducing HIV transmission. Efforts to reduce stigma have alleviated some of the concerns regarding prevention programmes aimed at HIV-infected persons. (4) As a result, HIV prevention activities increasingly target individuals who know that they are HIV+. (6) This strategy is known as positive prevention, although it has also been called prevention for, by or with positives, (1,7-11) and, most recently, positive health, dignity and prevention. (12) There is no clear consensus on what positive prevention entails, but it generally includes activities centred on four main goals: (i) keeping HIV+ individuals physically healthy; (ii) keeping such persons mentally healthy; (iii) preventing further transmission of HIV; and (iv) involving people living with HIV in prevention activities, leadership and advocacy. (4,13) Fig. 1 outlines a conceptual framework that shows how positive prevention goals are related to selected interventions and outcomes. The framework is broad and includes biomedical as well as behavioural interventions. The scope of our review was limited to behavioural interventions, which allowed for a more focused examination of one aspect of positive prevention.
Three previous reviews have examined behavioural interventions targeting people living with HIV. (14-16) However, almost all the included studies had been conducted in the United States of America. There have been no similar reviews of positive prevention interventions in developing country settings. Given the scale-up of HIV testing and treatment in developing countries and the unique social, economic and epidemiologic features of these settings, the purpose of this paper was to assess the efficacy of HIV prevention interventions with HIV+ individuals in developing country settings:
This review is part of a larger series of systematic reviews of HIV-related behavioural interventions in developing countries. Other interventions reviewed include mass media interventions, (17) psychosocial support, (18) treatment as prevention, (19) voluntary counselling and testing (20) and peer education. (21) We used standardized methods across all reviews and report results according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement. (22)
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People living with HIV may be reached by interventions that target a broad audience of both HIV+ and HIV--individuals or by interventions that target them specifically. Our review therefore had two objectives. The first was to assess the evidence for a differential effect of interventions by serostatus. In other words, do interventions that target both HIV+ and HIV--individuals work differently in these two groups? …