Table 1.
Biomedical approaches to HIV prevention and strength of evidence RCT=Randomized clinical trial; EPID=Epidemiologic evidence; ECOL=Ecological associations; OR=Outcomes research; PrEP=pre-exposure prophylaxis; PEP=post-exposure prophylaxis; STI=sexually transmitted infections
| Biomedical HIV prevention strategy | Highest Level of Evidence |
|---|---|
| Antiretroviral treatment to reduce infectiousness of HIV-infected persons | |
| --in sexual relations | RCT, >95% efficacy |
| --from mothers to infants | RCT, >98% efficacy |
| --among injection drug users | EPID |
| Antiretroviral prophylaxis to reduce susceptibility of vulnerable HIV-uninfected persons | |
| --oral PrEP in men | RCT, 44-68% efficacy |
| --oral PrEP in women | RCT (inconsistent) |
| --rectal microbicides (topical PrEP) for men/women | Animal models |
| --vaginal microbicides (topical PrEP) for women | RCT (inconsistent) |
| --PEP for needle stick injuries | EPID |
| --PEP for sexual exposure, including rape | EPID |
| --PEP for infants born to mothers not receiving ART | RCT |
| Medical male circumcision to reduce susceptibility | |
| --Voluntary medical male circumcision in adults | RCT |
| --Infant circumcision | EPID and ECOL |
| Medical male circumcision to reduce infectiousness | |
| --i.e., reducing HIV transmission risk from an HIV+ man | RCT, 38-68% efficacy |
| HIV vaccines to reduce susceptibility (preventive vaccines) | |
| -- ALVAC-HIV® [vCP1521] prime plus AIDSVAX B/E® boost* | RCT |
| --Other vaccines | Animal models |
| HIV vaccines to reduce transmissibility (therapeutic vaccines) | |
| --i.e., vaccine given to HIV+ person to reduce viral load | Animal models |
| Treatment of co-infections to reduce HIV viral load and presumed transmission risk | |
| --e.g., tuberculosis, helminthes, STI | Animal models, EPID |
| Clean needles and syringes for injection | |
| --Needle/syringe exchange programs | EPID, OR |
| --Medical injections | EPID, OR |
| State-of-the-art blood banking | |
| -- Sensitive HIV tests to screening blood/blood products | EPID, OR |
| --Non-use of donations from higher risk sub-populations | EPID, OR |
| Physical barriers to virus-cell contact** | |
| Male condoms | EPID, OR |
| Female condoms | EPID, OR (inconsistent) |
| Prevention of unwanted pregnancy to reduce pediatric HIV infections | |
| Contraception: e.g., hormonal, intrauterine device, barrier | EPID |
4 injected priming doses of recombinant canarypox vector vaccine (ALVAC-HIV® [vCP1521]) followed by 2 injected booster doses with recombinant glycoprotein 120 subunit (AIDSVAX B/E®); details of vaccines are in the online manuscript supplement: http://www.nejm.org/doi/suppl/10.1056/NEJMoa0908492/suppl_file/nejm_rerks-ngarm_2209sa1.pdf, accessed May 12, 2012
Not listed are other techniques that are theoretically beneficial, but have not proven efficacious, e.g., vaginal diaphragm, or have not been tested, e.g., cervical cap
NOTE: Beyond the scope of this table are behavioral approaches towards abstinence, delayed sexual debut, risk reduction among seropositive persons, partner fidelity, including reducing the number of partners, partner selection, including serosorting for persons to have sex only with others with the same serostatus, exclusive breastfeeding for seropositive mothers and uninfected infants, community mobilization for stigma reduction and changes in behavioral and social norms, and altered health care worker practices such as avoiding unnecessary blood/blood product use. Similarly, structural changes are beyond our table's scope, including enforced 100% condom use policies in brothels, behavioral economic approaches such as contingency case transfers to maintain desired behaviors, and adherence to prescribed risk reduction or therapeutic strategies. The authors wish to emphasize the importance of these approaches, but we do not categorize them as biomedical interventions, the topic of this paper.