Guide to alternative HIV prevention strategies

HIV remains a persistent global health challenge, particularly in low-resource and marginalized communities. While traditional methods like condom use and abstinence education remain valuable, emerging biomedical, behavioral, and structural strategies are reshaping the prevention landscape. 

1. Understanding HIV Transmission: Why Prevention Matters

Preventing HIV starts with a solid grasp of how the virus spreads. HIV (Human Immunodeficiency Virus) is primarily transmitted through:

  • Unprotected sexual intercourse (anal or vaginal)

  • Shared injection equipment (e.g., needles)

  • Vertical transmission from mother to child (during pregnancy, delivery, or breastfeeding)

  • Blood transfusions with contaminated blood (rare in countries with blood screening)

High-risk populations include men who have sex with men (MSM), transgender individuals, sex workers, intravenous drug users, and adolescents in high-incidence regions. Social determinants such as poverty, stigma, limited healthcare access, and gender inequality further exacerbate risk.

Prevention strategies, therefore, must be diverse, inclusive, and community-sensitive—not just medically effective.

2. Biomedical Innovations in HIV Prevention

In recent years, biomedical strategies have emerged as some of the most promising methods for preventing HIV transmission. Unlike behavioral or barrier methods, these approaches use medical interventions—drugs or biological agents—to prevent infection at the cellular level. This section delves into the major biomedical innovations, how they work, who they benefit, and the challenges they still face.

2.1 Pre-exposure Prophylaxis (PrEP): Daily Prevention, Daily Commitment

What It Is:
Pre-exposure prophylaxis, or PrEP, involves taking antiretroviral (ARV) medications regularly to prevent HIV infection before potential exposure. The most commonly prescribed regimen is Truvada (tenofovir disoproxil fumarate + emtricitabine), approved by the FDA in 2012, and later Descovy (tenofovir alafenamide + emtricitabine), approved in 2019.

How It Works:
ARVs block the enzyme reverse transcriptase, which HIV needs to replicate. When taken consistently, PrEP ensures that if the virus enters the body, it cannot establish an infection.

Effectiveness:

  • According to the iPrEx study involving over 2,000 men who have sex with men (MSM), daily PrEP reduced HIV risk by 44% overall, and by more than 90% among those with high adherence.

  • In heterosexual serodiscordant couples (where one partner is HIV-positive), the Partners PrEP study found risk reductions of up to 75%.

Limitations and Challenges:

  • Adherence-dependent: PrEP's effectiveness drops significantly with inconsistent use.

  • Access barriers: Cost, lack of awareness, and medical stigma limit access, particularly among people of color, rural populations, and adolescents.

  • Side effects: Though rare, some users experience kidney function changes or bone density loss.

  • Not universally recommended: Descovy is not approved for people assigned female at birth engaging in vaginal sex.

2.2 Post-exposure Prophylaxis (PEP): HIV Prevention After Risk

What It Is:
PEP is a short-term course of ARV medications taken within 72 hours after possible HIV exposure. It is designed as an emergency measure rather than a routine strategy.

How It Works:
By quickly introducing ARVs into the bloodstream, PEP attempts to prevent HIV from replicating and integrating into host DNA. Treatment typically lasts 28 days and includes a combination of at least three ARVs.

Effectiveness:

  • Data suggests that PEP can reduce HIV risk by over 80%, especially when initiated within 2 hours post-exposure.

  • Commonly prescribed regimens include Truvada + raltegravir or Truvada + dolutegravir.

Who Uses It:

  • Victims of sexual assault.

  • Healthcare workers after accidental needle sticks.

  • Individuals after a condom breaks or other unprotected sexual exposure.

Challenges:

  • Requires rapid initiation, which is logistically difficult for many.

  • May cause side effects like nausea, fatigue, and headaches.

  • High cost can deter uninsured individuals from completing the regimen.

2.3 Long-Acting Injectable PrEP: Convenience Meets Consistency

What It Is:
Long-acting injectable PrEP uses cabotegravir, an integrase inhibitor, administered via intramuscular injection once every two months. It was FDA-approved in 2021 under the brand name Apretude.

Clinical Evidence:

  • The HPTN 083 and HPTN 084 trials compared injectable PrEP with daily oral PrEP among MSM, transgender women, and cisgender women in sub-Saharan Africa.

  • Results showed that injectable PrEP was even more effective than oral PrEP, with:

    • 66% fewer new HIV infections among MSM and trans women in HPTN 083.

    • 89% reduction in risk among African women in HPTN 084.

Advantages Over Oral PrEP:

  • Improved adherence: Removes the burden of daily pill-taking.

  • Discretion: Avoids the stigma sometimes associated with HIV medication.

  • Reduced human error: Ensures protective drug levels in the body without user intervention between appointments.

Challenges:

  • Requires healthcare visits every 8 weeks, which can be difficult in low-resource settings.

  • Cost remains high; not yet widely available in low- and middle-income countries.

  • Potential injection site pain or irritation.

Current Status:
Rollouts have begun in select clinics in the U.S., South Africa, and parts of Latin America. The World Health Organization (WHO) has recommended inclusion in national HIV prevention strategies where feasible.

2.4 Emerging Biomedical Strategies: Beyond the Pill and Needle

Several innovative biomedical approaches are in development or early use, showing potential to further diversify prevention options:

  • Vaginal Rings (e.g., Dapivirine Ring):
    A silicone ring containing antiretrovirals is inserted vaginally and releases medication over 28 days. Approved in some African countries, it provides a discreet method for women to self-administer PrEP.

  • Microbicides:
    Topical gels or films containing ARVs applied before intercourse. Trials have shown mixed results due to adherence variability, but newer formulations are in development.

  • Broadly Neutralizing Antibodies (bNAbs):
    Administered via infusions or injections, bNAbs can block multiple HIV strains. Although still experimental, they may offer seasonal or semi-annual protection in the future.

  • Implants (like those used in contraception):
    Trials are ongoing for under-the-skin ARV implants that could protect against HIV for 6–12 months at a time.

3. Barrier Methods and Their Expanded Applications

Condoms have long been central to HIV prevention. Still, alternative barrier tools and nuanced applications offer enhanced protection, especially in underserved communities.

Male and Female Condoms

Male (external) condoms are cheap and widely distributed, but usage rates remain inconsistent due to stigma, accessibility, and negotiation difficulty in relationships.

Female (internal) condoms empower women and receptive partners, providing agency in settings where condom negotiation is challenging or unsafe.

Lubricants as Adjuncts

Water-based lubricants reduce friction and micro-tears, especially during anal sex, lowering HIV transmission risk. Promoting their use alongside condoms can significantly boost protection effectiveness.

Expanding distribution and education around all barrier methods is critical, particularly in rural areas or where gender norms suppress open dialogue.

Table 1: Comparative Effectiveness of Biomedical vs Barrier HIV Prevention Strategies

Strategy Estimated Risk Reduction Requires Daily Adherence User-Controlled Best For
Daily Oral PrEP Up to 99% Yes Partially MSM, serodiscordant couples
Injectable PrEP Up to 98% No (bi-monthly) Yes Youth, privacy-concerned
Male Condoms 85-95% No Yes General population
Female/Internal Condoms ~79-85% No Yes Women, transgender women
PEP (within 72 hrs) ~80% (if started early) Short-term No Emergency use only

4. Behavioral Interventions: Educating to Empower

Changing behavior is central to HIV prevention—especially in communities where stigma or misinformation persists.

Risk Reduction Counseling and Peer Education

Personalized counseling helps individuals identify high-risk behaviors and adopt safer practices. Peer-led models, such as those in Kenyan youth groups or Brazilian trans collectives, have shown success in fostering trust and credibility.

Behavioral Contracts and Group Therapy

Behavioral contracts, where participants commit to specific goals (e.g., condom use, regular testing), have been effective in reducing high-risk practices in youth and substance users.

Group therapy programs—especially for LGBTQ+ youth or those with trauma histories—can help reduce psychological vulnerabilities linked to risky behaviors.

Digital Tools

Mobile apps and SMS programs remind users to take PrEP, promote testing reminders, and provide real-time risk reduction tips. Tools like Healthvana and MyPEEPS are gaining traction among younger populations.

Behavioral tools not only reduce HIV risk but also empower people to take control of their sexual and emotional health.

5. Harm Reduction Approaches

Recognizing that risk cannot always be eliminated, harm reduction accepts human behavior and works to make it safer—particularly for drug users and sex workers.

Needle and Syringe Programs (NSPs)

These programs distribute sterile injection equipment and safely dispose of used needles. Studies show NSPs reduce HIV incidence by up to 33% in intravenous drug user (IDU) populations.

Supervised Injection Sites

Available in countries like Canada and Switzerland, these centers offer a safe space for drug use with medical oversight, naloxone access, and HIV testing.

Safe Sex Work Programs

Legal frameworks supporting sex worker rights, condom distribution in brothels, and decriminalization policies lower both HIV rates and gender-based violence.

Integrated Treatment Models

Combining opioid substitution therapy (OST), mental health services, and HIV prevention has proven especially effective in Eastern Europe and Southeast Asia.

Harm reduction isn't about enabling risky behavior—it's about saving lives through compassion and practicality.

6. Structural and Community-Based Strategies

HIV prevention cannot succeed without addressing the underlying systems that perpetuate risk.

Decriminalization and Legal Reform

Laws criminalizing sex work, drug use, or same-sex relationships often push vulnerable populations underground, away from healthcare. Reforms that reduce incarceration and enhance civil rights directly improve HIV prevention outcomes.

Stigma Reduction Campaigns

Stigma fuels silence and discourages testing or treatment. Community-led campaigns—such as South Africa's LoveLife or India's Vihaan—combat myths, promote openness, and celebrate resilience.

Community Health Workers

Trained lay health workers—especially from within high-risk communities—bridge trust gaps and expand healthcare access. Programs in Uganda and Haiti show improved ART adherence and PrEP uptake via community outreach.

Healthcare Access and Equity

Universal healthcare access, transportation subsidies, and multilingual services ensure that prevention tools reach everyone—not just the privileged few.

Structural change is slow, but its effects are profound and far-reaching.

Table 2: Levels of HIV Prevention Interventions

Intervention Type Focus Area Key Strategies Examples
Biomedical Individual protection PrEP, PEP, injectables, microbicides Truvada, Cabotegravir
Behavioral Risk perception and reduction Counseling, digital apps, peer outreach MyPEEPS, Healthvana
Structural Social determinants and policy Decriminalization, stigma campaigns LoveLife, harm reduction centers

7. The Role of Vaccines and Research into Future Alternatives

Despite decades of effort, an effective HIV vaccine remains elusive. However, recent developments are promising.

HIV Vaccine Trials

The HVTN 702 trial in South Africa, once considered a top candidate, was halted in 2020 due to ineffectiveness. However, newer trials like mRNA-based vaccines are underway, building on COVID-19 vaccine technology.

Broadly Neutralizing Antibodies (bNAbs)

These laboratory-made antibodies target multiple HIV strains. Administered via infusion, they've shown temporary protection in trials and may complement future vaccine strategies.

Gene Therapy and Immune Modulation

Research into editing genes like CCR5—the receptor HIV uses to enter cells—is in early stages. Stem cell therapies have even led to rare cases of long-term remission, though they remain inaccessible for widespread prevention.

While none are ready for mass rollout, these innovations point toward a future with more robust and durable protection options.

FAQ Section

1. What's the difference between PrEP and PEP?
PrEP is taken daily before potential HIV exposure to prevent infection, while PEP is a 28-day emergency treatment taken after exposure, ideally within 72 hours.

2. Are condoms still necessary if someone uses PrEP?
Yes. While PrEP prevents HIV, condoms protect against other STIs like gonorrhea and syphilis, and also prevent pregnancy.

3. How do needle exchange programs help prevent HIV?
By providing clean syringes and safe disposal, these programs reduce the risk of HIV transmission among intravenous drug users.

4. Can behavioral strategies work on their own?
They can reduce risk significantly, especially in combination with biomedical tools. Alone, their effectiveness depends on user consistency and context.

5. What are the main obstacles to implementing structural prevention?
Legal barriers, funding limitations, political resistance, and societal stigma are major hurdles to widespread structural reform.

Conclusion

HIV prevention is no longer about a single method—it's about synergy. Biomedical tools, behavioral strategies, and structural reforms must work in concert to address diverse needs. By embracing innovation and equity, the global community can move closer to the goal of an HIV-free generation.