• Behavioral change and risk reduction interventions
• Biomedical prevention interventions
• Structural interventions

The priority of behavioral interventions is to delay sexual debut; reduce unsafe sex and multiple, especially concurrent sexual partnerships; and discourage cross-generational and transactional sex.

• Service delivery
• Risk assessment for client
• Provide socio-behavioral change Communication (SBCC) and link to services as appropriate
• Condom promotion and provision

The government of Uganda ensures that:

1. Each health facility/program should have a focal person for HIV prevention.
2. All staff offering prevention services need to be trained.
3. Outreaches for key and priority populations must be conducted.

4. Offer HTS (HIV Testing Services) to sexually active adolescents, pregnant mothers who have not tested in the last 12 months or have had unprotected sex in last three months.
5. HIV testing for infants born of HIV infected mothers.
6. Assess sexual behavior of the pregnant mothers and adolescents (ask if condoms are used, frequency, the number of partners, transactional sex/sex work) and if the client is involved in transactional sex/sex work encourage correct and consistent condom use.

7. Discuss delay of onset of sexual debut in children and adolescents (abstinence). Discuss correct and consistent condom use and offer condoms as appropriate to adolescents. Discourage multiple, concurrent sexual partnerships to promote faithfulness with a partner of known status.
8. Discuss with the adolescents about sexual and reproductive health services and link to services as appropriate.
9. Discourage risky cultural practices such as childhood marriages.
10. Identify, refer and link clients to other available facility and community programs.
11. Assess for violence (physical, emotional, or sexual); if a child discloses sexual violence, assess if the client was raped and act immediately.

12. Discuss condom use as an option for risk reduction in pregnant mothers and adolescents. Discuss barriers to condom use to pregnant mothers and adolescents.
13. Clarify any questions and dispel myths around condoms.

The key biomedical interventions include:

• EMTCT (Elimination of Mother-to-Child Transmission)
• Safe Male Circumcision (SMC)
• ART (Antiretroviral Therapy as prevention / Treatment as Prevention)
• PEP (Post-Exposure Prophylaxis)
• PrEP (Pre-Exposure Prophylaxis)
• Blood Transfusion Safety
• STI Screening and Treatment

Male circumcision is the surgical removal of the foreskin of the penis. SMC reduces the risk of HIV acquisition among circumcised men (adolescents) by approximately 60%.

• Ensuring the screening of blood donors for HIV and hepatitis B.
• Ensuring proper storage and administration.

Integration of STI services in all health programs e.g. YCC (Young Child Clinic), MCH (Maternal and Child Health).

Post-exposure prophylaxis (PEP) is the short-term use of ARVs to reduce the likelihood of acquiring HIV infection after potential occupational or non-occupational exposure.

• Occupational exposures: Occur in the health care or laboratory setting and include sharps and needlestick injuries or splashes of body fluids to the skin and mucous membranes.
• Non-occupational exposures: Include unprotected sex, exposure following assault like in rape and defilement, and road traffic accidents.

Conduct a rapid assessment of the client to assess exposure and risk and provide immediate care. Occupational exposure (After a needlestick or sharp injury):

• Do not squeeze or rub the injury site.
• Wash the site immediately with soap or mild disinfectant (chlorhexidine gluconate solution).
• Use antiseptic hand rub/gel if no running water.
• Don’t use strong, irritating antiseptics (like bleach or iodine).

After a splash of blood or body fluids in contact with intact skin:

• Wash the area immediately.
• Use antiseptic hand rub/gel if no running water.
• Don’t use strong, irritating antiseptics (like bleach or iodine).

• Provide PEP when:
  • Exposure occurred within the past 72 hours; and
  • The exposed individual is not infected with HIV; and
  • The ‘source’ is HIV-infected, has unknown HIV status or is high risk.
• Do not provide PEP when:
  • The exposed individual is already HIV-positive.
  • The source is established to be HIV-negative.
  • Individual was exposed to bodily fluids that do not pose a significant risk (e.g. tears, non-blood stained saliva, urine, sweat).
  • Exposed individual declines an HIV test.

Counsel on:

• The risk of HIV from the exposure.
• Risks and benefits of PEP.
• Side effects of ARVs.
• Enhanced adherence if PEP is prescribed.
• Importance of linkage for further support for sexual assault cases.

• PEP should be started as early as possible, not beyond 72 hours of exposure.
• Recommended original regimens include:
  • Pregnant mothers/adults: TDF + 3TC + ATV/r
  • Children: ABC + 3TC + LPV/r
• A complete course of PEP should run for 28 days.
• Do not delay the first doses because of lack of baseline HIV test.
• Document the event and patient management in the PEP register (ensure confidentiality of patient data).

UPDATED CLINICAL GUIDELINE (NEW DISCOVERY): Due to improved tolerability, fewer side effects, and higher genetic barrier to resistance, the World Health Organization (WHO) and updated national guidelines now strongly recommend Dolutegravir (DTG) based regimens for PEP in adults and adolescents (e.g., TDF + 3TC + DTG) over older protease inhibitors like ATV/r.

• Discontinue PEP after 28 days.
• Perform follow-up HIV testing three months after exposure.
• Counsel and link to HIV clinic for care and treatment if HIV-positive.
• Provide prevention and education/risk reduction counseling if HIV-negative.

PrEP is the use of ARV drugs by people who are not infected with HIV to block the acquisition of HIV.

PrEP provides an effective additional biomedical prevention option for HIV-negative people at substantial risk of acquiring HIV infection. These include people who:

• Have multiple sexual partners.
• Engage in transactional sex including sex workers.
• Use or abuse injectable drugs and alcohol.
• Have had more than one episode of an STI within the last twelve months.
• Are part of a discordant couple, especially if the HIV-positive partner is not on ART or has been on ART for less than six months.
• Are recurrent users of PEP (3 consecutive cycles of PEP).
• Engage in anal sex.

These risk factors are likely to be more prevalent in populations such as sex workers, fisher folk, long distance truck drivers, men who have sex with men (MSM), uniformed forces, and adolescents and young women engaged in transactional sex.

After meeting the eligibility criteria:

• Confirm HIV-negative status.
• Rule out acute HIV infection.
• Assess for hepatitis B infection: if negative, patient is eligible for PrEP; if positive, refer patient for management.
• Assess for contraindications to TDF/FTC (e.g., renal impairment).

Provide risk-reduction and PrEP medication adherence counseling:

• Provide condoms and education on their use.
• Initiate a medication adherence plan.
• Prescribe a once-daily pill of TDF (300mg) and FTC (200mg).
• Initially, provide a 1-month TDF/FTC prescription (1 tablet orally, daily) together with a 1-month follow-up date.
• Counsel client on side effects of TDF/FTC (e.g., gastrointestinal upset, mild bone mineral density loss, potential renal toxicity).

• After the initial visit, the patient should be given a two-month follow-up appointment and thereafter quarterly appointments.
• Perform an HIV antibody test every three months.
• For women, perform a pregnancy test based on clinical history.
• Review the patient’s understanding of PrEP, any barriers to adherence, tolerance to the medication as well as any side effects.
• Review the patient’s risk exposure profile and perform risk-reduction counseling.
• Evaluate and support PrEP adherence at each clinic visit.
• Evaluate the patient for any symptoms of STIs at every visit and treat as needed.

• Acquisition of HIV infection.
• Changed life situations resulting in lowered risk of HIV acquisition.
• Intolerable toxicities and side effects.
• Chronic non-adherence to the prescribed dosing regimen despite efforts to improve daily pill-taking.
• Personal choice.
• HIV-negative in a sero-discordant relationship when the positive partner has achieved sustained viral load suppression (condoms should still be used consistently).

The landscape of HIV prevention has evolved dramatically with recent clinical trials and approvals introducing new modalities to improve adherence and efficacy.

• Discovery: Approved by the WHO as a highly effective prevention choice. The HPTN 083 and 084 trials demonstrated that CAB-LA is actually superior to daily oral TDF/FTC in preventing HIV acquisition among MSM, transgender women, and cisgender women.
• Administration: Administered as an intramuscular gluteal injection every 2 months (after an initial 1-month lead-in dose).
• Advantage: Eliminates the burden of daily pill-taking, making it a game-changer for individuals who struggle with oral adherence or face stigma holding pill bottles.

• Mechanism: A flexible silicone ring inserted into the vagina that slowly releases the ARV drug dapivirine over a period of 28 days.
• Target Population: Offers an essential, discreet, female-controlled prevention method for women at substantial risk of HIV who are unable or unwilling to take oral PrEP.

• Recent Trials (PURPOSE 1 & 2): Lenacapavir, a first-in-class capsid inhibitor, recently made global headlines. Trials showed 100% efficacy in preventing HIV in young women and highly significant efficacy in MSM.
• Administration: Given as a subcutaneous injection only twice a year (every 6 months), representing the frontier of ultra-long-acting prevention.

• Guideline Update: WHO endorses ED-PrEP specifically for men who have sex with men (MSM).
• Regimen: Taking 2 pills of TDF/FTC 2-24 hours before sex, 1 pill 24 hours after the first dose, and 1 pill 48 hours after the first dose. This reduces overall drug burden for infrequent sexual encounters.

• Concept: Massive paradigm shift based on the PARTNER 1, PARTNER 2, and HPTN 052 trials.
• Principle: People living with HIV who achieve and maintain an undetectable viral load (usually defined as <200 copies/mL) by taking ART cannot sexually transmit the virus to others.
• Impact: Crucial for treatment-as-prevention (TasP), reducing systemic stigma, and promoting ART adherence.

For People Who Inject Drugs (PWID), specific evidence-based structural and biomedical interventions must be implemented:

• Needle and Syringe Programs (NSP): Providing sterile injecting equipment to prevent sharing of contaminated needles.
• Opioid Agonist Maintenance Therapy (OAMT): Using methadone or buprenorphine to reduce injecting behaviors, stabilize lifestyles, and significantly lower HIV transmission rates.

Approximately one-third of the women who are infected with HIV can pass it to their babies without intervention.

1. Primary prevention of HIV infection: Women and men of reproductive age including adolescents.
2. Prevention of unintended pregnancies among women living with HIV: Women including adolescents living with HIV and their partners.
3. Prevention of HIV transmission from women living with HIV to their infants: Pregnant and breastfeeding women including adolescents living with HIV.
4. Provision of treatment, care, and support: To women infected with HIV, their children, and their families.

• During pregnancy (15-20%)
• During time of labour and delivery (60%-70%)
• After delivery through breast feeding (15%-20%)

• High maternal viral load.
• Depleted maternal immunity (e.g. very low CD4 count).
• Prolonged rupture of membranes.
• Intra-partum haemorrhage and invasive obstetrical procedures.
• If delivering twins, first twin is at higher risk of infection than second twin.
• Premature baby is at higher risk than term baby.
• Mixed feeding carries a higher risk than exclusive breastfeeding or use of replacement feeding.

• Blood: HIV serological test for the mother.
• HIV-DNA/PCR testing of babies: (Early Infant Diagnosis - EID).

All HIV services for pregnant mothers are offered in the MCH clinic. After delivery, mother and baby will remain in the MCH postnatal clinic till the HIV status of the child is confirmed, then they will be transferred to the general ART clinic.

The current policy aims at elimination of Mother-to-Child Transmission (eMTCT) through provision of a continuum of care with the following elements:

• Primary HIV prevention for men, women and adolescents.
• Prevention of unintended pregnancies among women living with HIV.
• Prevention of HIV transmission from women living with HIV to their infants.
• Provision of treatment, care and support to ALL women infected with HIV, their children and their families.

• Routine HIV Counseling and Testing during ANC (at 1st contact). If negative, repeat HIV test in the third trimester/ labour.
• Enrolment in HIV care if mother is positive and not yet on treatment.
• If mother already on ART, perform viral load and continue current regimen.
• ART in pregnancy, labour and post-partum, and for life – Option B+.

• One daily Fixed Dose Combination (FDC) pill containing TDF + 3TC + EFV started early in pregnancy irrespective of the CD4 cell count and continue during labour and delivery, and for life.
• Alternative regimens for women who may not tolerate the recommended option are:
  • If TDF contraindicated: ABC + 3TC + EFV
  • If EFV contraindicated: TDF + 3TC + ATV/r

• Cotrimoxazole 960 mg 1 tab daily during pregnancy and postpartum.
• NB. Mothers on cotrimoxazole DO NOT NEED IPTp with SP for malaria.

• TDF, EFV, and DTG are safe to use in pregnancy.
• Those newly diagnosed during labour will begin HAART for life after delivery.
• Caution with TDF: In case of low body weight, high creatinine, diabetes, hypertension, chronic renal disease, and concomitant nephrotoxic medications: perform renal function investigations before starting TDF. TDF is contraindicated in advanced chronic renal disease.

Historically, all exposed infants received daily Nevirapine (NVP) for 6 weeks. New guidelines focus on risk stratification to further drive mother-to-child transmission rates to zero.

• Standard Risk Infants: Mothers who have been on ART for > 4 weeks prior to delivery with suppressed viral load. The infant receives 6 weeks of daily NVP or AZT.
• High-Risk Infants (Enhanced Post-Natal Prophylaxis - ePNP): Mothers newly diagnosed at delivery, have a high viral load, or have been on ART for < 4 weeks. High-risk infants now receive Dual Prophylaxis (AZT + NVP) for 12 weeks to aggressively prevent transmission via breastfeeding and delivery exposure.
• Point-of-Care Early Infant Diagnosis (POC-EID): New molecular tools allow for same-day PCR testing of infants at birth or 6 weeks, rather than waiting weeks for central laboratory results, enabling immediate initiation of pediatric ART if positive.

Addressing the social, economic, and political environments that drive the HIV epidemic is paramount for sustainable prevention:

• Keeping Girls in School: Secondary education for young women drastically reduces HIV incidence by lowering economic dependency and vulnerability to cross-generational sex.
• Cash Transfers / Economic Empowerment: Conditional or unconditional cash transfers to vulnerable households reduce engagement in transactional sex.
• Legal Reforms and Stigma Reduction: Decriminalization of key populations (sex workers, MSM, PWID) removes barriers to accessing testing, PrEP, and ART services.
• Gender-Based Violence (GBV) Response: Strengthening post-rape care (incorporating PEP, emergency contraception, and psychosocial support) and implementing community programs that challenge toxic masculinity and gender inequality.