Despite the fact that antiretroviral therapy has made a significant impact on the survival of people with HIV, the epidemic still rages on. Cases of HIV are being reported all over the world at a still alarming rate. In the U.S. African Americans are being disproportionately impacted and new infections in middle-aged and young gay men are increasing once again.

We are at a crucial moment in AIDS history where new prevention technologies are coinciding with the burden of new infections and they are gaining attention due to more and more research. At the International AIDS Conference in Toronto this past summer HIV prevention gained ground as the world was brought together to focus on the worldwide pandemic. Now, at CROI there appeared to be an even better focus on prevention possibilities, especially in the biomedical realm. It is now becoming more apparent that we may soon have a range of prevention possibilities as we currently have several treatment options.

At CROI there were dozens of important papers presented on the state of HIV prevention research. There are currently five prevention technologies in 14 ongoing clinical trials. To date, only three approaches have been proven through randomized clinical trials—male circumcision, antiretroviral prophylaxis to prevent vertical transmission, and contraception barriers for HIV prevention. But prevention strategies that made the biggest news at CROI include antiretroviral pre-exposure prophylaxis (or PrEP), male circumcision, vaccines, and microbicides (see vaccine update on page 28). Other methods for HIV prevention have less evidence, but the foundation has been laid for effective prevention strategies. In the next four years, results from these 14 studies will hopefully give us a shot in the arm for possibilities in stemming new HIV infections.

The unfortunate news for prevention at CROI was the CONRAD trial using a cellulose sulfate vaginal microbicide that was held in several developing countries and the U.S. At least two studies were closed when they discovered that women randomized to receive the microbicide were at an increased risk of HIV infection. It’s not clear why this product did not prove effective in these studies, however, other work is being done in several other candidates, including different compounds and rectal microbicides. This disappointing trial closure is not a reason for giving up, as there are many other ongoing clinical trials and much preclinical work being done in different targets and with different products. As in all research, there are occasional pitfalls while there are also gains being made.

A controversial yet potentially big breakthrough in HIV prevention is the use of antiretroviral medications to prevent exposure to HIV. Called PrEP (pre-exposure prophylaxis), one study is currently looking into whether Truvada or Viread is effective in preventing HIV transmission. There was no PrEP data presented at CROI except for one CDC survey that asked if gay men had ever used PrEP before. The concern is gay men will use PrEP thinking they are protected from HIV before the strategy has been proven. There are widespread rumors that there is a lot of “off-label” use of PrEP in the gay male community, but there are many issues about toxicity and resistance not to mention effectiveness using this strategy that still need to be answered. The survey reported that out of 400 HIV-negative gay men, 0.3% said they had used PrEP before. Almost 22% said they had heard of PrEP. The survey was given at Gay Pride events nationwide.

Male circumcision has become an important strategy to consider when talking about HIV prevention due to several studies that have shown it to be effective in up to 50–60% of cases. At CROI two major late breakers showed that circumcision may reduce genital ulcers and thereby reduce HIV transmission in a large randomized study in Uganda. However, another World Health Organization study of circumcision released after CROI showed the intervention was not effective for HIV-positive men with heterosexual HIV transmission. In this study the reason for the poor results were because men did not wait until their circumcision healed before they had sex with their partners, thereby most likely transmitting HIV to their female partners through open wounds. Male circumcision has many possible outcomes for reducing HIV transmission, but more work needs to be done to clarify how it can be most effective. It will continue to be a major prevention strategy.

Although it has always been said that HIV testing is not HIV prevention, the test site can be a great place to educate people about the risks of HIV transmission. New rapid testing technologies combined with HIV RNA screening and counseling may improve the opportunity of identifying those who may have recently acquired HIV and thus may be more infectious. Implementation of HIV testing at venues where high risk activity may occur is also a strategy that is proving effective. A study of rapid testing at New York City bathhouses showed a 5% seropositivity rate and that 40% of those were recently infected.

All of these new prevention strategies by themselves will most likely not be 100% effective; however, use of them in combination may improve the overall outcome. Combination prevention is a strategy that makes sense, just as highly active antiretroviral therapy (HAART) used combinations of medications and completely changed the lives of those living with HIV for the better.

To become more involved in HIV prevention advocacy, join the CHAMP (Community HIV/AIDS Mobilization Project) Action Network at www.champnetwork.org.