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One Step at a Time: Incremental Approaches to HIV Prevention

Emmanuel Ifeanyi Obeagu *

Department of Biomedical and Laboratory Science, Africa University, Zimbabwe

 

 

Introduction

The global fight against HIV has seen significant advancements over the last few decades, yet HIV prevention remains a complex and evolving field. With over 38 million people living with HIV worldwide, there is a pressing need for prevention strategies that can adapt to diverse contexts, particularly in areas with limited resources or unique cultural challenges. Traditional prevention efforts, such as large-scale public health campaigns and one-size-fits-all interventions, have been effective to some extent, but have not always addressed the nuanced needs of various communities. Incremental approaches to HIV prevention—characterized by gradual, small-scale advancements tailored to specific populations—are emerging as a promising strategy. These approaches focus on setting realistic, short-term objectives that cumulatively contribute to long-term reductions in HIV transmission, often engaging local communities to foster sustainable change.^1-2 Incrementalism, as a strategy, is particularly valuable in addressing HIV due to the varied risk factors and socio-economic contexts that influence transmission. Unlike broad, sweeping interventions, incremental approaches allow for fine-tuning and customization, ensuring that each step aligns with the specific needs of the target population. For instance, certain high-risk populations—such as men who have sex with men (MSM), sex workers, and people who inject drugs—require prevention methods that are tailored not only to their risk profiles but also to the unique social and cultural barriers they may face. By employing step-by-step methods, stakeholders can test, evaluate, and adjust their strategies incrementally, which enhances both efficacy and community acceptance.^3-4

A significant advantage of incremental approaches is their ability to integrate with existing public health systems and leverage current resources. This is particularly important in low- and middle-income countries, where healthcare infrastructure and funding may be limited. Incremental strategies are adaptable and cost-effective, often implemented in a way that aligns with local healthcare policies and practices. For example, the gradual rollout of Pre-Exposure Prophylaxis (PrEP) in select high-risk communities has allowed for focused education and resource allocation, gradually expanding access in a way that manages costs and prioritizes areas of greatest need. This approach is not only more sustainable but also allows for more effective monitoring and evaluation, ensuring that resources are being used where they will have the most impact.^5-6 Behavioral interventions are another cornerstone of incremental HIV prevention. Educating communities on safe sex practices, reducing stigma, and building awareness about HIV transmission are all essential components that can be introduced incrementally. By beginning with small-scale, community-led sessions, these interventions have the potential to shift norms over time, making safer practices more acceptable and accessible. The gradual introduction of behavioral changes has shown particular promise in conservative communities, where initial resistance may be high. Incremental approaches allow for the development of trust and cultural sensitivity, which are critical for long-term success in HIV prevention.^7-8

In addition to behavioral interventions, biomedical innovations such as microbicides and vaccines are being tested and introduced incrementally. Microbicides, for instance, have shown potential as topical agents that reduce the risk of HIV transmission. By introducing these products in pilot programs and refining their formulations based on user feedback, researchers and healthcare providers can incrementally improve the efficacy and accessibility of such biomedical solutions. The incremental introduction of these products also allows communities to adapt gradually, ensuring that new technologies are better received and utilized over time. This staged approach fosters confidence in biomedical solutions and can ultimately lead to higher adherence and greater protection.^9-10 Finally, community involvement is central to the success of incremental approaches in HIV prevention. Grassroots organizations and local partnerships are often the driving force behind incremental changes, as they understand the unique needs of their communities and can implement prevention strategies in a culturally sensitive manner. Local involvement ensures that interventions are relevant and accepted, which significantly improves their sustainability and effectiveness. By engaging communities in the design and implementation of prevention measures, incremental approaches build a foundation of trust and empowerment, essential elements in any successful public health initiative.^11-12

The Concept of Incremental Approaches in HIV Prevention

The incremental approach in HIV prevention is grounded in the principle of achieving change through small, successive steps that cumulatively contribute to substantial outcomes. Unlike comprehensive, large-scale interventions, incrementalism emphasizes gradual progress, adjusting strategies based on observed outcomes and community feedback at each stage. This approach is particularly beneficial in the context of HIV, where diverse populations with varied risk profiles and cultural sensitivities often require tailored interventions. By setting achievable short-term goals, incremental strategies create momentum that builds trust within communities, allows for careful resource allocation, and enhances the overall sustainability of prevention efforts.^13-14 Incremental approaches are distinguished by their adaptability, which allows programs to be tailored to the unique needs and capacities of each target group. For instance, introducing Pre-Exposure Prophylaxis (PrEP) incrementally—first to high-risk groups in areas with significant HIV prevalence—enables public health officials to gauge the community’s acceptance, address initial barriers, and refine the program for broader rollouts. This step-by-step approach helps in identifying potential challenges, such as adherence issues, stigma, or logistical constraints, and in addressing them before scaling up. Such an approach ensures that HIV prevention interventions are not only evidence-based but also culturally sensitive and contextually appropriate, which increases the likelihood of long-term success.^15-16 Another core advantage of incremental HIV prevention is its focus on community involvement and empowerment. By breaking down large objectives into smaller, manageable interventions, incremental approaches foster a sense of ownership among local stakeholders, which is crucial for sustained engagement and behavioral change. Community-led initiatives, such as peer education programs or localized awareness campaigns, can be gradually expanded as they gain traction and acceptance. This progressive build-up strengthens community trust and resilience, making HIV prevention a collaborative endeavor. Additionally, incremental approaches allow for real-time learning, where successful elements of a program can be expanded upon, and less effective aspects can be modified or replaced, optimizing resources and fostering sustainable impact in HIV prevention.^17-18

Key Incremental Approaches to HIV Prevention

Several incremental strategies have emerged as impactful methods to address the diverse and evolving challenges of HIV prevention. These approaches span biomedical, behavioral, and structural interventions, with each offering distinct yet complementary benefits. The following are some key incremental approaches in the realm of HIV prevention:

PrEP has proven to be one of the most effective biomedical tools for preventing HIV, particularly among high-risk populations such as men who have sex with men (MSM), sex workers, and people who inject drugs. An incremental approach to PrEP introduction allows for targeted rollouts, beginning with high-prevalence areas and populations most vulnerable to HIV. Starting with pilot programs, health officials can monitor uptake, adherence, and potential side effects, while also engaging communities to address stigma and misinformation. As the program gains acceptance, PrEP distribution can be gradually expanded, with adaptations made based on observed challenges and successes, such as integrating PrEP services into broader healthcare settings.^19-20

Harm reduction, particularly for people who inject drugs, is another critical area where incremental approaches are beneficial. This includes the stepwise introduction of needle exchange programs, safe injection sites, and education on safer drug use practices. By incrementally implementing these services, public health agencies can work with local communities to gauge acceptance, reduce stigma, and address legal or social barriers. With each phase, monitoring data informs adjustments to services, ensuring they are culturally appropriate and effectively reduce transmission risk without alienating the target population.^20-21

Behavioral interventions, such as safe-sex education and condom distribution, are often more effective when gradually introduced. Starting with small, targeted campaigns in schools, community centers, or among at-risk groups, these interventions can be expanded based on their effectiveness and community feedback. By beginning with informational sessions and low-stakes workshops, communities can learn to understand and normalize safer practices at their own pace. Gradually, these sessions evolve into comprehensive prevention programs, potentially including partnerships with local organizations to reinforce the message and reach a wider audience.^22-23

Microbicides, topical agents designed to reduce HIV transmission risk during sexual activity, represent another promising prevention method that benefits from an incremental approach. Starting with small-scale clinical trials and pilot programs in high-risk areas, microbicides can be tested for safety, efficacy, and acceptability. By introducing these products incrementally, researchers and health workers can refine formulations and usage guidelines based on user feedback and adherence patterns, eventually making them available on a larger scale once their efficacy and safety profiles are confirmed.^24-25

Structural and policy-level interventions are essential to create an enabling environment for HIV prevention. However, implementing these changes incrementally can be more effective than attempting comprehensive reform at once, particularly in regions where stigma or legal restrictions pose significant challenges. For example, decriminalizing same-sex relationships or providing legal protections for sex workers and people who inject drugs can be phased in incrementally to foster societal acceptance. Such stepwise policy shifts allow communities to adjust progressively, reducing backlash and enhancing support for prevention programs by gradually changing public attitudes and legal landscapes.^26-27

Digital health platforms, such as mobile health apps, online counseling, and social media campaigns, offer opportunities for incremental outreach, particularly in settings where face-to-face interactions may be limited by stigma or geographic constraints. Starting with basic educational content or virtual consultations, these tools can slowly introduce more interactive services, such as telemedicine for PrEP counseling or virtual support groups. Over time, digital platforms can be expanded to provide more comprehensive support, empowering individuals to seek information and care at their own pace and fostering a supportive online community for HIV prevention.²⁸

Challenges of Incremental Approaches

While incremental approaches offer a promising path to HIV prevention, they also come with several challenges that can impact their effectiveness. Understanding and addressing these obstacles is essential for successfully implementing incremental strategies on a larger scale.

Incremental approaches require sustained resources and long-term funding commitments, which can be challenging to secure. Gradual interventions often need consistent monitoring, evaluation, and adaptation, all of which require ongoing financial support. Additionally, incremental strategies may appear slower to yield significant results compared to large-scale programs, potentially leading to funding agencies and stakeholders questioning their effectiveness. As a result, securing continuous support for stepwise programs, especially in resource-limited settings, can be challenging and may hinder the long-term sustainability of these efforts.²⁹

Incremental approaches are typically gradual and may take time before substantial results are visible. For example, small pilot programs or targeted PrEP rollouts in specific populations might initially only reach a limited number of people, resulting in modest declines in HIV transmission rates. This limited initial impact can lead to skepticism among policymakers, funders, and communities about the effectiveness of the approach. Without visible, short-term outcomes, it may be challenging to justify expanding incremental interventions or gaining broader community support.³⁰

One of the hallmarks of incremental approaches is the need for continuous monitoring, feedback, and adaptation. Implementing interventions in phases requires careful tracking of progress, outcomes, and community responses to ensure each stage is effective before expanding further. However, this need for detailed data and regular assessment can place a strain on resources, especially in regions with limited infrastructure for data collection and analysis. Insufficient or inconsistent monitoring can undermine the effectiveness of incremental approaches, potentially resulting in unaddressed issues or inadequate improvements at each stage.³¹

While incremental approaches aim to increase community acceptance, they can still face resistance or stigma, particularly in conservative or marginalized communities. Programs targeting specific populations, such as people who inject drugs or the LGBTQ+ community, may encounter resistance due to prevailing social norms and discrimination. Incremental steps may not be sufficient to overcome entrenched stigma, and limited progress in changing attitudes can slow down the expansion of these programs. Additionally, this approach requires building trust over time, which can be challenging if initial efforts are met with suspicion or resistance.³²

Incremental approaches must strike a balance between adapting interventions based on local feedback and maintaining consistency to achieve intended outcomes. Frequent adaptations can lead to changes in the delivery or focus of programs, which can confuse participants or disrupt continuity. For example, if a PrEP program repeatedly modifies access points or eligibility criteria in response to community feedback, individuals might struggle to stay engaged. This balancing act requires skillful management to ensure that interventions remain accessible and effective without causing confusion or frustration among the target population.³³

Incremental approaches focus on specific populations and locations, which can create a fragmented HIV prevention landscape where some communities receive robust support while others are left behind. For example, if PrEP rollout focuses on urban high-risk populations first, rural or lower-risk areas may experience delays in access to the same preventive resources. This fragmented approach can lead to disparities in prevention efforts, with some regions or populations progressing faster than others. Coordinating incremental interventions to ensure equitable access and avoiding gaps in coverage is a significant challenge for HIV prevention programs.³³

Conclusion

Incremental approaches to HIV prevention offer a pragmatic and adaptive framework for addressing the complexities of the HIV epidemic. By emphasizing gradual, step-by-step interventions, these strategies can cater to diverse populations and adjust to the varying social, cultural, and economic contexts in which HIV persists. The flexibility inherent in incremental methods enables health programs to refine their approaches over time, allowing for real-time learning and community-centered adjustments that increase acceptance and effectiveness. This patient and deliberate expansion can foster trust, reduce stigma, and ensure that interventions are sustainable and responsive to actual needs.

Conflict of Interest: Author declares no potential conflict of interest with respect to the contents, authorship, and/or publication of this article.

Source of Support: Nil

Funding: The authors declared that this study has received no financial support.

Informed Consent Statement: Not applicable. 

Data Availability Statement: The data supporting in this paper are available in the cited references. 

Ethics approval: Not applicable.

References

1. Obeagu EI, Obeagu GU. Neonatal Outcomes in Children Born to Mothers with Severe Malaria, HIV, and Transfusion History: A Review. Elite Journal of Nursing and Health Science, 2024; 2(3):38-58

2. Obeagu EI, Ubosi NI, Obeagu GU, Obeagu AA. Nutritional Strategies for Enhancing Immune Resilience in HIV: A Review. Int. J. Curr. Res. Chem. Pharm. Sci. 2024;11(2):41-51. https://doi.org/10.22270/ijmspr.v10i2.102

3. Obeagu EI, Obeagu GU. Understanding Immune Cell Trafficking in Tuberculosis-HIV Coinfection: The Role of L-selectin Pathways. Elite Journal of Immunology, 2024; 2(2):43-59

4. Obeagu EI. Erythropoietin and the Immune System: Relevance in HIV Management. Elite Journal of Health Science, 2024; 2(3):23-35

5. Obeagu EI, Obeagu GU, Obiezu J, Ezeonwumelu C, Ogunnaya FU, Ngwoke AO, Emeka-Obi OR, Ugwu OP. Hematologic Support in HIV Patients: Blood Transfusion Strategies and Immunological Considerations. Applied Sciences (NIJBAS). 2023;3(3). https://doi.org/10.59298/NIJBAS/2023/1.2.11000

6. Parker RG, Perez‐Brumer A, Garcia J, Gavigan K, Ramirez A, Milnor J, Terto Jr V. Prevention literacy: community‐based advocacy for access and ownership of the HIV prevention toolkit. African Journal of Reproduction and Gynaecological Endoscopy. 2016;19(1). https://doi.org/10.7448/IAS.19.1.21092 PMid:27702430 PMCid:PMC5045969

7. McNeish R, Rigg KK, Tran Q, Hodges S. Community-based behavioral health interventions: Developing strong community partnerships. Evaluation and Program Planning. 2019; 73:111-115. https://doi.org/10.1016/j.evalprogplan.2018.12.005 PMid:30580000

8. Dave P, The Correlation Between Stigma and Mental Health Disorders in People Living with HIV/AIDS, Journal of Drug Delivery and Therapeutics, 2024;14(3):227-233 https://doi.org/10.22270/jddt.v14i3.6490

9. Obeagu EI, Obeagu GU. Immune Modulation in HIV-Positive Neonates: Insights and Implications for Clinical Management. Elite Journal of Nursing and Health Science, 2024; 2(3): 59-72

10. Obeagu EI, Obeagu GU. Understanding ART and Platelet Functionality: Implications for HIV Patients. Elite Journal of HIV, 2024; 2(2): 60-73

11. Navarra AM, Rosenberg MG, Gormley M, Bakken S, Fletcher J, Whittemore R, Gwadz M, Cleland C, Melkus GD. Feasibility and acceptability of the adherence connection counseling, education, and support (ACCESS) proof of concept: a peer-led, mobile health (mHealth) cognitive behavioral antiretroviral therapy (ART) adherence intervention for HIV-Infected (HIV+) adolescents and young adults (AYA). AIDS and Behavior. 2023; 27(6):1807-23. https://doi.org/10.1007/s10461-022-03913-0 PMid:36574184 PMCid:PMC9792943

12. Frew PM, Archibald M, Schamel J, Saint-Victor D, Fox E, Smith-Bankhead N, Diallo DD, Holstad MM, Del Rio C. An integrated service delivery model to identify persons living with HIV and to provide linkage to HIV treatment and care in prioritized neighborhoods: a geotargeted, program outcome study. JMIR public health and surveillance. 2015; 1(2):e4675. https://doi.org/10.2196/publichealth.4675 PMid:27227134 PMCid:PMC4869208

13. Obeagu EI, Obeagu GU. Optimizing Blood Transfusion Protocols for Breast Cancer Patients Living with HIV: A Comprehensive Review. Elite Journal of Nursing and Health Science, 2024; 2(2):1-17

14. Obeagu EI, Obeagu GU. Hematologic Considerations in Breast Cancer Patients with HIV: Insights into Blood Transfusion Strategies. Elite Journal of Health Science, 2024; 2(2): 20-35

15. Obeagu EI, Obeagu GU. Advancements in HIV Prevention: Africa's Trailblazing Initiatives and Breakthroughs. Elite Journal of Public Health, 2024; 2 (1): 52-63

16. Bond V, Chase E, Aggleton P. Stigma, HIV/AIDS and prevention of mother-to-child transmission in Zambia. Evaluation and program planning. 2002; 25(4):347-356. https://doi.org/10.1016/S0149-7189(02)00046-0

17. Zukoski AP, Thorburn S. Experiences of stigma and discrimination among adults living with HIV in a low HIV-prevalence context: a qualitative analysis. AIDS patient care and STDs. 2009;23(4):267-276. https://doi.org/10.1089/apc.2008.0168 PMid:19260770

18. Shafique S, Bhattacharyya DS, Nowrin I, Sultana F, Islam MR, Dutta GK, Del Barrio MO, Reidpath DD. Effective community-based interventions to prevent and control infectious diseases in urban informal settlements in low-and middle-income countries: a systematic review. Systematic Reviews. 2024;13(1):253. https://doi.org/10.1186/s13643-024-02651-9 PMid:39367477 PMCid:PMC11451040

19. Pandya S, Kan L, Parr E, Twose C, Labrique AB, Agarwal S. How Can Community Data Be Leveraged to Advance Primary Health Care? A Scoping Review of Community-Based Health Information Systems. Global Health: Science and Practice. 2024; 12(2). https://doi.org/10.9745/GHSP-D-23-00429 PMid:38626945 PMCid:PMC11057800

20. Navarra AM, Rosenberg MG, Gormley M, Bakken S, Fletcher J, Whittemore R, Gwadz M, Cleland C, Melkus GD. Feasibility and acceptability of the adherence connection counseling, education, and support (ACCESS) proof of concept: a peer-led, mobile health (mHealth) cognitive behavioral antiretroviral therapy (ART) adherence intervention for HIV-Infected (HIV+) adolescents and young adults (AYA). AIDS and Behavior. 2023;27(6):1807-1823. https://doi.org/10.1007/s10461-022-03913-0 PMid:36574184 PMCid:PMC9792943

21. Billings DW, Leaf SL, Spencer J, Crenshaw T, Brockington S, Dalal RS. A randomized trial to evaluate the efficacy of a web-based HIV behavioral intervention for high-risk African American women. AIDS and Behavior. 2015; 19:1263-1274. https://doi.org/10.1007/s10461-015-0999-9 PMid:25616838 PMCid:PMC4506203

22. Kessy F, Charle P. Evidence of the Impact of IMF Fiscal and Monetary Policies on the Capacity to Address HIV/AIDS and TB Crises in Tanzania. CEGAA/RESULTS Educational Fund, June (Cape Town: Centre for Economic Governance and AIDS in Africa). 2009.

23. Akhtar MH, Ramkumar J. Primary Health Center: Can it be made mobile for efficient healthcare services for hard to reach population? A state-of-the-art review. Discover Health Systems. 2023;2(3). https://doi.org/10.1007/s44250-023-00017-x PMid:37520517 PMCid:PMC9870199

24. Lynn VA, Webb FJ, Joerg C, Nembhard K. Behavioral Health Disorders and HIV Incidence and Treatment Among Women. InWomen's Behavioral Health: A Public Health Perspective 2024: 129-150. Cham: Springer International Publishing. https://doi.org/10.1007/978-3-031-58293-6_6

25. Lassi ZS, Salam RA, Das JK, Bhutta ZA. The conceptual framework and assessment methodology for the systematic reviews of community-based interventions for the prevention and control of infectious diseases of poverty. Infectious diseases of poverty. 2014; 3:1-7. https://doi.org/10.1186/2049-9957-3-22 PMid:25105014 PMCid:PMC4124965

26. Belus JM, Msimango LI, van Heerden A, Magidson JF, Bradley VD, Mdakane Y, van Rooyen H, Barnabas RV. Barriers, Facilitators, and Strategies to Improve Participation of a Couple-Based Intervention to Address Women's Antiretroviral Therapy Adherence in KwaZulu-Natal, South Africa. International Journal of Behavioral Medicine. 2024; 31(1):75-84. https://doi.org/10.1007/s12529-023-10160-7 PMid:36854871 PMCid:PMC10803380

27. Obeagu EI, Obeagu GU. Unmasking the Truth: Addressing Stigma in the Fight Against HIV. Elite Journal of Public Health. 2024;2(1):8-22.

28. Obeagu EI, Obeagu GU, Odo EO, Igwe MC, Ugwu OP, Alum EU, Okwaja PR. Combatting Stigma: Essential Steps in Halting HIV Spread.

29. Obeagu EI. Breaking Barriers: Mitigating Stigma to Control HIV Transmission. Elite Journal of Public Health. 2024;2(8):44-55.

30. Obeagu EI, Obeagu GU. Preventive measures against HIV among Uganda's youth: Strategies, implementation, and effectiveness. Medicine. 2024; 103(44):e40317. https://doi.org/10.1097/MD.0000000000040317 PMid:39496029 PMCid:PMC11537624

31. Shafique S, Bhattacharyya DS, Nowrin I, Sultana F, Islam MR, Dutta GK, Del Barrio MO, Reidpath DD. Effective community-based interventions to prevent and control infectious diseases in urban informal settlements in low-and middle-income countries: a systematic review. Systematic Reviews. 2024; 13(1):253. https://doi.org/10.1186/s13643-024-02651-9 PMid:39367477 PMCid:PMC11451040

32. Muessig KE, Nekkanti M, Bauermeister J, Bull S, Hightow-Weidman LB. A systematic review of recent smartphone, Internet and Web 2.0 interventions to address the HIV continuum of care. Current Hiv/aids Reports. 2015; 12:173-190. https://doi.org/10.1007/s11904-014-0239-3 PMid:25626718 PMCid:PMC4370788

33. Perry H, Zulliger R, Scott K, Javadi D, Gergen J. Case studies of large-scale community health worker programs: examples from Bangladesh, Brazil, Ethiopia, India, Iran, Nepal, and Pakistan. Afghanistan: Community-Based Health Care to the Ministry of Public Health. 2013.