SeriesComing to terms with complexity: a call to action for HIV prevention
Section snippets
Momentum for HIV prevention
Although the gap between what is needed in HIV prevention worldwide and what has so far been achieved is huge, we should not neglect the momentum which has been generated, especially over the past decade. HIV prevalence has declined substantially in a growing number of countries and regions: Zimbabwe, Côte d'Ivoire, Burkina Faso, Thailand, Cambodia, southern India, and urban Haiti and Kenya.1 These reductions represent the payoff from investments made throughout the 1990s and into this century.
The epidemic could continue to surprise us
As Bertozzi and colleagues argue in this Series,1 HIV prevention responses must be informed by an analysis of where the next 1000 HIV infections are likely to come from in any given context. HIV/AIDS is highly dynamic. Initial HIV outbreaks in highly vulnerable populations might be followed by a slower spread which could nevertheless affect large numbers of people:11 in Thailand or Uganda, for example, a large proportion of transmission is among serodiscordant long-term couples. Epidemics could
Meeting the challenges of an expanded prevention response
Expanded HIV prevention grounded in a strategic analysis of the epidemic's dynamics in local contexts is the sine qua non of getting ahead of the epidemic. Shortcuts are tempting, but illusory. Every time a magic-bullet solution has been proposed for HIV/AIDS it has been found wanting, as Padian and colleagues argue in this Series17 in relation to biomedical interventions. The latest candidates for the single intervention which could stop the spread of HIV have been circumcision for adult men
Tackling sex in the right way
About 85% of HIV transmission is sexual. If the pandemic has proved nothing else, it is that a diverse sexual life is part of being human. But despite the vast increase in the awareness of sexual diversity which has come in the wake of HIV/AIDS-driven research and community action, programming responses still find it hard to tackle sexual transmission in the right way or in the right populations.
Programming efforts that focus on sexual transmission have been plagued by insufficient confidence
Educating young people frankly about sex
Any sustainable effect on the future of HIV/AIDS will depend on the behaviour of young people, the adults of tomorrow. The tragic reality is that we have not provided a clear focus to ensure that all young people have the information they need before and while they are engaging in sex, especially in light of the high infection rates in young people, especially girls, and the early ages of sexual initiation—in many countries, 14–15 years is the median age of first sexual intercourse.
Even in
Dealing rationally with drug use
The one issue that is more controversial than prevention of transmission through sex is prevention of transmission through injecting drug use. Scientific consensus has been achieved on the effectiveness of harm-reduction approaches to HIV among such users39 and its component elements have been fleshed out: needle and syringe programmes; opioid substitution therapy; voluntary counselling and testing; antiretroviral therapy; prevention of sexually transmitted infections; condom programming for
Eliminating mother-to-child transmission
High-income countries have almost eliminated transmission of HIV from mother to child (figure 4). Several middle income-income and lower middle-income countries have done the same—in El Salvador for example, in about 2003, some 150 infants were born HIV-positive, but within 3 years after the introduction of a nationwide programme to prevent mother-to-child transmission the numbers were reduced to below 20. Botswana had the distinction of being the first country in sub-Saharan Africa to achieve
Politics, leadership, and demand generation
Whereas leadership on HIV treatment in a growing number of countries has been exemplary, and has achieved clear results, leadership has been very uneven for HIV prevention. Some of this lack of explicit leadership relates to the controversial nature of what works in terms of HIV prevention, such as reduction of harm for injecting drug users, sex education for children, promotion of condom use, and societal norms about sexuality, in particular homosexuality.53 Overcoming reluctance to deal with
HIV hyperendemic countries: a full-scale emergency
Southern Africa, and to a lesser extent eastern Africa, is experiencing an unparalleled epidemic, with a prevalence of HIV/AIDS that until the mid-1990s was thought to be impossible in the population at large. Up to 25% of 15–49 year-olds are HIV positive,1 and the annual incidence in young women is 4–6%, which is worse than the cumulative prevalence in the whole population after 30 years almost anywhere else in the world.
Although some real reductions in HIV prevalence in the region have been
Reaching all those in need: the implementation science of HIV prevention
Most published work on HIV prevention focuses on debates about which discrete interventions should be used for HIV prevention. Surprisingly little attention focuses on how they should be used, which is where our biggest challenges lie.71 HIV prevention must be able to deal with complexity: what makes the difference between a growing and a diminishing HIV epidemic is not merely net changes in individual behaviours, but dynamic shifts in sexual and social networks. Analytical tools need to be
Reaching all those in need: going beyond health services
Whereas provision of HIV treatment and the prevention of HIV transmission from mother to child are the primary responsibility of the health-care system, prevention of sexual transmission of HIV and of transmission through sharing of needles largely happens outside the health sector and medical services. Therefore the much-needed strengthening of health services in developing countries might only be marginally beneficial for HIV prevention. For this and other reasons, the debate in some
The long-term view
A quarter of a century into the pandemic, with no vaccine in sight and the number of new infections outpacing the progress in access to treatment, we clearly need to take a long-term view in planning our actions.79 The HIV/AIDS response environment cannot be taken for granted: the pandemic is dynamic and moving; populations are dynamic and mobility only increasing; leadership at both state and non-state levels changes; the availability of resources and the demands upon them are highly variable;
A call to action on HIV prevention
A quarter of a century into the response to HIV/AIDS, we consider that our call for an all-out, unprecedented effort towards HIV prevention—as has been successfully made towards HIV treatment—is imperative. We have learnt much and we know much about this epidemic that can be harnessed to prevent more infections: we need to invest now in scaling up and building on our learnings and the results we are seeing. Global commitments have already been made: specific prevention targets set at the
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