HIV Prevention 6: Coming To Terms With Complexity: A Call To Action For HIV Prevention

Series
www.thelancet.com Vol 372 September 6, 2008 845

HIV Prevention 6
Coming to terms with complexity: a call to action for HIV
prevention
Peter Piot, Michael Bartos, Heidi Larson, Debrework Zewdie, Purnima Mane
A quarter of a century of AIDS responses has created a huge body of knowledge about HIV transmission and how to
prevent it, yet every day, around the world, nearly 7000 people become infected with the virus. Although HIV
prevention is complex, it ought not to be mystifying. Local and national achievements in curbing the epidemic have
been myriad, and have created a body of evidence about what works, but these successful approaches have not yet
been fully applied. Essential programmes and services have not had su cient coverage; they have often lacked the
funding to be applied with su cient quality and intensity. Action and funding have not necessarily been directed to
where the epidemic is or to what drives it. Few programmes address vulnerability to HIV and structural determinants
of the epidemic. A prevention constituency has not been adequately mobilised to stimulate the demand for HIV
prevention. Condent and unied leadership has not emerged to assert what is needed in HIV prevention and how to
overcome the political, sociocultural, and logistic barriers in getting there. We discuss the combination of solutions
which are needed to intensify HIV prevention, using the existing body of evidence and the lessons from our successes
and failures in HIV prevention.
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, Cte
dIvoire, Burkina Faso, Thailand, Cambodia, southern
India, and urban Haiti and Kenya.
1
These reductions
represent the payo from investments made throughout
the 1990s and into this century. Commitment of political
capital and other resources has been translated into
major increases in programmatic eort that are now
bearing fruit in improved outcomesinfections averted
and lives saved. But worldwide the current degree of
eort is not yet su cient: the epidemic continues to
extend its reach, and new infections continue at a rate
which puts unsustainable burdens on countries for
decades to come.
To intensify HIV prevention, programme
implementers need to know their epidemic, and to
respond in at least three dimensions. The rstHIV
rates and behaviours at a local levelis commonly
used. The secondthe state of HIV/AIDS spending
and programming in relation to the levels of need,
including in relation to each key subpopulationis
sometimes used. Bertozzi and colleagues in this Series
2

detail the mix of spending and programming required
for an optimum response. The thirdan appreciation
of macro-level political, demographic, and economic
changesis rarely used, but unless responses take
these changing social and cultural contexts into account,
they will miss their mark. This combination of
knowledge and context is what makes information
strategic and the basis for action (panel 1). Only when it
is applied in a comprehensive AIDS programming cycle
can it create an eective feedback loop between
information, programming, assessment of programme
eectiveness, and back to improved information and
programming (panel 2).
7
As Rao Gupta and colleagues note in this Series
8
other
public-health eorts have shown the consequences of
not conducting adequate analysis of the social and
political environment. One of the more extreme examples
has been in the global polio-eradication initiative, in
which an overly top-down eort neither adequately
assessed local cultural and political contexts nor
adequately engaged local communities early in the eort,
leading to a state-wide boycott of polio vaccination in
Northern Nigeria,
9
community-level refusals in northern
India, and pockets of refusals in other settings. To take
another example, reproductive-health programmes have
also recognised the need to understand social and cultural
systems in planning any interventionin-depth analysis
from nine countries showed that development entry
points and constraints that derive from social and cultural
systems and structures cannot be overlooked or
underestimated.
10
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 aect large numbers of people:
11
in Thailand
or Uganda, for example, a large proportion of
transmission is among serodiscordant long-term couples.
Epidemics could resurgeas among gay men in western
Lancet 2008; 372: 84559
Published Online
August 6, 2008
DOI:10.1016/S0140-
6736(08)60888-0
This is the sixth in a Series of
six papers about HIV prevention
Joint United Nations
Programme on HIV/AIDS
(UNAIDS), Geneva, Switzerland
(P Piot PhD, M Bartos MEd);
Department of International
Development, Community and
Environment, Clark University,
Worcester, MA, USA
(H Larson PhD); Center for
Population and Development
Studies, Harvard School of
Public Health, Harvard
University, Cambridge, MA,
USA (H Larson PhD); The World
Bank, Washington, DC, USA
(D Zewdie PhD); and United
Nations Population Fund
(UNFPA), New York, USA
(P Mane PhD)
Correspondence to:
Michael Bartos, Joint United
Nations Programme on
HIV/AIDS, 20 Avenue Appia,
CH-1211 Geneva 27, Switzerland
[email protected]
Series
846 www.thelancet.com Vol 372 September 6, 2008
Europe and Australia, or the higher than expected
incidence in the USAor move into new areas, such as
the apparently unchecked growth in many of the cities of
Asia of HIV in men who have sex with men and injecting
drug users, where synthetic-drug use is further catalysing
wider sexual spread (gure 1).
Past history shows we have failed to heed early
warning signs of these changing dynamics. In the
early 1990s, eastern Africa was regarded as the epicentre
of the pandemic. The explosive growth of HIV/AIDS in
southern Africa did not come until the second decade
of the pandemic. Southern and eastern Africa are now
the regions with the worlds second highest growth in
opiate use, since use follows the evolution of heroin
tra cking routes. Responses are as yet ill-prepared for
this new twist on the HIV threat.
12,13
West Africa has
emerged as a major cocaine tra cking route, and now
opiates are starting to be tra cked through the same
networks.
14
Russias 1 million HIV infections have
occurred since 1990largely as a result of explosive
growth of HIV transmission among injecting drug
users. More recently the epidemic has emerged in that
region much more strongly in women, both as injecting
drug users and partners of injecting drug users: women
account for 42% of newly reported HIV cases in
Moldova, 46% in Belarus, and 44% in Ukraine and
Russia.
15
Demographic, technological, sociopolitical, and
economic change will fundamentally shape the future
epidemic, but the Asian Development Banks systematic
incorporation of HIV/AIDS-related considerations into
large-scale infrastructure projects in the region and the
AIDS in Africa Three Scenarios to 2025 project are among
the few attempts to incorporate such analysis into
planning.
16
Both the internet and mobile telephony have
reshaped sexual conduct at its roots: for example, mobile
connections overtook the number of xed lines in Africa
at the end of the 1990s, but few national-scale campaigns
have played on this change (Swazilands bold if
controversial secret lover campaign in 200607 was a
notable exception). Economic development also changes
the nature of transactional sex: Cambodia has been
actively realigning its HIV/AIDS response in the light of
evidence that economic growth has changed the
traditional pattern of sex work into a much more uid
mode of sexual exchanges around new entertainment
venues.
Meeting the challenges of an expanded
prevention response
Expanded HIV prevention grounded in a strategic
analysis of the epidemics 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 Series
17
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 and, more recently, stopping concurrent
partnerships. However, from the point of view of those
who implement programmes and make policy, no
one-dimensional HIV/AIDS solution has ever become
available. Combination prevention is as necessary as
combination treatment when it comes to stopping the
pandemic.
An impressive range of both individuals
18
and states
19

subscribe to the global consensus that eective HIV
prevention requires locally contextualised approaches
that address both individuals and social norms and
structures, and are grounded in human rights.
Furthermore, HIV prevention must be one of the most
studied elds of health promotion: nearly 35 000 citations
on HIV prevention have been published internationally
in scientic research alone (compared with 27 000 about
prevention of smoking or tobacco use). But despite both
the broad consensus on what needs to be done and the
evidence base, we have only partial understanding of
what facilitates systematic implementation of prevention
Panel 1: Strategic reorientation of responses in Lesotho
An in-depth analysis of data from the 2004 Demographic
Health Survey in Lesotho showed prevalence of HIV was
61% among young women aged 1517 years, and 107% in
1819 year-old women.
3
HIV prevalence was higher in young
women with a regular partner than in those without, higher
in urban than in rural areas, and around the same for girls
with and without secondary education. On this basis, a
2007 joint UN system mission was able to argue that current
eorts by both the UN system and Lesothos government
that were directed towards out-of-school youth in rural areas
might be better reoriented to national eorts towards girls in
schools, and to making the link with adult sexual behaviour.
Panel 2: Using strategic information to reorient responses
in Bangkok
In Bangkok, Thailand, rates of HIV infection in men who have
sex with men rose from about 10% at the beginning of the
decade to 28% in 2005.
4
This upsurge was associated with
public-order campaigns that closed bars and sex venues, and
forced men into street-based or illegal settings for sex; weak
community organisation; and policy attention centred on
access to treatment.
5
Creditably, the resurgence led to a direct
response in both policy and action: a national target to
reduce new infections by half, extension of focused activities
and services for gay men, and launch of a massive safe-sex
campaign.
6
Equally, acting on new or persistent epidemics
among injecting drug users or other groups at most risk
needs to be grounded in an analysis of their socioeconomic
and political contexts: what eect, for example, do wars on
drugs have on HIV rates?
Series
programmes, what bottlenecks hold up progress, and
what strength of eort will be necessary.
Here, we discuss four of the core challenges which
stand in the way of fully eective combination prevention:
inadequacy of attempts to tackle sexual transmission,
unwillingness to be frank with young people, di culties
of dealing rationally with drug use, and the failure to yet
eliminate mother-to-child transmission.
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 nd it hard to tackle sexual
transmission in the right way or in the right
populations.
Programming eorts that focus on sexual transmission
have been plagued by insu cient condence in their
e cacy and hence inconsistency in their targets. As Coates
and colleagues point out in their contribution to this
Series,
20
behavioural research on HIV prevention has been
too focused on single interventions and individual
behaviours. In the USA, for example, the only best-evidence
interventions for HIV prevention that are recommended
by the Centers for Disease Control and Prevention to
guide prevention programming domestic ally are a series
of variants on intensive one-to-one counselling or
China

Vietnam

Shenzhen
2005
Ho Chi Minh
200104

Battambang
2005

Siem Reap
2005

Philippines

Phnom Penh
200005

144

87

58

80

53

367
08

08

Phuket
2005

55

173

330

400

250

283
22

253

153

114

176

20

115
67

119

144

Bangkok
200305
Pattaya
2005
1996
2006
Laos

Thailand

Chiang-Mai

Cambodia

Hanoi
2006

94 MSM

50

30

15

08

31

31

46

58

Bhutan

Burma

Mandalay

Yangon

Shanghai
200405

Beijing
200106

Hangzhou
2004

Transgender (all date ranges)
Male sex workers
Men who have sex with men (200203)
Men who have sex with men (before 2002)

Figure 1: HIV prevalence in men who have sex with men in 17 cities of east and southeast Asia
Data are HIV-positive people per hundred. Adapted from data in reference 4.
Tanzania
Zambia
Botswana
South
Africa
Orange Farm
Soweto
Gugulethu
Rwanda
Kenya
Eldoret
Kampala
Thika
Nairobi
Kitwe
Ndola
Gaborone
Both partners HIV-negative
One partner HIV-positive
Both partners HIV-positive
Figure 2: Couples with and without HIV in selected African countries
Adapted from data in reference 25.
Series
small-group discussion interventions.
21
The synergies
between interventions and action at the community level
have been neglected and are not amenable to proof via
randomised controlled trials, since this method is designed
precisely to eliminate synergies as confounders. As a
result, although data on behaviours and HIV transmission
show sustained positive change in dozens of settings on
all continents, precise assessment of what has brought
about the change has proved di cult, given that it has
almost certainly come from interactions between the
individual, community (or environmental), and structural
(population or national) levels, as described by Rao Gupta
and colleagues in this Series.
8

Much of the history of preventing sexual transmission
of HIV has concentrated on reducing multiple
partnerships or adopting condom use in casual sex.
However, especially as epidemics mature, a higher
proportion of HIV infections take place within marriages
or other long-term partnerships.
22
In Uganda, for
example, HIV is present in 8% of all married or
cohabiting couples, and in only about half the cases are
both the partners infected with HIV.
23
Similarly, across
Burkina Faso, Cameroon, Ghana, Kenya, and Tanzania,
two-thirds of couples in which HIV is present are
serodiscordant, and in 3040% of these cases the female
partner is infected.
24
A large-scale HIV-prevention trial
focusing on serodiscordant couples in eastern and
southern Africa reported that serodiscordancy varied
between 8% and 31% (gure 2).
25
In both Thailand and
Cambodia, a substantial proportion of HIV transmission
has occurred in the context of serodiscordant marriages.
The challenge for HIV-prevention programming is to
address couples: for example, the positive benets of
HIV testing are promoted when couples are tested
together, and negative consequences, such as violence
or exclusion, are reduced. Many couples will also want
to conceive, and to nd eective strategies for condom
use and other risk-reduction strategies. Eective HIV
treatment also modies the risk of HIV transmission,
and Switzerlands national HIV/AIDS organisation has
recently gone as far as to advise that serodiscordant
couples can forego condom use if the viral load of the
HIV-positive partner has been suppressed to
undetectable levels and in the absence of sexually
transmitted infections.
26
The applicability of such a
policy in settings where viral-load testing is not readily
available has yet to be established.
One particular subset of serodiscordant established
partnerships which has been discussed for more than a
decade as a major source of HIV transmission is
concurrent partnerships. High rates of concurrency
probably facilitate the spread of HIV, but we do not know
to what extent concurrency acts alone or in concert with
other factors, such as low rates of male circumcision,
27,28

mobility, family separation, religion, and other cultural
factors. To date, comparative data on rates of concurrency
across dierent global regions are scarce, although more
are starting to be collected; for example the Demographic
and Health Surveys are introducing a set of concurrency
questions. Rates of multiple partnership (which includes
concurrent partnerships, serial partners, and sex with
many casual partners) vary widely in dierent countries;
but in general, highly developed nations have the highest
rates.
29
However, national aggregate rates of multiple
partnership are not correlated with national rates of HIV
infection. At an individual level, relationships with
multiple partners remain a strong predictor of HIV
infection
30
a reminder that individual risk patterns do
not translate easily into explanations of national
dierences in HIV prevalence.
In any event, although the question of the role of
concurrent partnerships in explaining dierent epidemic
patterns is undoubtedly important, even more important
is what ought to be the HIV-prevention response to
concurrency, given that eective responses to HIV risk
within established intimate relationships has always
been the hardest of prevention challenges.
31
In response
to the declaration of prevention priorities made by the
Southern African Development Committee (SADC)
in 2006, work in that region has started to elaborate a
programmatic response to concurrency in southern
Africa. Formative research conducted in nine countries
of southern Africa in the second half of 2007 reported
very similar reasons across the subregion for multiple
and concurrent partnerships: dissatisfaction with main
relationships; social norms (cultural, gender, and
peer-pressure issues); poverty and materialism; male
domination; and alcohol use. On the basis of these
results, regional stakeholders have proposed a
communication campaign throughout the subregion to
tackle: communication between children and parents,
Targets include men who have sex with men
Targets do not include men who have sex with men
No targets set
Unknown
Figure 3: Global map showing low-income and middle-income countries with targets for universal access to
HIV prevention, care, and treatment include men who have sex with men
Adapted from data in reference 37.
Series
and between partners; gender disparities (including
dimensions of male domination and womens
empowerment); and socialisation and peer pressure.
32
The focus on sexual transmission has also been diluted
as a result of stigma. In both Latin America
33
and Asia
and the Pacic
34
the mismatch between the high
proportion of the epidemic in men who have sex with
men and the low level of funding and programming
eorts directed to this population has been repeatedly
observed.
35
Men who have sex with men account for a
larger proportion of the epidemic than hitherto assumed,
even where heterosexual transmission predominates,
such as in sub-Saharan Africa.
36
The most recent
collection of national reports that use the indicators
agreed after the UN General Assembly Special Session
in 2001 showed that only 40% of men who have sex with
men in 17 reporting countries were reached by prevention
services.
1
Similarly, in the annual analysis of national
responses conducted by UNAIDS country o ces, of
90 responding countries, 54 had included men who have
sex with men as a target population within their national
HIV/AIDS action framework; these countries were
mainly in the AsiaPacic region, the Caribbean, eastern
Europe, and Latin America (gure 3).
37
Representatives
of men who have sex with men were regarded as full
participants in national AIDS planning in 23 countries.
37

We hope that attempts to improve attention to this
population in national policy making will cause this gap
to be better addressed in the future.
37
The paucity of
eective attention to sexual diversity is especially
magnied in the case of transgender populations, which
are among the most marginalised, abused, and
HIV-aected populations anywhere, but which never-
theless receive scant programming attention.
Educating young people frankly about sex
Any sustainable eect 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
initiationin many countries, 1415 years is the median
age of rst sexual intercourse.
Even in settings where the epidemic is most
concentrated, we still need to ensure that all young
people have the information they need to prevent
infection with HIV, given that the epidemic is dynamic,
changing, and rarely stays in any one risk group. Yet as
Coates and colleagues discuss in this Series,
20
young
peoples knowledge is still far short of the global targets
set in 2001. The fact is that systematic HIV/AIDS
education, starting with young people before they
become sexually active, has not been made available.
Even in the city of New York, where rates of infection
with HIV among 1319 year-old boys have doubled in
the past 5 years, and one in four teenagers across the
USA has at least one sexually transmitted disease, many
schools block access to websites about HIV/AIDS and
Panel 3: Opiate substitution therapy
Methadone is used in the treatment of opiate addiction in
many countries, including pilot programmes: Albania,
Andorra, Australia, Austria, Belgium, Bosnia and Herzegovina,
Bulgaria, Canada, China (including Hong Kong), Croatia,
Czech Republic, Denmark, Estonia, Finland, France, Germany,
Greece, Hungary, Indonesia, Iran, Ireland, Israel, Italy,
Kyrgyzstan, Latvia, Liechtenstein, Lithuania, Luxembourg,
Macedonia, Malaysia, Malta, Mexico, Moldova, Nepal,
Netherlands, New Zealand, Norway, Poland, Portugal,
Romania, San Marino, Serbia, Slovakia, Slovenia, South
Africa, Spain, Sweden, Switzerland, Thailand, Ukraine, UK
(plus overseas territories and dependencies), and the USA.
Buprenorphine treatment (including pilot programmes) is
available in: Australia, Austria, Belgium, Canada, China
(including Hong Kong), Croatia, Czech Republic, Denmark,
Estonia, Finland, France, Germany, Greece, Iceland, India,
Indonesia, Israel, Italy, Lithuania, Luxembourg, Malaysia,
Norway, Portugal, Singapore, Slovakia, Slovenia, South
Africa, Sweden, Switzerland, Ukraine, UK, and the USA.
Panel 4: Scaling up services for injecting drug users in the
worlds largest countries
China, India, and Indonesia, with more than 40% of the
worlds total population between them, provide good
examples of large-scale programmatic responses to HIV
among injecting drug users. The fragmented approach to HIV
responses among users of such drugs in India reported only
3 years ago
42
is giving way to implementation of full-scale
approaches through the new National AIDS Control
Programme and other key partners such as the Avahan
project.
43
China had about 50 needle and syringe exchange
sites in 2004;
44
by the end of 2006 this had risen to 729, with
320 methadone clinics. By 2010, China plans to double the
number of needle and syringe exchanges and to reach 70% of
all heroin users with methadone clinics.
45
In Indonesia, harm
reduction has been progressively incorporated into national
policy and implementation.
46
Despite the impressive
commitment to scale up services for injecting drug users,
policy remains inconsistent. For example, methadone
remains illegal in India (where substitution therapy relies on
buprenorphine), and inconsistencies are also widespread in
other regions.
47
One example is southern Guangxi province in
China, where although police and local authorities have
supported needle and syringe exchange, police have also
committed growing numbers of injecting drug users to
detoxication centres and labour camps, which has driven
many drug users undergroundas a result, the average
number of needles provided by the service has dropped
from 12 000 every month in 2003 to 8000 in 2005.
48
Series
sex education. In much of the world, HIV/AIDS
education is not integrated into primary school
curricula. Less than 70% of countries with generalised
epidemics deliver school-based education about HIV/
AIDS in most or all districts.
The tremendous diversity in the personalities and
circumstances of young people drive their choices. If we
focus education eorts only on dened risk groups,
such as men who have sex with men or injecting drug
users, and neglect eorts which could reach young
people before they make life choices, we could miss
important opportunities to aect the course of the
pandemic over the next generation. Age-appropriate
universal sex education is clearly needed from
primary-school age, taking into account all sexual
choices. Sex education has never been shown to
encourage promiscuity, as is sometimes claimed. In
fact, the weight of evidence shows that it encourages
both the delay of rst sexual activity and higher rates of
protected sex.
38

Sex education should be a core part of education
budgets and not be a separate HIV/AIDS-related line in
the budget. HIV/AIDS budgets should also support
specic campaigns, such as those designed to reach
young people, from MTV to Ugandas straight talk.
Equally, the full range of new communications
technologies ought to be deployed to mobilise youth
networks, as for example, in Kenyas Partnership for an
HIV-Free Generationa partnership of government,
PEPFAR, MTV, businesses, and youth groups.
If social norms need to change, which in the absence of
a vaccine might be the only truly sustainable way to
change the course of the pandemic and its eects, it must
start with young people. For young people, the issue is
not about behaviour changeit is about motivating
informed, safer behaviour from the start.
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. Scientic consensus has
been achieved on the eectiveness of harm-reduction
approaches to HIV among such users
39
and its component
elements have been eshed out: needle and syringe
programmes; opioid substitution therapy; voluntary
counselling and testing; antiretroviral therapy; prevention
of sexually transmitted infections; condom programming
for users and their sexual partners; targeted information
provision; hepatitis diagnosis and treatment; and
tuberculosis prevention, diagnosis, and treatment.
40

Nevertheless, countries still struggle to balance
minimisation of harms to injecting drug users with the
goal of reducing supply and demand of illicit drugs,
which remains a complex regulatory task.
Methadone is available in only 52 countries worldwide
and buprenorphine in 32 (panel 3).
41
In most countries
where it is not available, possession is illegal. In Russia
and most countries of eastern Europe and central Asia,
despite the fact that use of injected drugs constitutes the
most important route of HIV transmission, access to
substitution therapy remains poor (panel 4).
Given these inconsistencies in policy and practice, rates
of HIV infection among injecting drugs users in many
parts of the world have remained stubbornly high or been
resurgent. In other places, new infections have started to
emerge in the wake of drug tra cking routes, as has
been reported in eastern Africa. One weak link in a chain
of responses can cause the whole HIV-prevention
apparatus to fail. A positive cycle needs to address
injecting drug users and their sexual partners; respond
to the links between injecting and the sale of sex; deal
with prison and rehabilitation settings; and tackle HIV/
AIDS, hepatitis, tuberculosis, and sexually transmitted
infections.
Although use of injected drugs has been the principal
focus of much of the drugs-related HIV/AIDS response,
other illicit-drug use also raises key issues. Subcultures
within the gay community which use amphetamines
have been a particular concern in relation to spread of
20
0
2005 2006
Year
2007
40
60
80
100
100000
N
u
m
b
e
r

o
f

H
I
V
-
p
o
s
i
t
i
v
e

p
r
e
g
n
a
n
t

w
o
m
e
n

w
h
o

r
e
c
e
i
v
e
d
a
n
t
i
r
e
t
r
o
v
i
r
a
l

t
h
e
r
a
p
y
P
r
o
p
o
r
t
i
o
n

o
f

H
I
V
-
p
o
s
i
t
i
v
e

p
r
e
g
n
a
n
t

w
o
m
e
n

w
h
o

r
e
c
e
i
v
e
d

a
n
t
i
r
e
t
r
o
v
i
r
a
l

t
h
e
r
a
p
y

(
%
)
0
200000
300 000
400000
500 000
600000
B
A
Figure 4: Number and proportion of HIV-positive pregnant women who
received antiretroviral therapy in 200507
Data are sourced from reference 50.
Series
HIV in the USA and to some extent Australia and Canada,
and more recently the spread of amphetamine use in
southeast Asia has posed similar concerns. HIV risk has
been strongly associated with both the use of illicit drugs
and with alcohol use, especially in settings where sexual
contacts are also made. Alcohol and drug use might not
be the straightforward causes of risky behaviour, but they
do seem to sustain subcultures of risk.
49
Eliminating mother-to-child transmission
High-income countries have almost eliminated
transmission of HIV from mother to child (gure 4).
Several middle income-income and lower middle-income
countries have done the samein 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 rst country in
sub-Saharan Africa to achieve practically universal
coverage of such programmes. But despite concerted
advocacy in every part of the world, the results are
variable.
51
Notably, of the 12 countries which contain three-quarters
of the worlds HIV-positive pregnant women, only Kenya
and South Africa have programmes to prevent
mother-to-child transmission of HIV that reach at least
half those in need. Global partners from both government
and non-government sectors have agreed that successful
programmes need: strong government commitment
able to rally partners around one national plan; strong
national management and coordination, including
non-governmental stakeholders; provider-initiated HIV
testing and counselling in antenatal care settings; lay
counsellors to alleviate shortages of health-care workers;
and a comprehensive set of services including
family-centred HIV/AIDS care; maternal, newborn, and
child health; and sexual and reproductive health care.
48
In November, 2007, when global partners considered
progress in implementation of programmes with these
characteristics, they concluded that the reasons only
17 countries globally were on track included poor
coordination of eorts between programmes for maternal
and child health and HIV/AIDS; insu cient resources;
stigma; insu cient engagement by men; and a failure to
tackle gender violence.
52
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 di cult issues can be an act of
enlightened top leadership; for example, in Thailand,
Uganda, and Brazil in the 1990s. However, such
leadership rarely happens by coincidence, and requires a
well designed political strategy that is embedded in
scientic evidence and that engages a broad set of sectors
and opinion groups in society.
Activism by those primarily aected by AIDS has
played an essential role throughout the history of the
AIDS response, whether by gay men in developed
countries or Brazil, sex workers in Calcutta, or the
Treatment Action Campaign in South Africa.
54
However,
in general, activism for HIV prevention is much less
than what it was in the early days of the epidemic in the
gay community, and less than activism for HIV treatment,
which has been so successful around the world.
HIV prevention must now come out of the closet of
prevention experts. Building a strong constituency for
HIV prevention should be a top priority. A broad-based
coalition from youth, womens, and religious
organisations to business leaders and HIV/AIDS activists
is what is needed.
55
The need for strong and well directed leadership to
keep HIV prevention at the forefront of social policy and
action is especially crucial because of the many
controversies associated with sex and drug use, the long
time lag between HIV infection and the appearance of
illness, and the pressing need to provide treatment to
those who live with HIV/AIDS. As illustrated in our
discussion of sex education and harm reduction, so-called
good politics provides the necessary leadership based on
scientic evidence and human rights, whereas bad
politics, including the absence of leadership, is one of the
main obstacles to eective HIV prevention.
53
The cost of
such bad politics is measured in human lives. Political
leadership and courage also underpin the will to change
laws that hinder HIV prevention and could even promote
the spread of the virus (such as anti-sodomy laws, laws
that criminalise prostitution and sex workers, barriers to
the legalised distribution of methadone and
uncontaminated injecting equipment, and the
criminalisation of HIV transmission). Such laws are key
structural barriers to prevention, as analysed by Rao Gupta
and colleagues in this Series.
8
The leadership that is needed is not only political in
nature, but in many settings also requires complementary
technical leadership in HIV prevention, which has too
often been lacking, especially by contrast with the strong
technical leadership for extending HIV treatment.
Unfortunately, weak technical leadership in prevention
areas is more often the rule than the exception, both in
public health and across other sectors which need to be
involved, including humanitarian responses, social
protection, and poverty alleviation, and Bertozzi and
colleagues
2
make a compelling case in this Series for the
mix of technical and managerial capacity which is needed
for optimal responses.
Series
The reasons that appropriate leadership has not
emerged are not hard to divine. First, HIV prevention, by
its nature, requires the engagement of many sectors.
Second, the solutions required can challenge personal
values (including the values held by implementers and
those needed to champion prevention). Third, as with
prevention of any disease or ill, treatment of the acute
crisis can produce immediate results, compared with
prevention of the root cause, which achieves results over
years and decades. Overcoming the decit of leadership
in HIV prevention will require much more systematic
investment than has been provided up to now.
Over the history of HIV/AIDS, political processes have
often come together to create a mass popular demand for
HIV prevention. In many instances, this demand has
coincided with periods of social and political
transformation. So, for example, Brazils HIV/AIDS
movement emerged hand in hand with the owering of a
strong civil society in creative tension with the state, after
the repressive period of the military dictatorship.
56
The
early and vigorous responses to HIV/AIDS by gay
communities in most developed countries were in part
mobilised by a desire to protect recently gained freedoms
and social recognition.
57
Ugandas social mobilisation
against HIV/AIDS came as the country emerged from
civil war, and both civil society and the state were
determined that the peace dividend should not be
undermined by this new threat. In South Africa, civil
society organised a militant approach to HIV/AIDS that
was grounded in the struggle against apartheid and the
conviction that the dividend of political transition was in
danger of being wiped away by HIV/AIDS. Thailand saw
a strong political and community response at the
beginning of the 1990s in the middle of its decade of
spectacular economic growth and integration into the
world economy.
58
Cambodias response was galvanised by
the appeal for HIV/AIDS not to be a second genocide.
However, we cannot rely on the hope that an eective
movement to demand HIV prevention will emerge
spontaneously. Social mobilisation has been recognised
as a key technique for national HIV/AIDS responses
since at least the late 1980s,
59
and has been a part of many
government, multilateral, donor, and non-governmental
eorts. These eorts at social mobilisation are
increasingly implemented at the scale of whole nations.
For example, Ethiopias HIV/AIDS Prevention and
Control O ce has given priority to cross-cutting eorts
to mobilise Ethiopian society from the level of local
kebeles upwards in its road map towards universal access
to HIV prevention, care, and treatment, and a collective
eort to generate community conversations on HIV/
AIDS is being rolled out across the country.
60

Religious organisations have also been a source of
mass mobilisation in HIV prevention, including both
systematic eorts led by international faith-based
organisations (such as World Vision, the Ecumenical
Advocacy Alliance, Caritas, Saddleback Church, Islamic
Relief, and the Sangha Metta Project), and local eorts by
religious leaders from various faiths. Many youth
organisations have also mobilised against HIV/AIDS,
with interesting examples of the conuence of youth
marketing, social networking, and corporate social
responsibility. These are best exemplied by MTVs
Staying Alive initiative, which began as HIV/
AIDS-related broadcasts for World AIDS Day in 1998, but
has now spawned a mix of music and television
programming and web-based networking with mass
youth participation.
Finally, although the HIV/AIDS activist movement is
today most often associated with access to treatment, we
should remember that the iconic movement of direct
AIDS activism, ACT-UP, took as its most recognisable
slogan silence=death, and at its founding in 1987 was
as much concerned about the silencing of eective HIV/
AIDS education as it was to accelerate processes for drug
development and approval.
61
More recently, as Merson
and colleagues
62
note, one of the worlds most successful
national HIV/AIDS activist organisations, South Africas
Treatment Action Campaign, has used its methods and
organisational capacity in direct support of HIV
prevention, with a series of advocacy eorts and marches
that demand intensied HIV prevention (gure 5).
54
Although each of these sectors can justiably claim to
having successfully generated demand for HIV
prevention, the challenge has been to join these eorts
into a coherent movement that is able to shift social
norms and sexual and drug-use practices. Instead, the
demands of these sectors have been competing or
contradictory: community versus state, religious versus
secular, local versus international, private versus public,
Figure 5: Prevention march by South Africas Treatment Action Campaign
5000 people marched through the streets of Cape Town at the start of the 38th Annual Union World Conference
on Lung Health in November, 2007, organised by the Treatment Action Campaign and the AIDS and Rights Alliance
of Southern Africa. Reproduced with permission of the photographer, Damien Schumann.
Series
and medical versus social. The extent of the pandemic
has made the need to overcome these dierences in the
creation of an eective movement to demand HIV
prevention even more compelling. Such a movement
must be underpinned by several core priorities: full-scale
emergency mobilisation in the worst-aected countries,
attempts to reach all those in need, and taking a
long-term perspective.
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
1549 year-olds are HIV positive,
1
and the annual
incidence in young women is 46%, 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 achieved by changes in sexual
behaviour, such as in Zimbabwe,
63
and HIV prevalence
in young attendees of antenatal clinics has started to
decline in most countries, HIV incidence continues to be
high (eg, half a million new infections per year in South
Africa alone), and could be even rising (eg, in
Mozambique, which could have a younger epidemic).
What makes these societies unique from the HIV/AIDS
perspective is that HIV transmission is far more diuse
than elsewhere, and occurs mostly within long-term and
occasional heterosexual partnerships, often transgressing
traditional concepts of high or low risk. Multiple
vulnerability and risk factors (such as mobility,
gender-based violence, or concurrent partnerships),
which individually exist to an even greater extent in other
regions (eg, low rates of male circumcision in Europe),
converge to act synergistically in these societies. In other
words, southern Africa seems to be experiencing a perfect
storm of HIV-related risks. Any explanation based on a
single risk factor for this very high HIV endemicity
ignores the realities of complex societies and human
behaviour. A complex and diuse epidemic should be
addressed by an equally nuanced and multipronged
response.
Even if greater coverage of all eective interventions
for HIV prevention is a priority in high-prevalence
societies, and would most probably result in large
reductions in HIV incidence, as argued in this Series,
8,21

individual behaviour change alone is unlikely to stop
the spread of HIV in a sustainable way. Comprehensive
HIV prevention should urgently include programmes
that address the key drivers of the epidemic in the
region, in particular those that change societal norms
and create safer sexual environmentseg, working
towards the elimination of sexual coercion and
violenceand those that reduce the vulnerability of
communities and individuals, such as food security
programmes or adjustments to labour migration to
minimise family disruption.
64
In communities that are heavily aected by HIV/
AIDS, HIV-prevention activities must also go hand in
hand with HIV treatment and strategies to mitigate
eects on individuals, households, and communities.
Promotion of HIV prevention without mitigating the
overwhelming consequences of the epidemic has little
credibility and provides few incentives for safe sexual
behaviour.
65,66
These principles have been put into
practice in many settings. For example, in Zambia, the
Antiretroviral Community Education and Referral
Project, ACER, aimed to bolster positive attitudes to
treatment and prevention in communities by employing
treatment-support workers and treatment mobilisers.
67

The project has since been extended to Uganda and
within Zambia on the basis of its generally positive
eects (although project sites and comparisons sites did
not dier on most measures, including sexual
behaviours).
68
Both operational research and systematic
evaluation should urgently try to not only capture the
ways in which integrated interventions which tackle
social vulnerability can be made more eective, but also
measure their eect on HIV-related outcomes, such as
quality of life, mortality, and HIV transmission.
The challenge in the hyperendemic context is not so
much to specify the content of HIV-prevention
programmes (with some exceptions such as interventions
for serodiscordant couples) but to identify the
mechanisms by which these programmes will be
implemented at su cient scale. The substance of HIV
prevention has been well developed in the region itself.
69

The di cult challenges are to elevate HIV prevention as
a national emergency,
70
and to deliver on leadership,
governance, institutional and community capacity,
account ability, and implementation in general. Initiation
of such a nationwide emergency response has at least
three major policy implications: (1) HIV prevention must
be an integral part of a countrys development plan;
(2) multiple sectors in government and civil society must
be actively engaged; and (3) the eort must be eectively
led at the highest level of the state, as is the case in
Botswana.
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 dierence 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 designed to capture these dynamics.
Agent-based models are increasingly being used to
Series
understand the dynamic characteristics of complex
systems, such as sexual networks. The analytical tools
which have led to the identication of characteristics
which make complex systems more able to adapt
positively to change and diuse innovation
72
could have
much to oer eorts to implement HIV-prevention
programmes.
Attention to the how of HIV prevention must also
entail attention to issues of scale: with the goal of
optimising programme settings (panel 5).
2
A dierent
set of operational issues come to the fore when full-scale
responses are attempted as opposed to pilot schemes or
research projects, but very little operational research
has investigated the means of going to scale, and
correspondingly lessons learnt in scaling up have not
been disseminated. The Avahan initiative in India (see
Bertozzi and colleagues)
2
has taken scale-up as one of
the key elements of its business model and has an
explicit strategy to achieve scale-up through partnerships
among four sectors: government, networks of
non-governmental and community organisations,
business, and donors.
73
Another example of a very large
country attempting to reach full national coverage is
Ethiopia and the ambitious targets of its Millennium
AIDS Campaign (commenced in 2007, at the turn of
the new millennium under the Julian calendar used in
Ethiopia).
74
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 benecial
for HIV prevention. For this and other reasons, the
debate in some public-health and political circles that
polarises so-called vertical HIV/AIDS programmes
versus horizontal strengthening of health services is the
wrong agenda, and is unhelpful for the HIV/AIDS
response. The needs of individuals or communities do
not come packaged into sectoral boxes, and an activist
HIV/AIDS movement, focused on meeting real needs
eectively, will not only be the strongest weapon against
the ine ciencies of 20th century verticality, but also a
corrective to system strengthening without clearly
dened objectives.
Clear and simple criteria for managing performance
within countries and between them is crucial to success
if we can measure it, we can manage it. Such criteria
allow us to highlight successes as best practice and to
identify underperformers for intensive interventions.
Positive competition can lead countries to review and
raise their performances. Other sectors provide important
lessons. Positive performance towards universally
respected goals, including increased immunisation,
education, or coverage of HIV/AIDS treatment, enhances
international condence in development in a way that
capacity or systems-building initiatives alone cannot do.
The delivery of immunisation (spearheaded by the Global
Alliance for Vaccines and Immunisation [GAVI Alliance]),
the international commitment to Education for All and
the associated Fast Track Initiative, and the roll-out of
antiretroviral therapy share some common and important
lessons. First, all set important ambitious goals that were
considered unattainable when rst proclaimed. Such
goals lift our vision of what is possible and lead to far
higher achievement than is possible in the absence of
such aspirational goals. Second, if we focus on crucial
development challenges with laser-like intensity, we can
achieve exceptional progress. Third, and relatedly, even
in an age of budget support, sector-wide approaches, and
health-systems development, special initiatives are
needed, supported by distinct goals, technical teams,
nancing, management, and monitoring mechanisms:
both system-wide and focused initiatives are needed.
Eective and large-scale HIV prevention requires the
active engagement of many state and non-state actors,
and has been a hallmark of successful AIDS programmes.
By contrast with some claims, such pluralism in action is
not a bad thing. Maximal eectiveness is achieved when
all entities working on HIV prevention in a given country
Panel 5: The programming cycle for HIV prevention
Know your epidemic, and create a situation analysis that
sets programmatic targets where new HIV infections are
occurring
Know your response, and ensure the response addresses
both the immediate risks and underlying drivers of the
epidemic
Allocate resources where they will make the biggest
dierence in the country, for reduction of both risk and
vulnerability
Implement in a very systematic way a business plan for
HIV prevention, with clear responsibilities and deliverables
for all actors, and address not only the individual
dimensions of HIV prevention but also the legal, cultural,
and social environment
Invest in the management capacity of both governmental
and non-governmental organisations
Use the integrated tools of social-change advocacy,
communication, and community mobilisation to
generate a prevention constituency and support
development of community capacity
Carefully design methods to assess eectiveness, measure
progress, and review implementation; hold people at all
levels of the response publicly accountable for their
performance and ensure that programmes are adapted in
the light of reviews
Series
commit to work towards the realisation and continuous
improvement of nationally and locally dened goals,
along the principles of the Three Ones (panel 6).
75
These
principlesa coherent AIDS response guided by one
national authority, one strategic plan, and a single
monitoring and assessment frameworkhave been
almost universally embraced.
The Three Ones have greatly strengthened the
partnership between developing countries and those who
provide nancial assistance to HIV/AIDS programmes.
However, embracing these principles has not yet realised
the practical benets of a reduced reporting burden; nor
has it produced predictability in funding or increased
investment in capacity building. These are precisely the
outcomes that are most needed in the context of HIV/
AIDS, since in the worst-aected countries, national
administrative and management capacities, which are
already often in a weak state, have been further depleted
by the epidemic.
76
Implementation of the HIV-prevention actions
proposed in this paper and Series will require a substantial
boost in spending, from both global and domestic
sources. As important as the level of funding is its
predictability. Many of the actions we have called for need
sustained long-term investmentbuilding prevention
capacity, for example, or developing the community
infrastructure that is essential to support demand for
HIV prevention.
About 40% of the US$10 billion spent on HIV/AIDS in
low-income and middle-income countries in 2007 went
to prevention. The recent UNAIDS estimate of global
resource needs estimated that HIV prevention activities
and services will cost US $116 billion by 2010 and US
$153 billion by 2015 as programmes phase up to reach
universal access.
77
That calculation was made on the basis
of several elements that are commonly used in
HIV-prevention programmes. The proposals we have
made here dier in emphasis but are unlikely to cost
more: our argument is as much about spending smarter,
once the threshold for universal access is met.
Implementing HIV prevention in this way would have a
major eect on the epidemicmore than half of the new
infections between now and 2015 would be averted. In
other words, if combination prevention is intensied as
rapidly as possible from today, then some 12 million HIV
fewer infections will occur between now and 2015 than
will occur if incidence at todays levels remains constant,
and the annual number of new infections in 2015 will
have reduced by two-thirds.
1,78

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; the geopolitical environment around HIV/AIDS
could take positive (or not so positive) turns in aecting
the legislative environment, bueted by the winds of
xenophobia and religious and other fundamentalisms;
and leaders and public opinion are prone to complacency
and fatigue.
The state of HIV/AIDS is at a highly vulnerable point.
Although we have made progress in some areas, the
gains made can be lost quickly if we are not vigilant in
sustainingand building onareas that already show
results. Beyond sustaining our gains, we need to keep
our eyes on the horizon, build in a readiness and
exibility to manage uncertainty and surprises, and
Panel 6: The Three Ones in India
The Indian Governments National AIDS Control Programme is now in its third 5 year
cycle, and is demonstrably reducing HIV infection in Indias southern and western states,
which have the highest prevalence of HIV. The key strengths of the programme are:
An institutional framework that supports central leadership and harmonisation,
combined with a sustained, decentralised response consisting of: a legislatively-based
National AIDS Control Authority (NACO), with senior Indian Administrative Service
leadership; a National AIDS Commission, chaired by the Prime Minister; and
independent state AIDS-control societies, established under the Societies Act and
functioning under the leadership of NACO. Indias robust approach to donor
harmonisation, and its 2003 policy to eliminate small bilateral programmes in favour
of programmes consolidated through multilateral donors or non-governmental
organisations (NGOs), is both a consequence of clear national leadership and a cause
of increased eectiveness of aid
Clear scientic leadership: Indias surveillance and research programme, supported by
local and international partners, decisively established that India faces a concentrated
epidemic
Translation of scientic vision into implementation systems and procedures: for
example implementation, funding, costing, performance, and monitoring systems
developed by NACO for sex-worker interventions enabled it to support thousands of
targeted interventions, and to better coordinate development partners
Recognition of what government can and cannot do: India recognised that the private
sector is better placed than government to develop media campaigns to change
behaviour and to socially market condoms and that NGOs are far better placed than
government to work with vulnerable groups of sex workers, men who have sex with
men, and injecting drug users. The Indian government recognised and partnered with
excellence outside government; for example, steps taken to ensure that expertise
from the Avahan programme, funded by the Bill & Melinda Gates Foundation, would
ow back into the national programme
Focus and prioritisation: as the character of Indias epidemic became clearer with
improved national surveillance, the HIV programme became more focused, resisting
the tendency for mission spread or for it to drift into low-priority activities
The achievements of Indias coordinated HIV response should not disguise the ongoing
challenges: in a large federal nation, some states lag far behind others in the scale and
eectiveness of their response. Some vulnerable groups have been neglected in the
response: for example, national eorts in relation to men who have sex with men were
only fully embraced in the most recent (third) National AIDS Control Programme, and
were also initially neglected by the Avahan programme.
Series
develop resilience to negative changes that could
undermine our progress to date.
We need resilience at many levels. We need predictability
in funding owsmoving from short-term to long-term
funding commitments. We need resilience in
leadershipbuilding coalitions that will not wane when
individual leaders change. We need resilience in public
awareness about the state of HIV/AIDS to ensure an
Call to action
We urge governments, communities and scientists to fully implement combination HIV prevention, and urge the
international community to mobilise all the support necessary for this eort
Every HIV/AIDS programme must know its epidemic and its response, by an analysis of where the epidemic is, where the next
1000 HIV infections are likely to come from, and where socioeconomic change suggests they could come from in 10 years time
Focus on an optimal mix of quality eorts in terms of what is most needed for the populations most aected and most at risk,
respecting dierent types of evidence, and connecting HIV prevention with treatment eorts
Scale up coverage to optimal levels to ensure universal access to HIV prevention, starting by using what we have more eectively
and giving access to basic programmes for HIV prevention (eg, condoms and prevention of mother-to-child transmission)
Set specic, ambitious, and actionable targets to reach universal access to HIV prevention
Generate systematic social change to prevent the spread of HIV and reduce vulnerability to it, by using the full range of
contemporary media, reforming discriminatory laws, supporting access to justice, creating safe spaces away from gender-based
violence, and prosecuting sexual violence
We call for sustained political and technical leadership for the AIDS response
Adopt HIV prevention as a national cause, and rally support for the cause in every possible context, including workplaces,
schools, communities, and places of worship
Establish clear responsibility and accountability for HIV prevention eorts, and make sure that national prevention taskforces
are established to push prevention goals
Muster the political courage to advocate scientically sound approaches in sensitive areas of sexuality, gender, and drug use,
including the full set of eective harm-reduction methods in relation to HIV and injecting drug use, addressing sex education to
children before they become sexually active, and including sexual minorities in HIV programmes
Support governments and donors to deliver on a shared commitment to predictable and sustained nancing for HIV prevention
that eliminates duplication and minimises transaction costs
Guide AIDS responses in a spirit of pragmatism and science, instead of using HIV/AIDS as a vehicle to advance dogma of any kind
We urge international institutions, national governments, and community activists to work together to build demand for
HIV prevention
Develop a broad HIV-prevention movement, grounded in the strengthening of natural constituencies for HIV prevention in the
communities of those who are most vulnerable and aected
Support HIV-prevention literacy at all levels, linked to the successful scaling up of treatment literacy
Identify and promote bold advocates and public models for changing harmful social, behavioural, and legal norms and practices
Create an active coalition between the movement for HIV prevention and the movement of people living with HIV/AIDS, and
link this coalition with other motors of social change, including treatment activists, entrepreneurs, rights activists, and womens
and youth activists
We urge scientists, research funders, and programme planners to broaden the HIV-prevention research agenda
Create an agenda for operations research and evaluation and ensure its funding, focused on what strategies work best under
what circumstances and how best to deliver them
Research novel approaches to implementation science and interdisciplinary applications to elucidate ways to tackle the
structural drivers of the epidemic
Continue the concerted and coordinated search for an HIV vaccine
Invest in research on many potential HIV-prevention technologies, including microbicides and antiretroviral prevention
We call for immediate investment in building capacities at all levels for HIV-prevention eorts
Invest in managerial, technical, and implementation capacity for national HIV/AIDS authorities, to allow them to direct the
HIV-prevention response with condence
Invest equally in capacity building in the community sector, which has the lions share of responsibility for HIV prevention
Adopt a combination approach to capacity building in governmental and non-governmental sectors, by developing a cadre of
competent HIV-prevention personnel in the range of professional disciplines that are needed to make up a strong HIV-
prevention response
Invest in the capacity for HIV-prevention policy, research, and assessment
Series
honest understanding of real risks rather than
complacency due to a perception that things are somehow
ok. And we need resilience in programmes and
researchrecognising that eective implementation
does not achieve, and cannot demonstrate, its results
over the short term.
We need to be thinking ahead, not only to anticipate
the next technologies in the pipeline, but also the issues
around their introduction. Experience with introduction
of other vaccines to target populations of reproductive
age, such as human papillomavirus and tetanus,
represents lessons that we can draw from. The
introduction of new technologies will not only need
long-term thinking in terms of the policy environment
and building community acceptance, but also the
long-term nancial implications.
In terms of a research agenda, in the same way that we
need to take multiple combination approaches to
prevention programming, we need to take a combination
approach to the development of new technologies and
build a research agenda that not only anticipates new
needs but addresses known needs, and encompasses the
full range of factors which aect the epidemic.
Ultimately, we need to come to terms with addressing
the underlying social drivers of HIV/AIDS. Prevention
work takes the longest time, is largely outside of health
services, and has no quick win. If not tackled,
prevention work will also continue to undermine all the
other gains. On the other hand, progress in addressing
social drivers will accelerate access to, and long-term
eects of, other prevention technologies and inter-
ventions. The aids 2031 project aims to address many of
these issues through the lens of looking at the longer
term implications of not analysing, anticipating, and
dealing with key drivers of the epidemic now. Its report
An Agenda for the Future will be delivered by the end
of 2009 with recommendations intended to guide
decision makers and activists as they plan for the future
response to HIV/AIDS.
80
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
eort towards HIV preventionas has been successfully
made towards HIV treatmentis 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: specic
prevention targets set at the historic UN General
Assembly Special Session on AIDS in 2001, together
with the political declaration adopted by the UN General
Assembly in 2006 that committed to coming as close as
possible towards universal access to HIV prevention,
treatment care, and support by 2010.
81
If access to
HIV-prevention knowledge and tools is recognised as a
basic human right, resources will have to be made
available and an enabling environment created so that
everyone has such access. This investment in our future
would make ethical and economic sense in terms of the
enormous dividends it will provide. The articles in this
Series point to some of the key action areas in HIV
prevention in which we need to make such an
unprecedented investment (see Call to Action panel).
None of the successes in HIV prevention over the past
quarter of a century have been easily won. They have
required taboos to be broken, pleasures foregone, and
resources reallocated. When HIV/AIDS was brand new
and seen clearly as an emergency, these costs seemed
easier to bear. The challenge for HIV prevention today is
to sustain a momentum for eective, complex,
combination eorts over the long haul. A failure of
condence now in our collective capacity to deliver
full-scale and eective HIV prevention would be
devastating, and its eect would be felt for generations.
We cannot expect that miraculous results will be
universally evident over the current political or funding
cycle, or even over the next one. But we must have the
courage to press ahead, because if we fail the challenge of
HIV prevention, HIV/AIDS will relentlessly undermine
human progress. An energised HIV-prevention move-
ment, marching hand in hand with the movement to
make access to treatment universal, is a goal truly worth
the eort it will take.
Conict of interest statement
We declare that we have no conict of interest.
Acknowledgments
We thank our reviewers David Apuuli, Agnes Binagwaho, Jerey OMalley,
Michael Merson, and Stefano Bertozzi for their helpful comments on
drafts of this paper; and Peter Ghys, Karen Stanecki, Jose-Antonio Izazola,
Carlos Avila, Matthew Warner-Smith, Paul De Lay, and Deborah Rugg of
the UNAIDS Secretariat in Geneva for useful comments and access to
information about global and national AIDS responses.
References
1 UNAIDS. UNAIDS report on the global AIDS epidemic2008.
Geneva, Switzerland: Joint United Nations Programme on HIV/
AIDS, 2008 (in press).
2 Bertozzi SM, Laga M, Bautista-Arredondo S, Coutinho A. Making
HIV prevention programmes work. Lancet 2008; published online
Aug 6. DOI:10.1016/S0140-6736(08)60889-2.
3 UNAIDS Eastern and Southern Africa Regional Support Team.
Review of HIV prevention response of the UN in Lesotho: joint UN
team on AIDS in Lesotho. Johannesburg, South Africa: Mission of
the Regional Inter-Agency Prevention Working Group, 2007. http://
www.unaidsrstesa.org/Documents/unaids_toolkit/data/D011_Lesot
hoInterAgencyReviewMissionOnHivPrevention_Mission_Report.
pdf (accessed June 18, 2008).
4 van Griensven F. The epidemiology of HIV and STI among men
who have sex with men and transgender in Asia. Presentation at the
8th International Congress on AIDS in Asia and the Pacic.
Colombo, Sri Lanka, 1923 August, 2007.
5 Baxter D. Bangkoks MSM HIV Explosionprecursor for Asias
mega-cities? HIV Australia 2006; 5: 611.
6 Ministry of Public Health, Thailand. Towards universal access
by 2010: Thailand national HIV and AIDS program. Bangkok,
Thailand: Bureau Of AIDS, TB and STIs, Department of Disease
Control, Ministry of Public Health, 2006.
7 UNAIDS. Practical Guidelines for Intensifying HIV Prevention.
Geneva, Switzerland: Joint United Nations Programme on
HIV/AIDS, 2007.
Series
8 Rao Gupta G, Parkhurst JO, Ogden JA, Aggleton P, Mahal A.
Structural approaches to HIV prevention. Lancet 2008; published
online Aug 6. DOI:10.1016/S0140-6736(08)60887-9.
9 Jegede AS. What led to the Nigerian boycott of the polio vaccination
campaign? PLoS Med 2007; 4: e73. DOI:10.1371/journal.
pmed.0040073.
10 UNFPA. Culture matters. working with communities and
faith-based organizations: case studies from country programmes.
New York, USA: United Nations Population Fund, 2004.
11 Anderson RM. The spread of HIV and sexual mixing patterns. In:
Mann JM, Tarantola DJM, eds. AIDS in the world II: global
dimensions, social roots, and responses. New York, NY, USA:
Oxford University Press, 1996: 7186.
12 UNODC. 2007 world drug report. Vienna, Austria: United Nations
O ce on Drugs and Crime, 2007. http://www.unodc.org/pdf/
research/wdr07/WDR_2007.pdf (accessed Jan 17, 2008).
13 Beckerleg S, Telfer M, Lewando Hundt G. The rise of injecting drug
use in east Africa: a case study from Kenya. Harm Reduct J 2005; 2: 12.
14 IRIN Africa. West Africa: Impunity and low risk make region
haven for tra ckers. July 5, 2007. http://www.irinnews.org/report.
aspx?ReportId=73105 (accessed Jan 23, 2008).
15 UNAIDS Eastern Europe and Central Asia. AIDS epidemic update:
regional summary Geneva, Switzerland: Joint United Nations
Programme on HIV/AIDS, 2008. http://data.unaids.org/pub/
Report/2008/jc1529_epibriefs_eeurope_casia_en.pdf (accessed June
20, 2008).
16 UNAIDS. AIDS in Africa: three scenarios to 2025. Geneva,
Switzerland: Joint United Nations Programme on HIV/AIDS, 2004.
17 Padian NS, Buv A, Balkus J, Serwadda D, Cates W Jr. Biomedical
interventions to prevent HIV infection: evidence, challenges, and
way forward. Lancet 2008; published online Aug 6. DOI:10.1016/
S0140-6736(08)60885-5.
18 Halperin D, Steiner MJ, Cassell MM, et al. The time has come for
common ground on preventing sexual transmission of HIV. Lancet
2004; 363: 191314.
19 UNAIDS. Intensifying HIV prevention: UNAIDS policy position
paper. Geneva, Switzerland: Joint United Nations Programme on
HIV/AIDS, 2005. http://data.unaids.org/publications/irc-pub06/
jc1165-intensif_hiv-newstyle_en.pdf (accessed Jan 17, 2008).
20 Coates TJ, Richter L, Caceres C. Behavioural strategies to reduce
HIV transmission: how to make them work better. Lancet 2008;
published online Aug 6. DOI:10.1016/S0140-6736(08)60886-7.
21 US CDC. Updated compendium of evidence-based interventions.
Atlanta, GA, USA: US Centers for Disease Control and Prevention,
2008. http://www.cdc.gov/hiv/topics/research/prs/evidence-based-
interventions.htm (accessed Jan 16, 2008).
22 Dunkle KL, Stephenson R, Karita E, et al. New heterosexually
transmitted HIV infections in married or cohabiting couples in
urban Zambia and Rwanda: an analysis of survey and clinical data.
Lancet 2008; 371: 218391.
23 Wabrire-Mangen F. Rapid assessment of trends and drivers of the
HIV epidemic and eectiveness of prevention interventions in
Uganda. Kampala, Uganda: Uganda AIDS Commission, 2006.
24 de Walque, D. Discordant couples: HIV infection among couples in
Burkina Faso, Cameroon, Ghana, Kenya, and Tanzania. World Bank
Policy Research Working Paper No 3956. Washington, DC, USA:
World Bank, 2006.
25 Lingappa JR, Lambdin B, Bukusi EA, et al 2008. Regional
dierences in prevalence of HIV-1 discordance in Africa and
enrollment of HIV-1 discordant couples into an HIV-1 prevention
trial. http://www.plosone.org/article/info:doi/10.1371/journal.pone.
0001411#pone.0001411-Allen1 (accessed April 28, 2008).
26 Vernazza P, Hirschel B, Bernasconi E, Flepp M. Les personnes
sropositives ne sourant daucune autre MST et suivant un
traitement antirtroviral e cace ne transmettent pas le VIH par
voie sexuelle. Bull Med Suisses 2008; 89: 16569. http://www.saez.ch/
pdf_f/2008/2008-05/2008-05-089.PDF (accessed Feb 5, 2008).
27 Morris M, Kretzchmar M. Concurrent partnerships and the spread
of HIV. AIDS 1997; 11: 68183.
28 Halperin D, Epstein H. Concurrent sexual partnerships help to
explain Africas high HIV prevalence: implications for prevention.
Lancet 2004; 364: 46.
29 Wellings K, Collumbien M, Slaymaker E, et al. Sexual behaviour in
context: a global perspective. Lancet 2006; 368: 170628.
30 Garnett GP. Theory is critical in understanding the risks of
acquiring HIV. Sex Transm Dis 2007; 34: 73738.
31 Prieur A. Norwegian gay men: reasons for continued practice of
unsafe sex. AIDS Educ Prev 1990; 2: 10115.
32 Soul City Research Unit. HIV prevention: multiple and concurrent
sexual partnerships among youths and adults in South Africa.
Johannesburg, South Africa: Soul City Institute, 2007. http://www.
soulcity.org.za/programmes/research/target-audience-research/
soul-city-series/South_Africa_MCP_Report_nal.pdf/ (accessed
June 16, 2008).
33 Izazola-Licea JA, Valladares R. Financing and expenditure in
response to HIV/AIDS in Latin America and the Caribbean.
Washington, DC: International Development Bank, 2002.
34 Health Policy Initiative. HIV expenditure on MSM programming in
the Asia-Pacic region. Presented at International Consultation on
Male sexual health and HIV in Asia and the Pacic. New Delhi,
India: September 2226, 2006.
35 Commission on AIDS in Asia. Redening AIDS in Asia: crafting an
eective response. New Delhi, India: Oxford University Press, 2008.
http://data.unaids.org/pub/Report/2008/20080326_report_
commission_aids_en.pdf (accessed May 26, 2008).
36 van Griensven, F. Men who have sex with men and their HIV
epidemics in Africa. AIDS 2007; 21: 136162.
37 UNAIDS. Information Dashboard. UNAIDS Country Coordinator
Annual Reports 2007. Geneva, Switzerland: Joint United Nations
Programme on HIV/AIDS, 2007.
38 Grunseit A, Kippax S, Aggleton P, Baldo M, Slutkin G. Sexuality
education and young peoples sexual behavior: a review of studies.
J Adolesc Res 1997; 12: 42153.
39 Committee on the Prevention of HIV Infection among Injecting
Drug Users in High-Risk Countries, Institute of Medicine.
Preventing HIV infection among injecting drug users in high-risk
countries an assessment of the evidence. Washington, DC, USA:
The National Academies Press, 2006.
40 WHO/UNODC/UNAIDS. Draft technical guide for countries to set
targets for universal access to HIV prevention, treatment and care
for injecting drug users. Geneva: Switzerland: WHO/UNODC/
UNAIDS, 2008. http://www.who.int/hiv/idu/TechnicalGuideTarget
SettingApril08.pdf (accessed June 16 2008).
41 The Travel Resource Centre, INDRO. International coordination
and information service for drug substitution patients seeking to
travel abroad. Mnster, Germany: INDRO, 2008.
http://www.indro-online.de/nia.htm (accessed April 14, 2008).
42 Cohen J. HIV/AIDS in India: the needle and the damage done.
Science 204; 304: 50912.
43 Chandrasekaran P, Dallabetta G, Loo V, Rao S, Gayle H,
Alexander A. Containing HIV/AIDS in India: the unnished
agenda. Lancet Infect Dis 2007; 6: 508521.
44 State Council HIV/AIDS Working Committee O ce. A joint
assessment of HIV/AIDS prevention, treatment and care in China.
Beijing, China: State Council HIV/AIDS Working Committee O ce
and UN Theme Group on HIV/AIDS in China, 2004.
45 Hammett TM, Wu Z, Duc TT, et al. Social evils and harm
reduction: the evolving policy environment for human
immunodeciency virus prevention among injection drug users in
China and Vietnam. Addiction 2008; 103: 137145.
46 Mesquita F, Winarso I, Atmosukarto II, et al. Public health the
leading force of the Indonesian response to the HIV/AIDS crisis
among people who inject drugs. Harm Reduct J 2007; 4: 9.
47 Schleifer R. Rhetoric and risk: human rights abuses impeding
Ukraines ght against HIV/AIDS. New York, USA: Human Rights
Watch, 2006. http://hrw.org/reports/2006/ukraine0306/ (accessed
Jan 20, 2008).
48 PMTCT Global Partners Forum. Consensus statement on achieving
universal access to comprehensive prevention of mother-to-child
transmission services. New York, USA: UNICEF, 2007.
www.unicef.org/aids/les/GPF_PMTCT_consensus_statement.pdf
(accessed May 26, 2008).
49 Degenhardt L, Mathers B, Guarinieri M, et al. The global
epidemiology of methamphetamine injection: A review of the
evidence on use and associations with HIV and other harm.
Thematic report produced for the reference group to the UN on
injecting drug use. New South Wales, Australia: National Drug and
Alcohol Research Centre, University of New South Wales, 2008.
Series
50 UNICEF, UNAIDS, WHO. Children and AIDS: Second stocktaking
report. New York, USA: UNICEF, 2008. http://www.unicef.org/
aids/les/ChildrenAIDS_SecondStocktakingReport.pdf (accessed
June 10, 2008).
51 WHO. Towards universal access: scaling up priority HIV/AIDS
interventions in the health sector. Progress Report 2008. Geneva,
Switzerland: World Health Organization, 2008.
52 Inter-Agency Task Team on Prevention of HIV Infection in
Pregnant Women, Mothers and their Children. Guidance on global
scale-up of the prevention of mother to child transmission of HIV:
towards universal access for women, infants and young children
and eliminating HIV and AIDS among children. Geneva:
Switzerland: WHO, 2007. http://www.unicef.org/aids/les/
PMTCT_enWEBNov26.pdf (accessed June 10, 2008).
53 Piot P, Russell S, Larson H. Good politics, bad politics: the
experience of AIDS. Am J Publ Health 2007; 97: 193436.
54 Treatment Action Campaign. Making HIV prevention work.
Equal Treatment, Newsletter of the Treatment Action Campaign.
Cape Town, South Africa: Treatment Action Campaign, 2006.
http://www.tac.org.za/documents/et21.pdf (accessed April 14, 2008).
55 Government of Sweden. Standing up for HIV prevention: Towards
a global movement for HIV prevention advocacy. Conference in
Stockholm, Sweden; May, 2006. http://www.sida.se/shared/jsp/
download.jsp?f=SIDA29040en_Speaking_up_HIV.pdf&a=24040
(accessed April 30, 2008).
56 Galvo J. Brazil and access to HIV/AIDS drugs: a question of
human rights and public health. Am J Public Health 2005;
95: 111016.
57 Watney S. Practices of freedom: citizenship and the politics of
identity in the age of AIDS. Rutherford J, ed. Identity. Community,
Culture, Dierence. London, UK: Lawrence & Wishart, 1990: 15787.
58 Jitsuchon S. Sources and pro-poorness of Thailands economic
growth. Thammasat Econ J 2006; 24: 68105.
59 Helguera G, Acuna ML, Chavez-Peon F, Sepulveda J. Social
mobilization in the prevention of AIDS. Int Conf AIDS 1990; 6: 294.
60 Federal Ministry of Health. Accelerated access to HIV/AIDS
prevention, care and treatment in Ethiopia. Road Map for
20072008/10. Addis Ababa, Ethiopia: Federal Ministry of Health,
2005. http://www.etharc.org/publications/moh/eth_
hivroadmap2007-2010.pdf (accessed April 3, 2008).
61 Crimp D, ed. AIDS: cultural analysis/cultural activism. Cambridge,
USA: MIT Press, 1988.
62 Merson MH, OMalley J, Serwadda D, Apisuk C. The history and
challenge of HIV prevention. Lancet 2008; published online Aug 6.
DOI:10.1016/S0140-6736(08)60884-3.
63 Hallet TB, Aberle-Grasse J, Bello G, et al. Declines in HIV
prevalence can be associated with changing sexual behaviour in
Uganda, urban Kenya, Zimbabwe, and urban Haiti.
Sex Transm Infect 2006; 82: 18.
64 Hankins C. From a vicious circle to a virtuous circle: reinforcing
strategies of risk, vulnerability, and impact reduction for HIV
prevention. Lancet 2004; 364: 191516.
65 UNAIDS. Expanding the global response to HIV/AIDS through
focused action. Reducing risk and vulnerability: denitions,
rationale and pathways. Geneva, Switzerland: Joint United Nations
Programme on HIV/AIDS, 1998.
66 UNAIDS. The global strategy framework on HIV/AIDS. Geneva,
http://data.unaids.org/Publications/IRC-pub02/
JC637-GlobalFramew_en.pdf (accessed June 10, 2008).
67 Population Council. Engaging communities in supporting HIV
prevention and adherence to antiretroviral therapy in Zambia.
Research Summary. Washington, DC, USA: Horizons/The
Population Council, 2008. http://www.popcouncil.org/pdfs/
horizons/Zambia_ARVAdherenceSum.pdf (accessed June 16, 2008).
68 Samuels F, Simbaya J, Sarna A, Geibel S, Ndubani P, Kamwanga J.
Engaging communities in supporting HIV prevention and
adherence to antiretroviral therapy in Zambia, Horizons Research
Summary. Washington, DC, USA: Population Council, 2008.
69 SADC. Expert think tank meeting on HIV prevention in
high-prevalence countries in southern Africa. Gabarone, Botswana:
Southern African Development Community, 2006.
http://data.unaids.org/pub/Report/2006/20060601_sadc_meeting_
report_en.pdf (accessed June 3, 2008).
70 Whiteside A, Whalley A. Reviewing emergencies in Swaziland.
Shifting the paradigm in a new era. Mbabane, Swaziland: Health
Economics and HIV/AIDS Research Division, University of
KwaZulu-Natal, Durban, 2007, http://data.unaids.org/pub/
Report/2007/swaziland%20emergency%20report_nal%20pdf_
en.pdf (accessed June 3, 2008).
71 Madon T, Hofman KJ, Kupfer L, Glass RI. Implementation science.
Science 2007; 318: 172829.
72 Rogers EM, Medina UE, Rivera MA, Wiley CJ. Complex adaptive
systems and the diusion of innovations. Pub Sector Innov J 2005;
10: 126.
73 Alexander A. Presentation at Partnerships: working together for
global health. Global Health Council Conference, Washington, DC,
USA; May 30, 2007. http://www.kaisernetwork.org/health_cast/
uploaded_les/050307_ghc_open_day1_transcript1.pdf (accessed
June 17, 2008).
74 Federal Democratic Republic of Ethiopia. Report on progress
towards implementation of the UN Declaration of Commitment on
HIV/AIDS. Addis Ababa, Ethiopia: Federal HIV/AIDS Prevention
and Control O ce, 2008. http://data.unaids.org/pub/Report/2008/
ethiopia_2008_country_progress_report_en.pdf (accessed
April 4, 2008).
75 UNAIDS. Three Ones. Key Principles. Geneva, Switzerland: Joint
United Nations Programme on HIV/AIDS, 2004. http://data.unaids.
org/UNA-docs/Three-Ones_KeyPrinciples_en.pdf (accessed
April 12, 2008).
76 Whiteside A. HIV/AIDS: a very short introduction. Oxford, UK:
Oxford University press, 2008.
77 UNAIDS. Financial resources required to achieve universal access
to HIV prevention, treatment, care and support. Geneva,
78 Stover J, Bertozzi S, Gutierrez JP, et al. The global impact of scaling
up HIV/AIDS prevention programs in low- and middle-income
countries. Science 2006; 311: 147476.
79 Piot P. AIDS: from crisis management to sustained strategic
response. Lancet 2006; 368: 52630.
80 aids2031 consortium. Developing an agenda for the future:
anticipating 50 years of AIDS. 2008. http://www.aids2031.org/pdfs/
aids2031%20-%20overview%20of %20aids2031-
%20march%207%202008.doc (accessed April 30, 2008).
81 UN General Assembly. Declaration of commitment on HIV/AIDS
and political declaration on HIV/AIDS: midway to the Millennium
Development Goals. Report of the Secretary-General (A/62/780).
April, 2008. http://data.unaids.org/pub/Report/2008/20080429_sg_
progress_report_en.pdf (accessed June 10, 2008).

HIV Prevention 6: Coming To Terms With Complexity: A Call To Action For HIV Prevention

Uploaded by

Copyright:

Available Formats

HIV Prevention 6: Coming To Terms With Complexity: A Call To Action For HIV Prevention

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

HIV Prevention 6: Coming To Terms With Complexity: A Call To Action For HIV Prevention

Uploaded by

Copyright:

Available Formats

Series

www.thelancet.com Vol 372 September 6, 2008 845

You might also like