The History and Challenge of HIV Prevention

Published as the first in a series of six articles about HIV prevention in The Lancet (Vol. 372, pp. 475–88), this report assesses strategies that have emerged throughout the history of efforts to respond to the global HIV and AIDS epidemic. The authors' primary claim is that the response has for the most part been delayed, fragmented, inconsistent, and - in general - insufficient. One way they make the case for this is through tables (e.g., the estimated number of people (children and adults) living with HIV, 2007), figures (e.g., estimates of the yearly number of new HIV infections and HIV incidence rate, 2005), maps (e.g., HIV prevalence in individuals aged 15-49 years in 2001 and in 2007), and panels (e.g., social and community structures and vulnerability to HIV/AIDS).

Tracing the critical events in the global response to HIV/AIDS since the first cases of AIDS were reported by the Centers for Disease Control and Prevention (CDC) in 1981, the authors outline various shortcomings along the way, such as the mistakes of the mid-1990s, when HIV/AIDS slipped down the political agenda and the pandemic greatly expanded. One reason for these failures is an insufficient focus on the role of communication; the authors claim that "[s]uccessful responses have addressed sensitive social factors surrounding HIV prevention, such as sexual behaviour, drug use, and gender equalities, countered stigma and discrimination, and mobilised affected communities; but such responses have been few and far between." They indicate that it was not until the turn of the millennium that a new receptivity to tackling HIV prevention emerged. In addition to the allocation of substantial resources to the effort, the authors stress the following elements as crucial in moving forward:

• "Successful prevention requires knowledge of the nature of the epidemic in individual countries, as well as community and country contexts. Broader socioeconomic and cultural factors (eg, poverty, human rights, religion) that affect the spread of the virus must be addressed, but our early assumptions about their interactions have been too simplistic and need to be better understood."
• "...[A]ll national-level successes have been associated with government (often inter-governmental) leadership and community activism. Such leadership and activism is particularly important for sustaining and renewing responses, especially among populations...who continue to face stigma and discrimination....They are also essential for achieving a truly multisectoral response of the type that occurred in countries with early prevention success (eg, Uganda, Thailand)..."
• "Early prevention successes evolved from collective responses generated by people living with HIV/AIDS and community groups, and confronted the stigma, discrimination, and denial associated with the disease..."
• "Combination prevention - ie, a combination of behavioural, structural, and biomedical prevention paradigms and approaches adapted and prioritised to specific contexts and based on scientifically derived evidence and bottom-up wisdom and ownership of local communities - offers the best hope for success in prevention. To achieve this will involve building synergies between prevention, care, and treatment."
• "We need not only more managers, public-health experts, physicians, and nurses, but also a new cadre of community workers whose education is rooted in community development, gender equity, human rights, and public health, and who will be equally powerful in the promotion of hygiene, sanitation, and use of bednets as they are in the generation of a community response to HIV prevention."
• "[T]here is a need for reliable evidence-based research to better guide the selection of available behavioural and structural interventions in specific areas or populations....We also require new and innovative ways to obtain, understand, and weigh different kinds of evidence on the outcome of prevention efforts."

Following through on this last point, the authors note that the UN General Assembly in 2008 made refinements to the core indicators agreed on by countries in 2001 to monitor the progress toward achieving universal access to prevention, treatment, and care by 2010 and reaching the Millennium Development Goal (MDG) of halting the spread of HIV/AIDS by 2015 (see "Panel 4"). Also, they explain that 15 additional indicators for monitoring programmes have also been proposed by major bilateral and multilateral agencies for use at the national level. They conclude by advocating that revitalising the global HIV prevention movement requires that future efforts be grounded in both an awareness of past missteps and in a better understanding of how to combine behavioural, structural, and biomedical approaches - an understanding that is based on scientifically derived evidence as well as the wisdom and ownership of particular communities.

Note: this article is freely accessible with a complimentary registration/log-in to the Lancet. Click here for access.

Click here to access "Putting prevention at the forefront of HIV/AIDS", by Richard Horton and Pam Das. This Introductory essay to the series of which the above-summarised article is a part provides background and the rationale for this Lancet effort to provide a simplified road map for countries seeking to develop their own evidence-driven strategies to respond to AIDS. The Lancet series was launched at the International AIDS conference in Mexico City, Mexico, in August 2008.