AIDS: lessons learnt and myths dispelled

One of the most common myths is that HIV prevention is not working. However, much evidence suggests that, in several countries, prevention programmes are effective.

Between 2005 and 2007, coverage of services to prevent mother-to-child transmission of HIV increased from 14% to 33%. As a result, in 2007, we noted for the first time a substantial decrease in the number of children born with HIV.

Prevention is, of course, about not only technology, but also behaviour.

In many countries on several continents, changes in sexual behaviour (such as waiting longer to become sexually active, having fewer partners, and increased condom use) have been followed by reductions in the number of new HIV infections, providing evidence that efforts to change behaviour can and do work.

However, sustaining behaviour change in the long term remains a major challenge.

For example, the number of new HIV diagnoses in men who have sex with men doubled in Germany between 2002 and 2006, and increased by more than three-quarters in Switzerland.

These data could be attributable to complacency about AIDS and the sense that a treatable disease is somehow less threatening than are other diseases, and to a decrease in HIV prevention efforts in western Europe.

Some developing countries that have previously had much success with HIV prevention, such as Uganda, have also had increases in rates of HIV transmission.

Another major challenge is that, nearly 30 years into the epidemic, only about half of countries have national HIV prevention targets, whereas nearly 90% have targets for AIDS treatment.

Furthermore, when prevention programmes do exist, they are often under-resourced and do not have the quality and scale that are needed to have a real effect in communities. They need to be better targeted to where the epidemic is, both in terms of populations at risk and geographic areas.

Much has been published about the need for precise targeting of HIV prevention, especially in concentrated epidemics. But even saturation coverage of vulnerable groups will have little lasting effect without concerted and concrete efforts to change social standards and tackle social factors of the epidemic, such as homophobia and the low status of women in many societies.

Programmes also need to be designed and managed more efficiently, including increased use of skills and practices from the business sector.

An increasingly recurrent myth is that one solution, or a so-called silver bullet, will comprehensively prevent HIV transmission. Elimination of concurrent partnerships, circumcision of all men, focusing of prevention efforts on sex workers, universal HIV testing, and provision of antiretroviral therapy as soon as possible after infection, have all received attention as potential solutions for prevention of HIV transmission.

Scaling up strategies for harm reduction, such as methadone substitution and the provision of clean needles for injecting drug users, remains neglected in many countries in which injection drug use is a major means of HIV transmission.

Although these strategies are all important, no approach will be enough on its own, and the promotion of one solution is, in our view, irresponsible.

If we have learned one lesson in the past 27 years, it is that effective HIV prevention depends on customising the right mix of interventions for every context and ensuring the necessary coverage of them.

If we are to successfully increase access to HIV prevention, we have to be prepared to come to terms with complexity, effectively use all the methods that are available, include affected communities, engage relevant business expertise, and foster leadership to help change harmful social norms.

Another prevailing misconception is that heterosexual transmission of HIV is uncommon outside Africa.

Generalised epidemics are occurring in Haiti and Papua New Guinea, whereas heterosexual transmission drives the epidemic between sex workers, their partners, clients, and clients' partners in Asia and elsewhere.

HIV infections in women are rising worldwide. The main method of transmission in Thailand is no longer between sex workers and their clients or between injecting drug users: it is between married couples.

Furthermore, AIDS remains the leading cause of death in African-American women in the USA.

To characterise all African epidemics as exclusively heterosexual is also incorrect. Methods of transmission and affected groups are many and varied. In Kenya, for example, HIV infections in men who have sex with men and injecting drug users are an increasing cause for concern.

Although such observations neither indicate nor predict extensive or generalised HIV epidemic spread, they do draw attention to the fact that heterosexual transmission of HIV occurs in a wide range of settings. They also show that the HIV epidemic is constantly evolving, and continually surprising.

As we approach the fourth decade of the AIDS epidemic, new global challenges are competing for the attention of political leaders and donors at the same time as they face the present financial crisis.

Alarmingly, a myth has begun to emerge that too much money is spent on AIDS. But AIDS remains the leading cause of death in Africa and the sixth highest cause of mortality worldwide.

It is fitting that investment in fighting AIDS has finally begun to increase substantially, rising from a paltry US$250 million in 1996 to around $14 billion in 2008.

Even so, UNAIDS estimates that available resources at present fall well short of what will be needed to reach coverage targets for 2010.

Moreover, mobilisation around AIDS has increased available resources for tuberculosis and malaria (largely through the Global Fund) to unprecedented amounts and generally contributed to an increase in global funding for health.

Increased resources are beginning to have an effect, as are antiretroviral treatment programmes, which have been established in developing countries for less than 5 years.

Among the first was in Malawi, which recorded a 44% reduction in mortality in workers at the national electricity company—one of the country's largest employers—after the roll-out of antiretroviral treatment.

In Botswana, where HIV prevalence has reached 30%, mortality has begun to fall in the age groups most affected by AIDS since the introduction of antiretroviral treatment.

Source: full text, The Lancet, 20 March 2009