Current Issues in HIV

Prevention
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Introduction Increased access to treatment improves opportunities

for HIV prevention through increased HIV- testing—
Although global attention to HIV and AIDS remains and increased testing can reduce stigma and act as an
strong, particularly regarding treatment initiatives, until entry point to prevention services. Recent research
recently HIV-prevention has garnered scant attention. findings also indicate that providing treatment and
Treatment alone will not reverse the epidemic, and lowering individuals’ viral load can decrease risk of
current prevention efforts have not been successful in infection and act as a method of prevention. It is clear
halting HIV transmission. Currently, for every two that reducing new infections—prevention—goes hand-
people who go on treatment for HIV and AIDS, five in-hand with treatment.
people become infected. In 2007 the Global HIV
Prevention Working Group (PWG) projected that 60 “Long-term, sustained progress in the fight against
million new cases of HIV will occur by 2015 unless AIDS demands more than an exclusive focus on
comprehensive HIV prevention is sufficiently either prevention or treatment alone. Prevention
increased. Those infected will require costly treatment, makes treatment affordable, and treatment can
make prevention more effective” [1].
care and support. It is expected that scaling up
combination prevention efforts would avert more than
half of all new HIV infections expected to occur SCALING UP
between 2005 and 2015, thereby disabling the epidemic Scaling up is key to realizing the potential of
and leading to a long-term decline. prevention. The PWG defines scaling up HIV
prevention as “ensuring that the appropriate mix of
Current Issues in HIV Prevention evidence-based prevention strategies achieves a
sufficient level of coverage, uptake, intensity and
duration to have optimal public health effect” [2].
• RESOURCES FOR PREVENTION AND Coverage levels for prevention services are extremely
TREATMENT OF HIV AND AIDS low. It is estimated that in 2005 a condom was used in
In June 2006, the United Nations General Assembly only 9% of sex acts involving a non-regular partner and
adopted a political declaration on HIV and AIDS which prevention programs reached a mere 20% of sex
included a commitment to pursue all necessary efforts workers, 9% of men who have sex with men and 8% of
towards the goal of universal access to comprehensive injecting drug users globally. Only 11 % of HIV-
prevention programs, treatment, care and support by infected pregnant women in low- and middle-income
countries received antiretrovirals to reduce the risk of
2010. To meet the goal of global universal access by
mother to child transmission. Globally, less than half of
2010, available financial resources for HIV and
all school attendees receive school-based HIV
AIDS must reach up to US$ 42.2 billion– more than education.
quadruple the resources that were available in 2007.
“A critical reason we are failing on HIV prevention
While a lack of resources for HIV and AIDS in general is that we have not yet reached individuals and
is an issue, there has been debate regarding the relative communities with the level of prevention coverage
allocation of HIV and AIDS funding—how much needed to have a major impact” [2].
should go towards treatment and how much towards
prevention. Although resource constraints make Factors which limit scale-up efforts include:
decisions about allocation inevitable, there is an
emerging consensus that treatment and prevention are • inadequate resources for HIV prevention;
best viewed as complementary strategies rather than in • poor planning, prioritization, and targeting of
competition with one another. programs;

Current Issues in HIV Prevention

1
 • lack of capacity, such as health human includes gathering information about HIV infection
resources and infrastructure; rates among different population groups within a given
• disjointed programs, such as prevention country. Ongoing country-level surveillance of the
programs not integrated into institutions or epidemic is essential for countries to plan and adjust
other health-related services; their prevention strategies accordingly. Moreover,
• reliance on ineffective interventions, such as political complacency needs to be overcome—in some
abstinence-based programs high-income countries, where HIV prevention was
• inadequate implementation of interventions and successful early on in the epidemic, HIV rates are now
approaches proven to be effective, such as harm on the rise.
reduction;
As part of “knowing your epidemic” there is a need to
• lack of coordination among stakeholders; and
increase HIV testing. It is estimated that just 11% of
• the challenge of stigma.
the world's population is aware of their HIV status. The
Public Health Agency of Canada estimates that only
There are many public health challenges surrounding 75% of Canadians living with HIV are aware of their
the development, implementation and evaluation of HIV status. Research has shown that people who are
HIV prevention programs. These challenges include: aware that they are HIV positive decrease their risk
behaviours. It is essential that there be widespread and
• a lack of surveillance data that countries need easy access for HIV-testing as part of comprehensive
to better understand which groups to target with HIV prevention programming. It must also be
prevention initiatives; emphasized that support for testing should not negate
• a lack of information on the impact and quality the need for privacy, confidentiality, and consent—
of prevention programs; safeguards must be in place to ensure that these rights
• a need for more rigorous and long-term are respected.
evaluations of prevention interventions,
including a need to evaluate cost-effectiveness • DEVELOPING EFFECTIVE PREVENTION
and appropriateness of interventions for MODELS
different populations;
Prevention efforts require the availability of sustainable
• the difficulty of evaluating specific prevention
and adequate resources and political leadership.
interventions, given that prevention efforts
Effective models of prevention efforts frequently have a
often involve multiple interventions;
number of common features. These include:
• the ethical challenges involved in research. For
example, researchers face ethical challenges in
• adequate human resource and institutional
conducting randomized trials where some
capacity;
individuals are assigned to a control group in
• a focus on interventions that are locally
which they do not receive the experimental
relevant, evidence-based, and targeted to the
prevention intervention;
appropriate population;
• the difficulty of sustaining political support for
• a comprehensive approach, including mass
prevention programs, compared with
media campaigns to increase awareness and
interventions with shorter time frames and
programs that build self-esteem and life skills
faster results, such as treatment.
such as safer sex negotiation;
• politics and ideologies, such as the United
• the involvement of multiple sectors, including
States’ global focus on abstinence-based
communities which are affected by HIV/AIDS;
prevention programs, which can interfere with
• initiatives to address stigma.
efforts to implement effective, evidence-based
prevention strategies.
Respect for human rights should underlie all
prevention efforts, including HIV-testing and
Improving HIV Prevention Efforts research on existing and new prevention
interventions. Prevention efforts should also involve
“KNOW YOUR EPIDEMIC” the pursuit of structural changes that will protect the
rights of people living with HIV and AIDS and
As the HIV/AIDS epidemic varies between countries, it people who are at risk of HIV infection.
is critical that countries understand how the epidemic is
affecting them specifically to ensure prevention
interventions are appropriate and cost-effective. This

2 Current Issues in HIV Prevention

• STRUCTURAL DETERMINANTS OF HEALTH Interventions to prevent blood-borne transmission
include providing clean injection equipment to injection
Structural determinants of health include the political,
drug users; substitution therapy for drug dependence;
economic, environmental and social factors that impact
blood safety; and infection control in health care
health. As a multi-dimensional health issue, HIV
settings.
demands a focus that transcends a health sector focus
and addresses these structural determinants.
Interventions to prevent mother-to-child transmission
Vulnerability to HIV infection is complex— it is shaped
include primary HIV prevention for women of
by a number of health determinants, such as gender,
childbearing age; antiretroviral drugs for mothers and
poverty, social support, education, human rights, and
newborns; prevention of unintended pregnancy among
culture. Stigma and discrimination also play a key role
HIV positive women; safe feeding alternatives; and
in increasing vulnerability to HIV, in part by deterring
caesarean delivery in the case of high maternal viral
people at risk from seeking HIV prevention services or
load.
from being tested for HIV. Prevention efforts must
reflect this complexity and address the structural
Existing prevention methods are at varying stages of
determinants of health if they are to be effective and
research1. For example, there is growing evidence that
sustainable.
male circumcision is effective in preventing female-to-
male transmission of HIV; however, there is still much
In order to have a long-term impact on HIV rates, the
that is unknown about this prevention strategy,
interaction and influence of structural factors need to be
including its impact on male-to-female transmission or
better understood, and broad interventions which focus
transmission through anal intercourse, or how best to
on these structural factors need to be implemented. It is
promote male circumcision without leading to a decline
argued that these underlying factors have not been
in condom use. In addition to existing interventions, it is
adequately addressed to date. Measures that address the
critical that new technologies in HIV prevention,
structural determinants of health and thus enhance
including vaginal and rectal microbicides2, pre-
prevention efforts may include legal reform, initiatives
exposure prophylaxis3 and vaccines, continue to be
to increase gender equity, and anti-poverty initiatives.
developed and researched in accordance with ethical
standards and guidelines. Moreover, we need to learn
“Reducing poverty and its associated conditions more about behavioural and structural strategies, and in
plays a key role in decreasing HIV-related particular how to measure their impact.
vulnerability, underscoring the importance of
integrating AIDS responses within broader
development efforts” [2]. Conclusion

• COMPREHENSIVE PREVENTION There are doubtlessly numerous challenges to

Not only does comprehensive prevention need to increasing and improving prevention efforts. However,
encompass structural interventions, successful if tackled with sustained and sufficient resources and
prevention efforts require a diversity of biomedical and dedication, comprehensive HIV prevention,
behavioural methods that will provide individuals with implemented alongside HIV treatment, has the
a range of options, and have the potential to further potential to significantly curb the HIV epidemic.
decrease the risk of HIV infection if used in
combination. There is evidence on some HIV
prevention interventions, while new approaches are 1
For more information about existing and potential
undergoing testing. The PWG provides a list of
prevention methods and their current state of research, please
'components of comprehensive HIV prevention' which see ICAD’s fact sheet on “Tools, Trends and New
includes interventions to prevent sexual transmission, Technologies in HIV Prevention,” January 2008.
blood-borne transmission and mother to child transmission. 2
Microbicides are a class of products currently being
researched and developed that are designed to reduce the
Interventions to prevent sexual transmission include transmission of HIV and/or other STIs when used in the
behaviour change programs (for example, programs vagina or rectum. Microbicides could come in many forms,
aimed at reducing multiple and concurrent sexual including a gel, film, sponge, vaginal ring or rectal enema.
3
partners); promoting male and female condoms; HIV Pre-exposure prophylaxis refers to an experimental HIV
testing; diagnosis and treatment of sexually transmitted prevention strategy that would use antiretrovirals to protect
HIV-uninfected people form HIV infection.
infections (STI); and adult male circumcision.

Current Issues in HIV Prevention 3

 Resources

• See ICAD’s other fact sheets, including those on prevention, for more information:
http://www.icad-cisd.com/
• World Health Organization: http://www.who.int/
• Global HIV Prevention Working Group (PWG): http://www.globalhivprevention.org/
• UNAIDS: www.unaids.org/

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ICAD’s mission is to lessen the spread and impact of HIV and AIDS in resource-poor communities and countries by providing
leadership and actively contributing to the Canadian and international response. Funding for this publication was provided by
PHAC. The opinions expressed in this publication are those of the authors/researchers and do not necessarily reflect the
official views of PHAC. Ce feuillet est également disponible en français.

4 Current Issues in HIV Prevention