Radical behavioural change needs to be initiated and sustained in enough people at risk of HIV infection, and these behavioural changes must be part of a comprehensive combination prevention package for the strategies to have any chance of success. These are among the conclusions of Professor Thomas Coates, University of California, Los Angeles, CA, USA and colleagues, authors of the third paper in The Lancet Series on HIV prevention.
Varieties of sexual expression are infinitely greater than is acknowledged or sanctioned by most societies' defined legal and moral systems. And substance use to the point of intoxication is not only allowed, but is central to many countries' economies. The authors say: "Little wonder that attempts to control such substances, especially alcohol, stimulants, and injecting drugs, have met with little success.
Behavioural strategies are those that attempt to delay first intercourse, decrease number of sexual partners, increase the number of sexual acts that are protected, provide HIV counselling and testing and access to treatment for those who are infected with HIV, provide access to male circumcision, decrease sharing of needles and syringes, and decrease substance abuse. The authors call for new initiatives based on behavioural science to add to those based on communications, peer education etc, as part of a combination framework. It is essential that the right programmes are initiated. They discuss programmes such as the US President's Emergency Plan for AIDS Relief (PEPFAR), which until recently insisted a third of its funding be spent on abstinence before marriage, instead of where the evidence suggested funds were most needed. And while advocacy has seen these restrictions reduced in the recently passed 2008 PEPFAR legislation, many advocates feel that the changes are not enough to ensure all the money is appropriately directed.
There are many challenges facing behavioural change for HIV prevention. Many people with HIV do not know they are infected – thus one of the major tasks for HIV prevention in the developing world must involve increasing the number of people who know they are infected. Risk compensation — where advances in HIV prevention are undone by increases in risky behaviour — must also be addressed. HIV prevention counselling and services need to be a regular part of treatment for persons with HIV. There is a shocking gulf in the knowledge that young people have of HIV, with indications that the UNGASS* target of 90% of young people having comprehensive HIV knowledge by 2010 will not even be half-met. The authors say: "Nothing should be more important than a major focus on young people, not only in sub-Saharan Africa but in many other parts of the world as well." Injecting drug use remains a controversial area, and while many governments will not object to their HIV-infected population receiving antiretroviral drugs, they can and do (eg, USA) refuse to implement harm-reduction policies to prevent HIV transmission in injecting drug users.
The authors conclude: "The radical behavioural change that is needed to reduce HIV transmission requires radical commitment. Prevention strategies will never work if they are not implemented completely, with appropriate resources and benchmarks, and with a view toward sustainability. The fundamentals of HIV prevention need to be agreed upon, funded, implemented, measured, and achieved. That, presently, is not the case."
Professor Thomas Coates, University of California, Los Angeles, CA, USA – attending International HIV conference T) +1 310 367 9044 E) tcoates@mednet.ucla.edu
Alternative contact: Enrique Rivero, Senior Media Relations Officer Phone: +1 310 794-2273; +1 310 794-0777 E) ERivero@mednet.ucla.edu
Please note: a press conference to launch this series will take place at the International AIDS conference on Tuesday 5 August, 1500-1545 (Mexico City time) in Room 1 (Aztecas), Media Centre, Hall A, Level 1, Centro Banamex, Mexico City
http://multimedia.thelancet.com/pdf/press/hiv3.pdf
http://multimedia.thelancet.com/pdf/press/hivcomment.pdf
Journal
The Lancet