Coming to terms with complexity: a call to action for HIV prevention

doi:10.1016/S0140-6736(08)60888-0

The Lancet

Volume 372, Issue 9641, 6–12 September 2008, Pages 845-859

https://doi.org/10.1016/S0140-6736(08)60888-0 Get rights and content

Summary

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 sufficient coverage; they have often lacked the funding to be applied with sufficient 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. Confident and unified 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.

Section snippets

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, Côte d'Ivoire, Burkina Faso, Thailand, Cambodia, southern India, and urban Haiti and Kenya.¹ These reductions represent the payoff from investments made throughout the 1990s and into this century.

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 affect large numbers of people:¹¹ in Thailand or Uganda, for example, a large proportion of transmission is among serodiscordant long-term couples. Epidemics could

Meeting the challenges of an expanded prevention response

Expanded HIV prevention grounded in a strategic analysis of the epidemic's 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 Series¹⁷ 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

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 find it hard to tackle sexual transmission in the right way or in the right populations.

Programming efforts that focus on sexual transmission have been plagued by insufficient confidence

Educating young people frankly about sex

Any sustainable effect 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 initiation—in many countries, 14–15 years is the median age of first sexual intercourse.

Even in

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. Scientific consensus has been achieved on the effectiveness of harm-reduction approaches to HIV among such users³⁹ and its component elements have been fleshed out: needle and syringe programmes; opioid substitution therapy; voluntary counselling and testing; antiretroviral therapy; prevention of sexually transmitted infections; condom programming for

Eliminating mother-to-child transmission

High-income countries have almost eliminated transmission of HIV from mother to child (figure 4). Several middle income-income and lower middle-income countries have done the same—in 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 first country in sub-Saharan Africa to achieve

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

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 15–49 year-olds are HIV positive,¹ and the annual incidence in young women is 4–6%, 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

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 difference 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

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 beneficial for HIV prevention. For this and other reasons, the debate in some

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;

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 effort towards HIV prevention—as has been successfully made towards HIV treatment—is 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: specific prevention targets set at the

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The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 cause-of-death analysis estimated mortality and years of life lost (YLLs) from 288 causes of death by age-sex-location-year in 204 countries and territories and 811 subnational locations for each year from 1990 until 2021. The analysis used 56 604 data sources, including data from vital registration and verbal autopsy as well as surveys, censuses, surveillance systems, and cancer registries, among others. As with previous GBD rounds, cause-specific death rates for most causes were estimated using the Cause of Death Ensemble model—a modelling tool developed for GBD to assess the out-of-sample predictive validity of different statistical models and covariate permutations and combine those results to produce cause-specific mortality estimates—with alternative strategies adapted to model causes with insufficient data, substantial changes in reporting over the study period, or unusual epidemiology. YLLs were computed as the product of the number of deaths for each cause-age-sex-location-year and the standard life expectancy at each age. As part of the modelling process, uncertainty intervals (UIs) were generated using the 2·5th and 97·5th percentiles from a 1000-draw distribution for each metric. We decomposed life expectancy by cause of death, location, and year to show cause-specific effects on life expectancy from 1990 to 2021. We also used the coefficient of variation and the fraction of population affected by 90% of deaths to highlight concentrations of mortality. Findings are reported in counts and age-standardised rates. Methodological improvements for cause-of-death estimates in GBD 2021 include the expansion of under-5-years age group to include four new age groups, enhanced methods to account for stochastic variation of sparse data, and the inclusion of COVID-19 and other pandemic-related mortality—which includes excess mortality associated with the pandemic, excluding COVID-19, lower respiratory infections, measles, malaria, and pertussis. For this analysis, 199 new country-years of vital registration cause-of-death data, 5 country-years of surveillance data, 21 country-years of verbal autopsy data, and 94 country-years of other data types were added to those used in previous GBD rounds.
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SeriesComing to terms with complexity: a call to action for HIV prevention

Summary

Section snippets

Momentum for HIV prevention

The epidemic could continue to surprise us

Meeting the challenges of an expanded prevention response

Tackling sex in the right way

Educating young people frankly about sex

Dealing rationally with drug use

Eliminating mother-to-child transmission

Politics, leadership, and demand generation

HIV hyperendemic countries: a full-scale emergency

Reaching all those in need: the implementation science of HIV prevention

Reaching all those in need: going beyond health services

The long-term view

A call to action on HIV prevention

Lancet

Lancet

Lancet

Science

Lancet

Lancet

Making HIV prevention programmes work

Lancet

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

Bangkok's MSM HIV Explosion—precursor for Asia's mega-cities?

HIV Australia

Towards universal access by 2010: Thailand national HIV and AIDS program

Practical Guidelines for Intensifying HIV Prevention

Structural approaches to HIV prevention

Lancet

What led to the Nigerian boycott of the polio vaccination campaign?

PLoS Med

Culture matters. working with communities and faith-based organizations: case studies from country programmes

The spread of HIV and sexual mixing patterns

2007 world drug report

The rise of injecting drug use in east Africa: a case study from Kenya

Harm Reduct J

West Africa: Impunity and low risk make region “haven” for traffickers

AIDS epidemic update: regional summary Geneva, Switzerland: Joint United Nations Programme on HIV/AIDS

AIDS in Africa: three scenarios to 2025

Biomedical interventions to prevent HIV infection: evidence, challenges, and way forward

Lancet

The time has come for common ground on preventing sexual transmission of HIV

Lancet

Intensifying HIV prevention: UNAIDS policy position paper

Behavioural strategies to reduce HIV transmission: how to make them work better

Lancet

Updated compendium of evidence-based interventions

Rapid assessment of trends and drivers of the HIV epidemic and effectiveness of prevention interventions in Uganda

Discordant couples: HIV infection among couples in Burkina Faso, Cameroon, Ghana, Kenya, and Tanzania. World Bank Policy Research Working Paper No 3956

Regional differences in prevalence of HIV-1 discordance in Africa and enrollment of HIV-1 discordant couples into an HIV-1 prevention trial

Les personnes séropositives ne souffrant d'aucune autre MST et suivant un traitement antirétroviral efficace ne transmettent pas le VIH par voie sexuelle

Bull Med Suisses

Concurrent partnerships and the spread of HIV

AIDS

Theory is critical in understanding the risks of acquiring HIV

Sex Transm Dis

Norwegian gay men: reasons for continued practice of unsafe sex

AIDS Educ Prev

HIV prevention: multiple and concurrent sexual partnerships among youths and adults in South Africa

Financing and expenditure in response to HIV/AIDS in Latin America and the Caribbean

Redefining AIDS in Asia: crafting an effective response

Men who have sex with men and their HIV epidemics in Africa

AIDS

Information Dashboard. UNAIDS Country Coordinator Annual Reports 2007

Series
Coming to terms with complexity: a call to action for HIV prevention