UNAIDS 2004 Report on the Global AIDS Epidemic - Executive Summary

IV. Bringing comprehensive HIV prevention to scale

Although prevention is the mainstay of the response to AIDS, fewer than one in five people worldwide have access to HIV prevention services. Comprehensive prevention could avert 29 million of the 45 million new infections projected to occur this decade. Although antiretroviral treatment is bringing hope to millions, without sharply reducing the number of new HIV infections, expanded access to treatment becomes unsustainable. Providers of antiretroviral treatment will be swamped by demand.

Prevention programmes are not reaching the people who need them, especially two highly vulnerable groups – women and young people. In order to prevent the high infection rates among women, the root causes of their vulnerability – their legal, social and economic disadvantages – must be addressed.

For young people, knowledge and information are the first line of defence; AIDS education is still far from universal. In sub-Saharan Africa, only 8% of out-of-school young people and slightly more of those in-school have access to education on prevention. They also need access to confidential health information and condoms. Protecting the rights of young girls is also key to lowering HIV prevalence among young people.

There are success stories. A number of countries, including Brazil, the Dominican Republic, Uganda and Thailand, have succeeded in reducing HIV infection. There is also a need for HIV prevention to evolve and be more innovative in addressing changes in the epidemic. In high-income countries, for example, risk behaviours and new infections are rising again, particularly among young men who have sex with men. The reasons probably include ‘prevention fatigue’ and complacency rising from the availability and promise of antiretroviral treatment.

Expanded access to antiretrovirals and other treatment offers a critical opportunity to strengthen prevention efforts by encouraging many more people to learn their HIV status. The promise of treatment should encourage greater use of voluntary counselling and testing. The current reach of HIV testing is poor. The proportion of adults needing voluntary counselling and testing who received it ranged from almost none in South East Asia to 7% in sub-Saharan Africa, and 1.5% in Eastern Europe. Where services do exist, uptake is also often low because of fear of stigma and discrimination.

Comprehensive prevention

Key elements in comprehensive HIV prevention include:

• AIDS education and awareness
• Behaviour change programmes especially for young people and populations at higher risk of HIV exposure, as well as for people living with HIV
• Promoting male and female condoms as a protective option along with abstinence, fidelity and reducing the number of sexual partners
• Voluntary counselling and testing
• Preventing and treating sexually transmitted infections
• Primary prevention among pregnant women and prevention of mother-to-child transmission
• Harm reduction programmes for injecting drug users
• Measures to protect blood supply safety
• Infection control in health-care settings
• Community education and changes in laws and policies to counter stigma and discrimination
• Vulnerability reduction through social legal and economic change

Next agenda:

• Create policies that help to reduce the vulnerability of large numbers of people – in effect, creating a social, legal and economic environment in which prevention is possible. This includes access to education, empowerment of women and international cooperation to prevent human trafficking for sexual exploitation.
• Close the ‘prevention gap’ – in 2004 less than one in five people has access to HIV prevention services.
• Ensure that prevention is comprehensive and involves a variety of interventions (see above), since no single element is enough.
• Eliminate AIDS-related stigma and discrimination through effective legal frameworks and by protecting the rights of all individuals.
• Tailor prevention to the specific needs of people, including vulnerable groups such as injecting drug users and men who have sex with men. Worldwide there are more than 13 million injecting drug users and in some regions more than 50% of them are infected with HIV. Experience in cities such as Dhaka, Bangladesh, and London, United Kingdom, shows it is possible to prevent and even reverse major epidemics among injecting drug users.
• Men who have sex with men account for 5-10% of all HIV cases worldwide. Prevention programmes must take into account that this group is highly stigmatized throughout much of the world – some 84 countries in 2002 had legal prohibitions against sex between men – and this hampers prevention efforts.