In one of six papers published in The Lancet Series on HIV prevention, Professor Thomas Coates (University of California, Los Angeles, CA, USA) and colleagues report that radical behavioral change is necessary in order for HIV prevention programs to be successful. The authors call for a critical mass of people at risk of HIV infection to initiate and sustain behavioral change as part of a comprehensive combination prevention package – changes that are necessary for the strategies to have any chance of success.
These recommendations come at a time when most societies’ defined legal and moral systems fail to sanction, or acknowledge, the diversity of sexual expression that exists. In addition, intoxicating substance use is not only condoned in several countries, but it is a key element of their economies. “Little wonder that attempts to control such substances, especially alcohol, stimulants, and injecting drugs, have met with little success,” write Coates and colleagues.
Many programs focus on behavioral strategies that attempt to prevent HIV. These include:
- Delaying first intercourse
- Decreasing the number of sexual partners
- Increasing the number of protected sexual acts
- Providing HIV counseling and testing and access to treatment for those with HIV
- Providing access to male circumcision
- Decreasing needle and syringe sharing
- Decreasing substance abuse
However, the authors suggest that new initiatives developed through behavioral science research should be added to the current communication and peer education programs. They stress the importance of initiating and properly managing the right program. For example, the US President’s Emergency Plan for AIDS Relief (PEPFAR) recently insisted that about 33% of its resources be spent on programs to support abstinence before marriage even though evidence suggested that funds were most needed elsewhere. In the most recent 2008 PEPFAR legislation, these restrictions have been reduced, but advocates still feel that more changes are necessary in order to properly direct the funds.
One of the biggest challenges facing behavioral change initiatives for HIV prevention is that people with HIV often do not know that they are infected. Therefore, a major task for preventing HIV in the developing world involves raising the number of people who know their infection status. Another challenge to recent prevention efforts is called risk compensation – the undoing of advances in HIV prevention by increases in risky behavior. People with HIV need counseling and other services to be a steady part of treatment. Young people have a disappointingly low knowledge of HIV, and it is unlikely that we meet the goal of having 90% of young people with comprehensive HIV knowledge by 2010 that has been set by the United Nations General Assembly Special Session. “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,” write the authors.
A third area challenging HIV prevention measures involves injection drug use. Though governments often do not object to giving antiretroviral drugs to their HIV-infected population, several – such as the USA – refuse to offer harm-reduction policies aimed at HIV prevention for users of injection drugs.
Coates and colleagues 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.”
Behavioral strategies to reduce HIV transmission: How to make them work better
Thomas Coates et al.
The Lancet (2008).
Written by: Peter M Crosta