HIV: Combination prevention is the way ahead and mistakes of mid-1990s must not be repeated

August 05, 2008

Combination prevention -- a combination of behavioural, medical, and structural approaches based on sound evidence -- offers the best hope for future successful HIV prevention. And the mistakes of the mid-1990s, when HIV/AIDS slipped down the political and financial agendas of many countries and the pandemic expanded greatly, must not be repeated. These are among the conclusions of Professor Michael Merson, Duke Global Health Institute, Duke University, Durham, NC, USA, and Jeffrey O'Malley, HIV/AIDS Practice, UN Development Programme, New York, USA, and colleagues, authors of the first paper in the Lancet Series on HIV prevention.

The paper charts the history of the HIV/AIDS pandemic, from the first confirmed reports of AIDS from the Centers for Disease Control and Prevention, USA, in 1981 through the development of antiretroviral drug (ARV) treatment, and development of donor programmes to recent high level UN meetings. The early struggles of various worldwide communities simply to get the disease accepted and acknowledged, and the inconsistent and poor response of governments in those early years, are discussed. The authors say: "Early prevention successes evolved from collective responses generated by people living with HIV/AIDS and community groups, and confronted the stigma, discrimination, and denial associated with the disease. A global response, involving social factors such as sexual behaviour, injecting drug use, and gender inequalities, is needed to fully address the HIV/AIDS pandemic."

HIV cases and incidence in each country with data are provided. The authors say that global prevention efforts remain woefully insufficient, with fewer than 10% of individuals at risk worldwide receiving key prevention services. They say: "Expansion of these services could avert more than half the HIV infections projected to occur by 2015 and save $24 billion in treatment costs." They refer to an estimate that 70% coverage of male circumcision services could prevent some 700000 HIV infections in sub-Saharan Africa up to 2015. And while the number of people on ARVs has increased more than ten times in the last five years, for every two patients placed on ARVs in 2007, five new HIV infections occurred.

The UN World Summit in 2006 embraced the goal of implementing a package for HIV prevention and care, with the aim of near-universal coverage by 2010 at an estimated cost in that year of US$42.2 billion, 36% of which would be for prevention. But resources alone are not enough. The authors say: "Successful prevention requires knowledge of the nature of the epidemic in individual countries, as well as community and country contexts." They add that there is a growing consensus that HIV prevention should be combined with overall health system strengthening. They say: "We need not only more managers, public-health experts, physicians, and nurses, but also a new cadre of community workers whose education is rooted in community development, gender equity, human rights, and public health, and who will be equally powerful in the promotion of hygiene, sanitation and use of bednets as they are in the generation of a community response to HIV prevention."

The authors conclude: "We now require an urgent and revitalised global movement for HIV prevention that supports a combination of behavioural, structural, and biomedical approaches and is based on scientifically derived evidence and the wisdom and ownership of communities...With millions of people on treatment and the incidence of HIV infection falling in places, many involved in public health and public policy are calling for a shift of attention from HIV to other diseases...HIV prevention must remain one of the world's top health and development priorities -- now and for a generation to come. The mistakes of the mid-1990s, when HIV/AIDS slipped down the political agenda and the pandemic greatly expanded, must not be repeated."
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Professor Michael Merson, Duke Global Health Institute, Duke University, Durham, NC, USA T) +1 919-681-7760 / +1 203 887 4149 E) Michael.merson@duke.edu

Alternative contact: Marsha Green, Assistant Director, Communications. Duke Global Health Institute T) +1 919-681-7717 / +1 919 923 4409 E) marsha.green@duke.edu

Jeffrey O'Malley, HIV/AIDS Practice, UN Development Programme, New York, NY, USA (attending conference) T) +55 27 32 36 33 (Mexico cell) E) jeffrey.omalley@undp.org

http://multimedia.thelancet.com/pdf/press/hiv1.pdf

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

Lancet

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