Roundtable 1: Prevention and Care
June 15, 2001
The most significant feature of the current situation is the gap between the challenge that HIV/AIDS represents and the resources available to halt the pandemic and reduce the suffering and death associated with it.
The Impact of HIV/AIDS is Increasing
More than 36 million people are currently living with HIV/AIDS. In the year 2000 alone, 5.3 million people became infected -- including 2.2 million women and 600,000 children under the age of 15. Around half of all new infections occur in young people under the age of 25. The rapid spread of HIV/AIDS in many regions means that alongside the continuing need for prevention, there is an escalating demand for care and support for those infected and a need to deal with the societal and developmental impact.
The Nature and Scale of the Pandemic Varies
Different settings have different kinds of epidemics. In parts of Africa, where the epidemic is long-established, the disease burden is very large. Some countries of Asia have generalized epidemics whose impact is potentially explosive due to sheer population size. Where the epidemic is in its early stages, such as in parts of the western Pacific and the Middle East, levels of infection are low but there is significant potential for expansion. In parts of Eastern Europe, Latin America, the Caribbean, and Asia, prevalence is increasing particularly fast among those most vulnerable to infection, such as injecting drug users. There is diversity also in the HIV/AIDS disease spectrum: in developing countries common infections -- tuberculosis, bacterial pneumonia, infectious diarrhoea -- are major causes of morbidity and mortality, while in developed countries the disease is characterized by less common "opportunistic" infections.
HIV/AIDS is Preventable
There is no cure for HIV/AIDS and, as yet, no vaccine. Therefore, prevention must be central to the response. Given vocal and innovative leadership and strong community involvement, well-targeted, low-cost prevention strategies have been effective in promoting behaviors such as delayed onset of sexual activity, reduction in sexual partners, abstinence, and safer sexual practices (including use of condoms). Ensuring the safety of blood and blood products, encouraging evidence-based demand reduction and harm reduction for injecting drug users, and managing sexually transmitted infections can also be effective in preventing transmission. It is increasingly possible to prevent transmission of infection from mother to infant. Unfortunately, such approaches have not been implemented on a scale sufficient to halt the pandemic.
HIV/AIDS is Not Curable But it is Treatable
HIV remains an incurable chronic infection, but in recent years treatments have become available that can reduce suffering and prolong and enhance the quality of life of HIV-infected people. Increased efforts are needed to ensure that people living with HIV/AIDS have access to the benefits of scientific progress. Currently, such treatments are available and affordable for only a small minority of those living with HIV/AIDS. Increasing access to treatment will have major resource implications for resource-constrained countries. At present, the annual cost of basic care and treatment for a person with HIV/AIDS (not including the costs of antiretroviral therapies) can be as much as two to three times the annual per capita gross domestic product in developing countries.
Health Systems are Inadequate
HIV/AIDS puts tremendous pressure on health systems, which are often unable to provide the continuum of care needed by people living with HIV/AIDS. In many settings, a lack of human resources is aggravated by high levels of infection among health-care providers themselves and their families.
Communities Need Support
The loss of so many adults in their productive years has created millions of AIDS orphans and increased the burden of care and support on women and the elderly. Resources for home- and community-based care are limited in most settings, and the need for psychological and palliative care is often poorly understood and they remain unavailable.
Over the past 20 years, much has been learned about what can be achieved given the necessary political commitment, community involvement, financial resources, and an enabling environment for change.
Communities are Key to the Response
Community involvement and action are essential. The successful mobilization of groups as diverse as young people, sex workers, and men who have sex with men, shows how it is possible to change sexual behaviors and increase condom use. Keys to success include widespread access to information and the means of prevention and a growing awareness of the individual and community impact of HIV/AIDS. Responses in Uganda, Senegal, and Thailand have demonstrated the effectiveness of community-centred approaches.
Advocacy is Crucial
Advocacy -- massive, unfailing, and unrelenting -- is critical and requires the support of political authorities at the highest levels. Leadership on the part of social institutions, both public and private, is vital for the success of efforts to reduce risky behavior and vulnerability, to mobilize support for those infected and affected by HIV/AIDS and mitigate the impact of the epidemic.
Different Settings Require Different Approaches
In Africa, where HIV spread is generalized and at a high level, a broad range of approaches is needed. For example, in Uganda, widespread HIV education and community action in support of behavior change, including delayed sexual relations among young people, reduced sexual partners and increased condom use, have been shown to be effective and can be replicated in similar settings. However, access to male and female condoms remains inadequate in most African countries. In Senegal, widespread access to voluntary counselling and testing appears to have enhanced HIV prevention efforts, but coverage is poor in most other developing country settings.
Vulnerability, Risk, and Impact are Linked
There are mutually reinforcing linkages between HIV risk, vulnerability, and impact. Strategies need to address both risky behaviors and factors that make people vulnerable, including poverty, discrimination, inadequate education, lack of basic infrastructure and gender inequality. For example, in many settings, HIV prevalence is higher among women and girls than among men and boys because of the increased biological and social vulnerability of women. The spread of HIV among vulnerable groups and its impact on physical, mental, and social well-being leads to further vulnerability. The connections between risk, vulnerability, and impact provide a rationale for addressing prevention, care, and support in synergy.
Targeted Prevention Works
Targeting prevention efforts toward those particularly vulnerable to HIV infection is most effective. Targeted HIV education and condom promotion among sex workers and their clients in Thailand increased condom use, changed risky behavior, and resulted in rapidly reduced HIV spread. The lessons are being applied with similar success in Cambodia. Comprehensive prevention strategies, including peer outreach, HIV risk reduction counselling and information, needle and syringe programs, and drug-dependency treatment, have been shown to be effective in preventing or reducing HIV spread among injecting drug users in many settings. This experience has not yet been applied on a large scale, as the rapid spread of HIV among injecting drug users in the Russian Federation, the newly independent States and Eastern Europe as well as in parts of Asia shows.
Education is Imperative
When done in the right way, education works to prevent transmission. If it is done immediately, it will have a long-term impact. If done on a massive scale, it can turn the tide of the pandemic. The critical test is the extent to which key messages reach the grass roots, particularly those who are most vulnerable, and lead to behavior change. Such change requires effective communication -- based on a sound understanding of the target audience and of the best way of getting the message across. Well-directed efforts are imperative to reach the young, whether in or out of school.
Care and Support Can Prolong Life, Reduce Suffering, and Strengthen Prevention Efforts
The advent of new HIV treatments has given rise to considerable optimism. Combination antiretroviral therapy can control infection, restore the immune system and prevent HIV/AIDS-related complications. In many countries, including Brazil, HIV/AIDS mortality has declined considerably since the widespread introduction of antiretroviral therapy. Other treatments, such as management of common infections, can improve the quality of life of those affected. The provision of high-quality care and support can also provide opportunities for HIV-prevention efforts. When HIV-positive people are treated with compassion and respect, not only are they more likely to act responsibly toward those around them, but they can also become powerful and credible advocates of HIV prevention.
What Needs to Be Done? Much has been learned about what works to halt the spread of HIV/AIDS. The time has come to put knowledge into action on a massive scale. An intensified national response calls for political courage on the part of Member States backed up by large-scale increases in funding for HIV prevention, care, and support. The way forward lies through improving knowledge and scaling up the implementation of prevention, care, and support strategies.
Improving HIV/AIDS knowledge and awareness -- coupled with improving access to the means of prevention -- is central to reducing its spread. Knowledge includes the evidence base for the development of strategies for prevention, care, and support.
People need preventive education and the knowledge, skills, and means to prevent HIV infection. Both general and targeted preventive education are essential, according to local needs and patterns of vulnerability and risk. Particular attention must be paid to addressing the sexual and reproductive health of young people, with the active participation of young people themselves. Improvements in general education and literacy will strengthen HIV preventive education, and training of community and primary-level health workers will enhance prevention, care, and support initiatives.
The scaling-up of HIV prevention, care, and support efforts must be based on sound evidence of what works in different settings. Interventions known to be effective include promoting condom use, providing voluntary counselling and testing, preventing mother-to-child transmission, providing information and services for those most vulnerable to infection (including injecting drug users and sex workers), ensuring safe injection practices and a safe blood supply, providing care and support (including palliative care) to those infected by HIV, managing opportunistic and concurrent infections (such as tuberculosis) and, where possible, providing antiretroviral therapies. Implementation of specific interventions should be guided by considerations of feasibility, appropriateness and effectiveness in different settings. However, cost-effectiveness considerations should inform but not drive the process.
Research and development on new technologies and approaches to the prevention and treatment of HIV/AIDS have the potential to radically change the course of the pandemic. Research priorities include developing effective HIV vaccines, improving simple and field-oriented HIV/AIDS diagnostic tests, developing microbicides against HIV and other infectious agents, refining affordable woman-controlled barrier methods of protection, simplifying treatments based on the current and next generation of antiretroviral compounds to increase their accessibility, safety, and affordability, finding ways of reaching young people with the information and services they need to protect themselves, and identifying the social and epidemiological factors that influence the success of interventions.
Surveillance of the changing patterns of disease spread and of related behaviors is essential for program development and implementation, helping to identify the nature and dimensions of the problem and its determinants and to evaluate what works in different settings. Surveillance of the development of antimicrobial resistance patterns is essential to ensure the regular updating and continuing efficacy of treatment regimens.
Prevention, Care, and Support Strategies
The spread of HIV/AIDS can be reversed if there is a concerted effort to increase access and equity in relation to a comprehensive range of strategies. There is a broad consensus around the interlocking and mutually reinforcing benefits of prevention, care and support. What is needed is widespread and sustained implementation of effective interventions. Access to information and means of HIV prevention and care must be promoted as a human right, and barriers to access must be overcome.
National HIV/AIDS strategies in many countries have stressed the involvement of people living with HIV/AIDS and community-based organizations in translating national-level strategy formulation to local-level action. National HIV/AIDS programs should monitor and evaluate the coverage of priority interventions in prevention, care, and support. Developing a national-level consensus will require the active participation of governments with civil society, the private sector, and people living with HIV/AIDS. The public health response should be one component of a multisectoral effort involving education, development, gender, poverty-reduction, and human rights initiatives.
A strengthened health sector response, within the overall multisectoral response, will be critical to the successful implementation of comprehensive prevention, care, and support interventions. Increased financial inputs will be needed and success will depend on the active involvement of communities in support of health care systems. HIV/AIDS prevention and care strategies can be integrated into other public health programs so that HIV/AIDS is addressed in programs directed toward improving reproductive health and the health of women and children. Collaboration between tuberculosis and HIV/AIDS programs can enhance both tuberculosis control and HIV care. Implementation of health sector-based prevention and care initiatives must take place alongside improvements in health systems. These dual endeavors need to be scaled up together, and should be mutually supportive. The training of health-care workers in HIV/AIDS needs to be intensified. A global health sector strategy is currently being developed in recognition that a strengthened health sector response will boost the global multisectoral response.
Prevention and care should be seen as mutually supportive interventions along the same continuum. Effective voluntary counselling and testing highlights this synergy in opening the door to HIV preventive efforts, counselling, and referral to care and support services. Earlier diagnosis of HIV provides an opportunity to strengthen HIV prevention efforts and to introduce effective treatment and care. In order to support this, the World Health Organization is developing an essential package of prevention and care interventions and tools that can be adapted to diverse country settings in order to facilitate the scaling-up of national programs. The aim is to start with what is feasible and to gradually build upon achievements, generating momentum for the implementation of more complex interventions. Thus, the package can be tailored to meet diverse situations in countries with different social and economic climates and at different stages of the pandemic.
HIV treatments, including antiretroviral therapy, should be made available to those infected, including in resource-constrained settings. This requires parallel public health infrastructure development and human resources. This should not impede the implementation of other care and support strategies, and close evaluation is essential. Substantial additional funding will be needed by national authorities if they are to be enabled to provide access to more than a small minority of people living with HIV/AIDS. Already, HIV care is creating a financial burden for families and communities in many countries. Large-scale funding for antiretroviral therapy also needs to be supported by greater levels of funding for other care and prevention activities, public health infrastructure, and training in clinical care.
A comprehensive approach to prevention, care, and support is essential if we are to halt the HIV/AIDS pandemic. Such an approach must involve communities and non-governmental organizations in a meaningful way and must invest in providing information and services to young people. A strong monitoring and evaluation component is key to ensuring that programs are meeting people's needs effectively.
We know what needs to be done. The time has come to turn knowledge into action.
This article was provided by UNAIDS. It is a part of the publication Special Session of the General Assembly on HIV/AIDS. Visit UNAIDS' website to find out more about their activities, publications and services.