V. Key Lessons Learned and Elements of a Successful Response
February 16, 2001
Twenty years of fighting the AIDS epidemic have resulted in a growing understanding of what constitutes effective action. Truly effective action is underpinned by the principles set and the lessons learned from the current global and national-level responses.
Fundamental principles guiding a successful response to HIV/AIDS are:
Successful Responses Are Linked to a Respect for Human Rights
A number of human rights concerns exist and must be addressed in order to combat stigma and eliminate discrimination based on HIV status. In addition to discrimination against people infected with HIV, other important issues include the right to health care, the right to information and other social and economic rights contained in United Nations human rights conventions and the Universal Declaration of Human Rights. The international guidelines on HIV/AIDS and human rights are key to a response based on human rights, and Governments should continue their efforts to implement them.
Success Has Been Demonstrated in Addressing the Epidemic
Collective experience with HIV/AIDS has evolved to the point where it is now possible to state with confidence that it is technically, politically and financially feasible to contain HIV/AIDS and dramatically reduce its spread and impact. The first two decades of the epidemic have generated unprecedented learning and mobilization throughout the world. HIV, the virus that causes AIDS, has been definitively established and sufficient knowledge is available about its modes of transmission to substantially slow its spread.
The most important lesson learned from countries that have successfully responded to the epidemic has been the critical role of government and civil society leadership in increasing the visibility of the epidemic while decreasing the stigma associated with it. In an increasing number of countries, partnerships between Governments and civil society have begun to bring together Governments, the international community and interested activists: people living with HIV/AIDS, NGOs, community-based organizations, religious and academic institutions and the private sector.
A Greater Epidemic Can Be Prevented
Vigorous measures taken now to reduce the rate of HIV infections will pay substantial dividends in years to come in countries with high or low prevalence. Large-scale prevention programs in virtually all settings have clearly demonstrated that the spread of HIV can be reduced, especially among young people. Prevention programs have also been successful among hard-to-reach populations, particularly in harm reduction among injecting drug users. In Asia, Australia, Europe, Latin America and the Caribbean, North America and sub-Saharan Africa, there is strong evidence of the decline of HIV incidence in populations with access to effective prevention programs.
Capacity and Commitment to Act Have Increased
There has been tangible progress in assembling the essential political, policy and technical experience required to mount a global response equal to the scale of the epidemic. Responses with strong political support across all planning and social sectors are increasing. Financial resources are now being made available at increased rates within affected countries, from bilateral and multilateral development agencies and the commercial and foundation sectors and through debt-relief efforts. In addition, new communications capabilities, such as the Internet, are enabling partners to interact and access information at a pace unimagined even a decade ago.
National Plans Involving Multiple Actors Have Been Developed
The basic lesson learned for any national AIDS plan is that interventions to reduce HIV risk and change behavior are effective when a range of government ministries and partners in the social, economic and health sectors are involved in providing an enabling environment for large-scale prevention, care and support programs. Single, isolated activities do not yield sustained results. Effective programs require focused action and steadily expanding coverage. The importance of involving the target population as well as people living with HIV/AIDS in the design and implementation of interventions cannot be stressed enough.
Intensive information and education programs are essential to reduce the risk of sexual transmission in the general population and to help promote safer sexual behavior, for example through abstinence, fidelity and condom use. The social marketing of both male and female condoms increases their accessibility, although condoms will need to become available on a much larger scale in many countries. Comprehensive (and targeted) interventions should respond specifically to the needs of young people before they become sexually active.
One particularly effective intervention is the prevention of mother-to-child transmission. A short one-month course of antiretroviral treatment given to HIV-infected mothers late in pregnancy can cut the rate of transmission to children by 20-50 per cent. Pilot projects target limited numbers of women and their unborn infants but have a huge potential for expansion. Voluntary HIV counselling and testing, at present available only to a tiny proportion of sub-Saharan African men and women, serves as a critical entry point for HIV care and prevention, with huge potential for accelerating the response.
A Comprehensive Approach to HIV/AIDS Care and Treatment Is Essential
The care and treatment of people living with HIV/AIDS represents one of the greatest challenges in the years to come. To meet it, a comprehensive approach to care must be adopted. This includes more effective support to home- and community-based care, as well as equitable access to medical treatment, including drugs for opportunistic infections and antiretroviral therapy.
In industrialized countries, advances in the management of opportunistic infections and the development of antiretroviral "combination" therapy for HIV infection itself have transformed the lives of people with HIV/AIDS. Increasingly, HIV/AIDS is being managed as a chronic condition, and new treatments have helped to improve people's health and enables them to continue normal lives within their communities. However, combination therapy is not a cure for HIV/AIDS and its long-term effects are not clear. Further research into new drugs and therapeutic approaches remains critical.
While medical care in high-income countries is significantly extending the lives of people living with HIV, the challenge now is to improve access to care in developing countries, where 95 per cent of the world's 36.1 million HIV-infected people live. Some countries, such as Brazil, have developed effective programs that implement a comprehensive approach to care, ranging from voluntary counselling and testing, psycho-social support and good nutrition to the strengthening of health systems to ensure access to the prevention and treatment of opportunistic infections, such as tuberculosis and antiretroviral therapy. Although these programs are not yet available to all that need them, they provide an important model for expansion. With international support, more developing countries are developing strategic plans that place access to care at the heart of their national responses to HIV/AIDS. Experience with home-based and community care is now rapidly developing as an essential component of HIV care and treatment, particularly in Africa.
As well as the need to strengthen health-care systems, we must address the affordability of medicines for opportunistic infections and antiretroviral therapy, which remains one of the greatest barriers to improving access to care. Some progress towards reducing the price of medicines has been made through partnership with several research and development-based pharmaceutical companies and through the increasing availability of generic versions of antiretroviral drugs. Despite these efforts, much more needs to be done if access to care and treatment is not to remain out of reach for the majority of people living with HIV and AIDS.
All the options for improving access to care at the global, regional and national levels need to be explored, taking into account the close relationships between pricing, financing, trade policy and health-care systems. At the country level, strategic plans for care need to be developed that address health and social systems, equity issues and the use to which public subsidies will be put. We need to find ways of more effectively using trade policy provisions, such as compulsory licensing or parallel importation, to increase access to care. The availability of low-cost generic drugs needs to be expanded, in accordance with national laws and international trade agreements and with guarantees of their quality. Other approaches, including tiered pricing, improved global and regional procurement policies and new funding mechanisms, also need to be explored.
Successful Responses Have Their Roots in Communities
Effective community-centred efforts have generally been both empowering, strengthening a community's capacity to make decisions, and enabling, assisting them in mobilizing the resources required to act on those decisions. Community leaders who are properly informed are better able to assess the reality of HIV/AIDS within their particular community and to analyse the determining factors of risk and vulnerability affecting them. On this basis, local actors can better address those determining factors and their consequences and determine their priorities for action accordingly.
Successful strategies addressing HIV/AIDS at the community level require the development of partnerships to mobilize local responses and access national resources. These partnerships, comprised of key social groups, government service providers, NGOs, people living with HIV/AIDS, community-based groups and religious organizations, serve to strengthen the awareness and capacity of the various stakeholders. HIV-positive women's collectives in many parts of the world have demonstrated effective community counselling and prevention interventions.
Empowering Young People Is Essential
An effective response involves a special focus on the needs of young people. Sexually active adolescents will require special family planning information counselling and health services, as well as treatment for sexually transmitted diseases and HIV/AIDS prevention. Governments, at the highest political levels, should take urgent action to provide education and services to prevent the transmission of all forms of sexually transmitted diseases and HIV. Governments should enact legislation and adopt measures to ensure non-discrimination against people living with HIV/AIDS and vulnerable populations, including women and young people, so that they are not denied the information needed to prevent further transmission and are able to access treatment and care services without fear of stigmatization, discrimination or violence.
People Living with HIV/AIDS Are Central to the Response
A renewed effort to combat stigma is needed. Effectively addressing stigma removes what still stands as a roadblock to concerted action, whether at the local, community, national or global level. Combating stigma is a human rights imperative on its own, as well as of instrumental value in fighting denial and shame, major obstacles in opening dialogue about HIV/AIDS. One of the best ways of combating denial is to give AIDS a "human face" through what is called the greater involvement of people living with HIV/AIDS, a principle formally launched at the Paris AIDS Summit on 1 December 1994. People who live with or are directly affected by HIV/AIDS bring personal experience to planning and carrying out a response to the epidemic, challenging complacency and denial, strengthening the call for urgency in the response, and moving Governments and their leaders to action.
Epidemic Must Be Tackled on Several Fronts
Although the complexity of the epidemic has far exceeded all expectations, we have come to recognize that there is a relationship between the basic dynamics of the epidemic and that an effective response needs to tackle three things. HIV infection is associated with specific risks, made up of behaviors and situations that might promote the transmission of HIV, with vulnerability, those factors that make it more likely that some individuals become infected rather than others, such as migrant populations or poor women, and with impact, the consequences of the epidemic for individuals and communities.
Experience has demonstrated that it is not possible to sustain a long-term and effective response to the epidemic unless each of these strands -- risk, vulnerability and impact -- are addressed. It is through respecting the relationship between these three dynamics -- which are different for men and women -- that a truly effective response can be engineered. In particular:
Effective Response Varies in Different Settings
Different settings require a different focus and a different balance between these three elements. National strategic planning processes have stimulated central and local governments, NGOs, communities and international partners in many countries to define strategies that are tailored to the different contexts within which HIV/AIDS evolves. Regional and subregional strategies have complemented and added value to national responses. Settings with low prevalence but increasing incidence and those with high prevalence of HIV both require urgent priority. Strategy development within each setting will need to reflect its particular opportunities and constraints.
This article was provided by UNAIDS. It is a part of the publication Review of the Problem of HIV in All Its Aspects. Visit UNAIDS' website to find out more about their activities, publications and services.