When it comes to the strategies of preventing HIV/AIDS, many say the world has failed. They point to daunting numbers from last year: an estimated 2.7 million new HIV infections, while 1 million were put on treatment. The race is still being lost, and it’s common to hear now that countries can’t treat their way out of the epidemic.
But Marie Laga, an epidemiologist from the Institute of Tropical Medicine, Antwerp, led off a plenary session today at the HIV/AIDS Implementers’ Meeting not with a message of doom, but one of hope.
She said prevention has had an impact. Her proof: men having sex men in the United States and other developed countries showed sharp HIV incidence decrease from the mid-1980s to mid-1990s; Thailand reduced its rate of new infections 10-fold over 20 years; HIV incidence among sex workers in Cambodia also declined by 10 times; and several countries in Africa, notably Kenya, Ethiopia, and Zimbabwe, have shown declining incidence rates, even if the rates are still high.
“It can work, and has worked, and as an international community, we need to be more confident about it,’’ Laga said. “It doesn’t mean we shouldn’t do more or we couldn’t do it better. We have to go back to the basics, understand where and when the infections occur. … Knowing your epidemic is critical, and there should be a convergence of all data.
“The most relevant question for prevention planning: Where do we think the next 1000 infections will occur?’’
Many African countries already have participated in these so-called modes of transmission studies, learning that the HIV epidemic in their nation shifts – and also learning that most countries were not paying attention to discordant couples, in which one partner is HIV positive and the other is not. Prevention planners focusing on Africa’s high HIV-prevalence countries have pinpointed the major drivers of the epidemic as multiple and concurrent partners; low condom use; low levels of male circumcisions; gender inequities; male attitudes and behaviors; inter-generational sex, and in some countries, men having sex with men.
“What can we do about this?’’ Laga asked. “We must realize there is no simple quick fix. We have to avoid being paralyzed by the complexity. We need to work on changing social norms and values.’’
The evidence around the effectiveness of prevention tools is inadequate, she said. Some studies, for instance, show that sex education in schools has not reduced HIV infections among young people, but Laga asked, “I don’t think we should abandon sex education all together, given the needs for young girls.’’
Overall, she said, “in the absence of perfect evidence, we should use common sense more often. For instance, young people are a priority by definition in high-prevalence countries.’’
She foresaw a future in which communities will be increasingly asking for help on prevention tactics, and she also warned that as AIDS treatment spreads, risk factors could well increase as well.
“I would caution a little bit of the optimism of an automatic prevention benefit of ART (antiretroviral therapy) rollout. Yes, patients will be less infectious. But with treatment, many more HIV-positive people are now having sex for a longer time. More worrisome is the perception of AIDS changes and may result in unsafe sex in the community,’’ she said.
Laga used a Netherlands study as an example. Since ART became available in 1996 there, risk behavior rates increased by 66 percent. “The benefits of ART and early diagnosis have been entirely offset by increases in risk behavior,’’ she said.
Now, she said, tough messages about AIDS needed to go out.
“We should again tell people HIV is no picnic,’’ she said.
The title of the session: The Puzzle of Prevention. After Laga’s presentation, moderator Mark Stirling, director of UNAIDS Regional Support Team in Eastern and Southern Africa, echoed her message. “We don’t have a puzzle that is impossible to put together,’’ he said.