HIV prevention 1 - The history and challenge of HIV prevention

Duke Global Health Institute, Duke University, Durham, NC, USA.
The Lancet (Impact Factor: 45.22). 09/2008; 372(9637):475-88. DOI: 10.1016/S0140-6736(08)60884-3
Source: PubMed


The HIV/AIDS pandemic has become part of the contemporary global landscape. Few predicted its effect on mortality and morbidity or its devastating social and economic consequences, particularly in sub-Saharan Africa. Successful responses have addressed sensitive social factors surrounding HIV prevention, such as sexual behaviour, drug use, and gender equalities, countered stigma and discrimination, and mobilised affected communities; but such responses have been few and far between. Only in recent years has the international response to HIV prevention gathered momentum, mainly due to the availability of treatment with antiretroviral drugs, the recognition that the pandemic has both development and security implications, and a substantial increase in financial resources brought about by new funders and funding mechanisms. 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.

Download full-text


Available from: Jeffrey O'Malley, Oct 08, 2014
179 Reads
  • Source
    • "Interventions addressing the social drivers of vulnerability and resilience have been termed the “game changer” needed for the HIV/AIDS response [4]. The notion of “combination prevention” has gained ground [1, 5, 6], emphasizing the value of comprehensive interventions which combine biomedical interventions with social or structural programming [7, 8]. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Introduction Contemporary HIV-related theory and policy emphasize the importance of addressing the social drivers of HIV risk and vulnerability for a long-term response. Consequently, increasing attention is being given to social and structural interventions, and to social outcomes of HIV interventions. Appropriate indicators for social outcomes are needed in order to institutionalize the commitment to addressing social outcomes. This paper critically assesses the current state of social indicators within international HIV/AIDS monitoring and evaluation frameworks. Methods We analyzed the indicator frameworks of six international organizations involved in efforts to improve and synchronize the monitoring and evaluation of the HIV/AIDS response. Our analysis classifies the 328 unique indicators according to what they measure and assesses the degree to which they offer comprehensive measurement across three dimensions: domains of the social context, levels of change and organizational capacity. Results and discussion The majority of indicators focus on individual-level (clinical and behavioural) interventions and outcomes, neglecting structural interventions, community interventions and social outcomes (e.g. stigma reduction; community capacity building; policy-maker sensitization). The main tool used to address social aspects of HIV/AIDS is the disaggregation of data by social group. This raises three main limitations. Indicator frameworks do not provide comprehensive coverage of the diverse social drivers of the epidemic, particularly neglecting criminalization, stigma, discrimination and gender norms. There is a dearth of indicators for evaluating the social impacts of HIV interventions. Indicators of organizational capacity focus on capacity to effectively deliver and manage clinical services, neglecting capacity to respond appropriately and sustainably to complex social contexts. Conclusions Current indicator frameworks cannot adequately assess the social outcomes of HIV interventions. This limits knowledge about social drivers and inhibits the institutionalization of social approaches within the HIV/AIDS response. We conclude that indicator frameworks should expand to offer a more comprehensive range of social indicators for monitoring and evaluation and to include indicators of organizational capacity to tackle social drivers. While such expansion poses challenges for standardization and coordination, we argue that the complexity of interventions producing social outcomes necessitates capacity for flexibility and local tailoring in monitoring and evaluation.
    Journal of the International AIDS Society 08/2014; 17(1):19073. DOI:10.7448/IAS.17.1.19073 · 5.09 Impact Factor
  • Source
    • "One need only sample the patchwork of agencies serving G/MSM to see evidence of this challenge. Traditional HIV behavioral prevention, at least when targeted to HIV-negative individuals, has been centered in community-based organizations that offer few medical services [9]. Testing and treatment of sexually transmitted infections are frequently conducted in standalone STI clinics, due in part to historical and existing stigma against venereal disease [10]. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Research on gay and other men who have sex with men's (G/MSM) preferences for sexual healthcare services focuses largely on HIV testing and to some extent on sexually transmitted infections (STI). This research illustrates the frequency and location of where G/MSM interface with the healthcare system, but it does not speak to why men seek care in those locations. As HIV and STI prevention strategies evolve, evidence about G/MSM's motivations and decision-making can inform future plans to optimize models of HIV/STI prevention and primary care. We conducted a phenomenological study of gay men's sexual health seeking experiences, which included 32 in-depth interviews with gay and bisexual men. Interviews were transcribed verbatim and entered into Atlas.ti. We conducted a Framework Analysis. We identified a continuum of sexual healthcare seeking practices and their associated drivers. Men differed in their preferences for separating sexual healthcare from other forms of healthcare ("fragmentation") versus combining all care into one location ("consolidation"). Fragmentation drivers included: fear of being monitored by insurance companies, a desire to seek non-judgmental providers with expertise in sexual health, a desire for rapid HIV testing, perceiving sexual health services as more convenient than primary care services, and a lack of healthcare coverage. Consolidation drivers included: a comfortable and trusting relationship with a provider, a desire for one provider to oversee overall health and those with access to public or private health insurance. Men in this study were likely to separate sexual healthcare from primary care. Based on this finding, we recommend placing new combination HIV/STI prevention interventions within sexual health clinics. Furthermore, given the evolution of the financing and delivery of healthcare services and in HIV prevention, policymakers and clinicians should consider including more primary care services within sexual healthcare settings.
    PLoS ONE 08/2013; 8(8):e71546. DOI:10.1371/journal.pone.0071546 · 3.23 Impact Factor
  • Source
    • "Human immunodeficiency virus (HIV) infection is a serious public health disorder that affects up to 34 million people in the world [1]. Since this disease was firstly identified and described in the 80s, it has infected at least 60 million people and caused more than 25 million deaths [2]. The introduction of highly active antiretroviral therapy (HAART) has considerably improved the prognosis of HIV-infected patients leading to a significant reduction of HIV-related morbidity and mortality [3]. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Highly active antiretroviral therapy (HAART) has considerably improved the prognosis of HIV-infected patients. However, prolonged use of HAART has been related to long-term adverse events that can compromise patient health such as HIV-associated lipodystrophy syndrome (HALS) and nonalcoholic fatty liver disease (NAFLD). There is consistent evidence for a central role of mitochondrial dysfunction in these pathologies. Nucleotide reverse transcriptase inhibitors (NRTIs) have been described to be mainly responsible for mitochondrial dysfunction in adipose tissue and liver although nonnucleoside transcriptase inhibitors (NNRTIs) or protease inhibitors (PIs) have also showed mitochondrial toxicity, which is a major concern for the selection and the long-term adherence to a particular therapy. Several mechanisms explain these deleterious effects of HAART on mitochondria, and evidence points to other mechanisms beyond the “Pol- γ hypothesis.” HIV infection has also direct effects on mitochondria. In addition to the negative effects described for HIV itself and/or HAART on mitochondria, HIV-infected patients are more prone to develop a premature aging and, therefore, to present an increased oxidative state that could lead to the development of these metabolic disturbances observed in HIV-infected patients.
    Oxidative Medicine and Cellular Longevity 07/2013; 2013(12, article 1109):493413. DOI:10.1155/2013/493413 · 3.36 Impact Factor
Show more