Reassessing HIV prevention

School of Public Health, University of California at Berkeley, Berkeley, CA 94720, USA.
Science (Impact Factor: 33.61). 06/2008; 320(5877):749-50. DOI: 10.1126/science.1153843
Source: PubMed


The largest investments in AIDS prevention targeted to the general population are being made in interventions where the evidence for large-scale impact is uncertain.

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Available from: Richard G Wamai,
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    • "Uganda adopted a “Zero Grazing” campaign in the 1980’s, where having concurrent partners was discouraged. This campaign showed a 50% reduction in the number of people reporting casual and multiple partners between 1989 and 1995 [58,95]. It is also believed that partner reduction and fidelity are the main behavioral changes responsible for the decline in Kenya’s HIV infection rates. "
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    ABSTRACT: Thirty years since the discovery of HIV, the HIV pandemic in sub-Saharan Africa accounts for more than two thirds of the world's HIV infections. Southern Africa remains the region most severely affected by the epidemic. Women continue to bear the brunt of the epidemic with young women infected almost ten years earlier compared to their male counterparts. Epidemiological evidence suggests unacceptably high HIV prevalence and incidence rates among women. A multitude of factors increase women's vulnerability to HIV acquisition, including, biological, behavioral, socioeconomic, cultural and structural risks. There is no magic bullet and behavior alone is unlikely to change the course of the epidemic. Considerable progress has been made in biomedical, behavioral and structural strategies for HIV prevention with attendant challenges of developing appropriate HIV prevention packages which take into consideration the socioeconomic and cultural context of women in society at large.
    AIDS Research and Therapy 12/2013; 10(1):30. DOI:10.1186/1742-6405-10-30 · 1.46 Impact Factor
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    • "The increasing evidence of the linkages between transactional sex or multiple sexual partners and HIV has led to calls for greater investment in prevention efforts that try to address these behaviours, particularly among youth [65,66]. Work on understanding the determinants and associations with these behaviours, from the structural to individual level, is therefore imperative for HIV and STI prevention efforts. "
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    ABSTRACT: Background Ethnographic evidence suggests that transactional sex is sometimes motivated by youth’s interest in the consumption of modern goods as much as it is in basic survival. There are very few quantitative studies that examine the association between young people’s interests in the consumption of modern goods and their sexual behaviour. We examined this association in two regions and four residence zones of Madagascar: urban, peri-urban and rural Antananarivo, and urban Antsiranana. We expected risky sexual behaviour would be associated with interests in consuming modern goods or lifestyles; urban residence; and socio-cultural characteristics. Methods We administered a population-based survey to 2, 255 youth ages 15–24 in all four residence zones. Focus group discussions guided the survey instrument which assessed socio-demographic and economic characteristics, consumption of modern goods, preferred activities and sexual behaviour. Our outcomes measures included: multiple sexual partners in the last year (for men and women); and ever practicing transactional sex (for women). Results Overall, 7.3% of women and 30.7% of men reported having had multiple partners in the last year; and 5.9% of women reported ever practicing transactional sex. Bivariate results suggested that for both men and women having multiple partners was associated with perceptions concerning the importance of fashion and a series of activities associated with modern lifestyles. A subset of lifestyle characteristics remained significant in multivariate models. For transactional sex bivariate results suggested perceptions around fashion, nightclub attendance, and getting to know a foreigner were key determinants; and all remained significant in multivariate analysis. We found peri-urban residence more associated with transactional sex than urban residence; and ethnic origin was the strongest predictor of both outcomes for women. Conclusions While we found indication of an association between sexual behaviour and interest in modern goods, or modern lifestyles, such processes did not single-handedly explain risky sexual behaviour among youth; these behaviours were also shaped by culture and conditions of economic uncertainty. These determinants must all be accounted for when developing interventions to reduce risky transactional sex and vulnerability to HIV.
    Globalization and Health 03/2013; 9(1):13. DOI:10.1186/1744-8603-9-13 · 2.25 Impact Factor
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    • "Indeed, worldwide there are few success stories: Thailand with its ‘100% condom’ intervention [6] and Uganda with its ‘ABC approach’ [7] are routinely mentioned. We need to reprioritize strategies for HIV prevention, based on evidence [8], integrated into recently scaled-up treatment [9] and tailored to the local context [10]. "
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    ABSTRACT: Background We determine efficient, equitable and mixed efficient-equitable allocations of a male circumcision (MC) intervention reducing female to male HIV transmission in South Africa (SA), as a case study of an efficiency-equity framework for resource allocation in HIV prevention. Methods We present a mathematical model developed with epidemiological and cost data from the nine provinces of SA. The hypothetical one-year-long MC intervention with a budget of US$ 10 million targeted adult men 15–49 years of age in SA. The intervention was evaluated according to two criteria: an efficiency criterion, which focused on maximizing the number of HIV infections averted by the intervention, and an equity criterion (defined geographically), which focused on maximizing the chance that each male adult individual had access to the intervention regardless of his province. Results A purely efficient intervention would prevent 4,008 HIV infections over a year. In the meantime, a purely equitable intervention would avert 3,198 infections, which represents a 20% reduction in infection outcome as compared to the purely efficient scenario. A half efficient-half equitable scenario would prevent 3,749 infections, that is, a 6% reduction in infection outcome as compared to the purely efficient scenario. Conclusions This paper provides a framework for resource allocation in the health sector which incorporates a simple equity metric in addition to efficiency. In the specific context of SA with a MC intervention for the prevention of HIV, incorporation of geographical equity only slightly reduces the overall efficiency of the intervention.
    Cost Effectiveness and Resource Allocation 01/2013; 11(1):1. DOI:10.1186/1478-7547-11-1 · 0.87 Impact Factor
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