(introduction...)

² A full review of interventions against HIV/AIDS is beyond the scope of this document. Readers who wish to explore these in detail are encouraged to examine the growing literature on prevention, care and impact mitigation, including Merson et al. (2000), UNAIDS (2000a), Ainsworth and Teokul (2000), Jha et al. (2000) and Hunter (2000).

In general, effective responses would address the needs of each country, taking into account the status of the epidemic, the likely impact of a range of cost-effective interventions in a given context, as well as the capacity for large-scale programme planning, funding and implementation. The range of actions would include the development or strengthening of institutions for planning and coordination, multisectoral approaches to programme development and implementation, prevention of new infections, affordable care for persons living with HIV/AIDS (PLWHAs), social support to mitigate the impact of AIDS on families and orphans, as well as effective monitoring and evaluation of programme efforts.

Country teams are likely to be more credible and effective advocates if their proposals are based on evidence of what works against HIV/AIDS, with clear outlines of the approaches to be taken in the national response to the epidemic and its consequences. Although a great deal remains to be understood about the evolution of the epidemic and its consequences, much has been learned regarding effective interventions for HIV prevention, cost-effective care for persons who are already infected, and actions to mitigate the impact on orphans, families and communities. When the first cases of AIDS were reported in the early 1980s, individuals and groups acted to alert people to this dangerous new disease and the steps that could be taken to protect against it. Even before HIV was isolated, safer sex and safer drug use guidelines had been developed based upon epidemiological evidence concerning patterns of transmission. However, providing people with information about how to protect against infection has proven to be insufficient in and of itself. People require enabling environments that will reduce their susceptibility and vulnerability, and allow them to modify their behaviour based on their knowledge gained through information provision (UNAIDS, 2000a).

2.2.1. An enabling environment across multiple sectors

At the national level, political commitment at all levels has been shown to be essential for programme success. Multilevel interventions that seek to involve a variety of partners in coordinated action have been shown to be more successful than those that work in isolation (UNAIDS, 1999, 2000a). Furthermore, coordinated economic, political and social effort are required to reduce societal vulnerability, alongside programmes and interventions operating at individual and community levels. Global experience has shown the following elements to be among those central to effective national HIV prevention efforts (Piot and Aggleton, 1998):

· General awareness-raising activities to provide information and counter negative reactions among the population at large

· Focused persuasive action to meet the needs of specially vulnerable groups and communities, with steadily expanding coverage

· Multisectoral and multilevel partnerships to deliver programmes and services across a range of contexts

· Community ownership of programmes, and building upon the will of groups and individuals to contribute to national HIV prevention efforts

· Greater integration between prevention and care to reduce costs and to reduce levels of discrimination and stigmatization

· Action to build societal resistance to HIV transmission and reduce the systematic vulnerability of particular individuals, groups and sections of society

2.2.2. Preventing HIV infection

There are still few systematic reviews of the evidence on preventive interventions in the published literature. Merson et al. (2000) reviewed the effectiveness of projects and programmes in developing countries that aim to reduce sexual transmission of HIV infection or transmission related to injection drug use. They found that behavioural change interventions are effective when targeted to populations at high risk, particularly female sex workers and their clients. Few studies have evaluated harm reduction interventions in injecting drug users (IDUs). Evidence on the effectiveness of voluntary counselling and testing programmes was mixed, and results varied according to the population being studied. STI treatment appeared highly effective in reducing HIV/STI transmission, particularly in the earlier stages of the epidemic. Structural and environmental interventions show great promise, although more evaluation is needed. Merson et al. concluded that:

· HIV prevention interventions can be effective in changing risk behaviours and preventing transmission in low- and middle-income countries;

· when the appropriate mix of interventions is applied, they can lead to significant reductions in the prevalence of HIV at the national level; and

· additional research is needed to identify effective interventions, particularly in men who have sex with men, youth, IDUs and HIV -infected persons.

In practice, countries will strike a pragmatic balance, based on the capacity for programme implementation, the expected effects of interventions, their political feasibility and the availability of financial resources. For practical purposes, countries would need to consider interventions aimed at reducing risk and those aimed at reducing vulnerability (Table 1).

Table 1. Interventions for prevention of HIV infection

2.2.3. Care, support and impact mitigation

With millions infected and many more affected by HIV, the need has become urgent for improved access to affordable care, support and mitigation of the impact on individuals, communities and countries. Table 2 shows a summary of interventions to be considered for care, support and impact mitigation.

Table 2. Care and support packages, according to resource availability

Package	Contents
The essential package	· Voluntary HIV counselling and testing
	· Psychosocial support for HIV -positive people and their families
	· Palliative care and treatment for pneumonia, oral thrush, vaginal candidiasis and pulmonary tuberculosis
	· Prevention of infections with cotrimoxazole prophylaxis for symptomatic HIV -positive people
	· Official recognition and facilitation of community activities that reduce the impact of HIV infection
The intermediate package	All of the above plus one or more of the following:
	· Active case-finding (and treatment) of tuberculosis among HIV -positive people
	· Preventive therapy for tuberculosis for HIV -positive people
	· Systemic antifungals for systemic fungal infections (such as cryptococcosis)
	· Treatment of Kaposi sarcoma
	· Surgical treatment of cervical cancer
	· Treatment of extensive herpes with acyclovir
	· Funding for community activities that reduce the impact of HIV infection
The advanced package	All of the above plus:
	· Triple antiretroviral therapy
	· Diagnosis and treatment of opportunistic infections that are difficult to diagnose and/or expensive to treat, such as atypical mycobacterial infections, cytomegalovirus infection, multiresistant tuberculosis, toxoplasmosis and HIV -associated cancers
	· Specific public services that reduce the economic and social impacts of HIV, to supplement community efforts that reduce the impact of HIV infection

Source: UNAIDS (2000a), pp. 96-98.

2.2.4. Mobilization of resources

It is important to mobilize resources for all aspects of the response to HIV/AIDS described above. For sub-Saharan Africa alone, scaling up a wide range of interventions would require US$1.5-2.3 billion per year. Providing highly active antiretroviral therapy (HAART) would add another US$1.5-2.4 billion depending on the prices at which drugs would be available. These estimates are based on relatively conservative estimates of likely coverage that can be achieved by 2005 (World Bank, 2000c).

Country-specific estimates of the resource gaps will make the case for additional resources highly compelling. In Zambia, resources required for implementing the National HIV/AIDS Strategic Framework were estimated at US$558.6 million for 2001-2003. A total of US$25.5 million had been committed by October 2000, leaving a resource gap of US$382 million (Bail and Mwikisa, 2000).