WHAT WORKS IN HIV PREVENTION?

Over the last two decades, a great deal has been learned regarding effective interventions for HIV prevention. 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.

National level

At the national level, political commitment at all levels has been shown to be essential for programme success. Multi-level 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, 1998a, 1998b, 1998c, 1999). Furthermore, coordinated economic, political and social effort are required to reduce societal vulnerability alongside programmes and interventions operating at individual and community levels (UNAIDS, 1998d).

Global experience has shown the following elements to be among those central for effective national HIV prevention efforts:

· 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;

· multi-sectoral and multi-level partnerships to deliver programmes and services across a range of contexts;

· community involvement in programme and intervention development, 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.

(Piot and Aggleton, 1998)

Community level

Following a recent review of successful community-based projects and activities (UNAIDS, 1999), a further set of principles has been identified outlining some of the factors that need to be taken into account if community-based prevention activities are to be effective. These include:

· engaging the community through existing organizations, groups and structures for education and support;

· building partnership and trust through communication, networking and collaboration;

· including people with HIV and AIDS at all stages of the process so as to enhance visibility and benefit from their skills and experiences;

· creating an accepting community environment in which HIV and AIDS are acknowledged to be everyone’s concern.

Beyond these principles, community-based approaches need to make certain that resources are directed towards community capacity-building in order to ensure sustainability.

Programme/project level

At the programme/project level, the following factors are central to programme success when adequately operationalized.

· the provision of information in culturally appropriate ways about how HIV is and is not transmitted;

· the inclusion of activities that encourage people (both as individuals and communities) to appraise the risks that face them personally;

· the provision of training in skills for communication and (where it is feasible) sexual negotiation;

· the provision of enhanced access to resources such as condoms and appropriate and affordable health services, including those for the early detection and treatment of sexually transmitted diseases (STDs).

· the participation of target groups at all stages of design, implementation and evaluation;

· the monitoring of programmes/projects at all stages of development and implementation.

Group level

Prevention approaches need to be tailored to the needs of particular groups.

When working with young people, for example, it is important to:

· take into account the diversity of young people and their needs;

· encourage youth participation in project design and implementation;

· work in a climate of openness that recognizes and respects the realities that young people face;

· focus on young men’s sexual health, as well as sexual health issues relating to young women;

· examine the positive aspects of sexual health;

· promote greater awareness of sexual and reproductive rights;

· provide opportunities to address issues of gender, social status and sexuality;

· undertake work with young men to enable them to think about their role in relation to both their sexual health and that of their partners;

· promote greater awareness of the structural issues affecting the sexual and reproductive health of young people, including the need for improved rights and protection for young people;

· improve access to basic education and timely sex and HIV-related education;

· provide access to voluntary counselling and testing services, along with appropriate referrals;

· increase access to youth-friendly health services.

When working with women, it is important to:

· use a multifaceted approach that addresses economic and other needs which may take priority over HIV/AIDS in the daily lives of women living in poverty in developing countries;

· focus on improving communication between sexual partners which acknowledges the difficulties women encounter in talking and negotiating with men about sex;

· increase awareness of the importance of including men in work for the prevention of HIV among men, women and children;

· address the need for improved health services for women;

· acknowledge the importance of a gendered approach to HIV prevention work, which includes discussions of power relations between men and women;

· provide access to voluntary counselling and testing services, along with appropriate referrals;

· acknowledge the support that women can provide to each other through open discussion and the development of networks.

When working with people who inject drugs, it is important to:

· focus on harm reduction as well as rehabilitation;

· advocate to protect the rights of people who inject drugs;

· adopt a multi-pronged approach including needle and syringe exchange and the provision of drug treatment, including detoxification, substitution pharmacotherapy, HIV/AIDS care and social network interventions;

· provide drop-in services, mobile services and outreach work;

· work to improve the sexual health and sexual practices of people who inject drugs;

· undertake HIV prevention activities when seroprevalence is still low;

· establish trust between people who inject drugs and health workers through outreach work;

· provide good access to sterile injecting equipment and condoms;

· provide access to voluntary counselling and testing services, along with appropriate referrals;

· establish high levels of knowledge about HIV infection and modes of transmission among people who inject drugs.

When working with men who have sex with men, it is important to:

· acknowledge the wider concerns of MSM in developing countries, including issues such as harassment, poverty and responsibilities towards family members;

· recognize the importance of raising public awareness about issues concerning MSM, countering prejudice and discrimination, and the promotion of human rights;

· provide training for professionals working with MSM, including health workers, teachers and prison officers;

· address homophobia, including internalized homophobia;

· help MSM develop support networks;

· provide access to voluntary counselling and testing services, along with appropriate referrals;

· acknowledge the diversity of MSM in developing and developed countries.

When working with sex workers, it is important to:

· acknowledge the wider concerns and priorities of sex workers, which include social, legal and economic issues as well as concern for their families and children;

· address the prejudice and stigmatization that sex workers face;

· acknowledge the importance of helping to empower sex workers;

· provide improved and more accessible health services, most especially for the diagnosis and treatment of STDs;

· seek the cooperation and support of gatekeepers in the sex industry, including brothel owners and bar owners as well as employers of potential clients of sex workers;

· legitimize the role of sex workers as educators, providing them with the respect of their peers;

· acknowledge the importance of providing sex workers with financial incentives for peer-led work;

· work, where possible, with men as well as women through a focus on clients and, in some cases, boyfriends. This is important given the prevalent power relations between both men and women and clients and sex workers.

SOURCES OF EVIDENCE

There are clearly a number of different ways of generating knowledge about HIV prevention methods and their effects. All rely to some extent upon observation and the amassing of information, but each differs according to the rigour with which data and information are collected and made sense of. The kinds of relatively casual observations that contribute to intuitions and gut reactions are different in kind from the more systematic approaches used in observation studies and objectives-based evaluations. These in turn differ from the approaches often used in more formally conducted experimental and comparative evaluations.

It is crucial to bear in mind the strengths and limitations of different kinds of approaches (and different kinds of evidence) when making judgements about what works, and what might prove to be a promising approach, in HIV prevention. By itself, no one approach can answer all the questions we may have about appropriateness and effectiveness. Taken together, different kinds of evidence, and different kinds of methodology, can be persuasive in helping us identify the most useful approaches to adopt in particular circumstances and with particular groups.

The following sections provide case study examples of interventions conducted for the prevention of HIV/AIDS for the aforementioned most vulnerable groups, and describe promising HIV prevention interventions geared to addressing their specific needs.