[This section presents, with permission, a report from the Global HIV Prevention Working Group (PWG). The Working Group is an international panel of over fifty leading public health experts, clinicians, biomedical and behavioral researchers, advocates, and people affected by HIV/AIDS that was convened by the Bill and Melinda Gates Foundation and the Henry J. Kaiser Family Foundation.
The goal of PWG is to inform global policymaking, program planning, and donor decisions on HIV prevention. The Working Group issues periodic reports and fact sheets on key issues in HIV prevention science and policy; works to build consensus on evidence-based HIV prevention programming; advocates for a comprehensive response to HIV/AIDS that integrates prevention, treatment, and care; and provides information and guidance to donors, media, and policy makers. Working Group publications are available at www.GlobalHIVPrevention.org.]
Behavioral HIV prevention programs that target individuals, families, communities, entire societies, or a combination of all these have been shown to significantly reduce the rate of new HIV infections. Prevention programs build the skills needed to use prevention tools properly and, to the extent feasible, to avoid or effectively negotiate risky situations. Countries in diverse regions and of different income levels have significantly lowered the rate of new HIV infections—in all such cases, favorable outcomes were the result of major shifts in human behavior (Global HIV Prevention Working Group, 2008).
Behavioral HIV prevention programs might include direct interventions that introduce prevention tools into particular environments. For example:
Indirect social or structural interventions can improve overall protection by promoting human rights, reducing income inequality, and addressing gender inequities.
HIV prevention is one of the world’s most important priorities and behavior change remains the driving force for national success against HIV. It is clear that as the HIV epidemic continues to expand treatment alone will not reverse the incidence of new infections. For example, in sub-Saharan Africa, where the HIV burden is heaviest, programs focusing on individual risk behavior are unlikely on their own to achieve the level of success needed to reverse the epidemic. In most countries prevention efforts should focus on populations at highest risk of infection (men who have sex with men, sex workers, injection drug users, prisoners, mobile populations, and other vulnerable groups.) (PWG, 2008).
[These examples are from PWG, 2008.]
In the early 1980s Australia mounted a national AIDS response that included broad public-awareness campaigns, specific behavioral interventions for gay men, public-sector support for needle and syringe exchange, and voluntary HIV counseling and testing. Dramatic declines in unprotected anal intercourse and the sharing of needles for drug use were recorded.
As a result of Australia’s early, comprehensive response, focused largely on behavior change, annual HIV incidence peaked in 1985 and declined through the end of the 1990s. Between 1990 and 2000, the annual number of new HIV diagnoses fell by half.
Brazil has encouraged open discussion of HIV, supporting frank public-awareness campaigns, condom promotion, focused behavioral interventions, syringe and needle exchange, school-based HIV education, prevention services in prisons, and voluntary HIV counseling and testing. Especially noteworthy is Brazil’s success in reversing a serious epidemic among injection drug users. Condom use increased by almost 50 percent among sexually active adults between 1998 and 2005, and focused behavior change prevention programs also maintained HIV prevalence at low levels among sex workers. Although the World Bank had predicted in 1990 that 1.2 million Brazilians would be infected by 2000, fewer than 600,000 were living with HIV in 2002.
In response to an increase in infections in the late 1980s, Thailand initiated an innovative national program that has served as a model for other countries. The country’s 100 percent condom-usage program promoted condom use in brothels and national leaders encouraged discussion of the HIV threat and the fair treatment of those who were infected.
Annual HIV incidence declined from 143,000 in 1991 to 19,000 in 2003, helping reverse what was once one of the world’s fastest-growing epidemics. Had Thailand not brought comprehensive HIV prevention to scale, it would now have 7.7 million HIV infections, rather than the estimated 580,000 residents currently living with HIV.
Uganda moved in the mid-1980s to address the rapid spread of HIV, implementing public-awareness campaigns that encouraged young people to delay initiation of sex and urged sexually active adults to reduce the number of sex partners. In the 1990s, the country supplemented these early measures with condom promotion and programs for voluntary counseling and testing.
The results of these efforts were remarkable. The percentage of young people who were sexually active fell by more than half between 1989 and 1995, and Ugandans were significantly less likely to have multiple sex partners than people living in neighboring countries. Increases in condom use in the 1990s helped preserve and accelerate early prevention gains. By the late 1990s, infection levels in capital city Kampala had fallen by two-thirds, and national HIV prevalence had been cut in half.
In 2010 the Global HIV Prevention Working Group issued a report that indicated that although great strides have been made with antiretroviral treatment, the world is currently doing a poor job of implementing sound, evidence-based, well-planned HIV prevention programs (PWG, 2010). Overall findings indicate:
The PWG report focuses specifically on behavioral HIV prevention. The report surveys what we know about the effectiveness of behavior change strategies, what we still need to learn, and what we need to do to advance such efforts in coming years.
Recent results from clinical trials of potential new HIV prevention interventions underscore what we have known for decades: Wider delivery of effective behavior change strategies is central to reversing the global HIV epidemic. The availability of new biomedical HIV prevention modalities, such as vaccines and microbicides, is still many years away. Even when these tools finally emerge, human behavior will remain critical, as new prevention strategies are unlikely to be 100% effective in preventing transmission.
With 2.5 million new HIV infections in 2007, there is an obvious and urgent need to pursue the effective strategies we have to promote safer behaviors. Human behavior is complex; widespread behavior changes are challenging to achieve; and there are important gaps in our knowledge about the effectiveness of HIV prevention. Yet the research to date clearly documents the impact of numerous behavioral interventions in reducing HIV infection. We also know that in all cases in which national HIV epidemics have reversed, broad-based behavior changes were central to success.
To be more effective in the twenty-first century, the HIV prevention effort must confront several challenges of perception:
Randomized controlled trials and observational research have shown that individual, small group, and community-level interventions can generate safer behaviors. Brazil was especially effective in reducing expected infection trends through prevention efforts.
Research has helped to identify common elements in successful programs. According to the available evidence from these and other studies, effective strategies pursue a combination of behavior change approaches that are delivered with sufficient coverage, intensity, and duration, and that are tailored to address the main drivers of HIV transmission in national epidemics. Effective HIV prevention addresses the specific needs and circumstances of the target population and aims to affect multiple determinants of human behavior, including individual knowledge and motivations, interpersonal relationships, and societal norms. Community engagement and strong political support have been key ingredients of successful national efforts to change behavior to prevent HIV infection.
Although much evidence exists to demonstrate that it is possible to change human behavior to reduce the risk of HIV transmission, there are important gaps and limitations in what is known. There is also an inherent challenge in measuring the impact of any health effort that includes HIV prevention: measuring and determining causality for an event that did not occur (for example, an HIV infection averted) is intrinsically more complicated than evaluating an event or phenomenon that did happen.
An important challenge for both biomedical and behavioral interventions lies in how to turn success in clinical trials into the same kind of success in real-world situations and from there into all the many subgroups of the real world. A second challenge lies in finding ways to maintain long-term behavior change.
Yet a third challenge lies in our understand of human behavior and individual motivations. HIV prevention efforts must take into account the reality that individual personal agency in decisions around HIV is often heavily influenced by broader socioeconomic, cultural, and environmental factors. And finally, the conditions in which studies are undertaken tend to be far more one-dimensional than either actual prevention practice or peoples lives.
The Prevention Working Group (PWG) calls on all elements of global society—national authorities and governments, international donors, technical agencies, HIV service providers, civil society, HIV Prevention Researchers—to take up the challenge of improving HIV prevention through developing and implementing national strategies, funding national prevention programs, developing the means to assess strategies accurately, pursue partnerships with other related groups and programs, advocate for programs and then monitor them, and place greater priority on social research to improve the design and delivery of prevention programs and services.