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Tuesday, 11th of November 2008 Print

This series of articles from The Lancet places the emphasis on HIV
 prevention. With a disease so diverse in different cultural, economic and
 epidemiological settings, a 'once size fits all approach' will not work. We
 need a menu driven approach in each country, choosing the interventions
 which are locally appropriate.


To access full text of each article, go to www.thelancet.com, then type the author’s

name in the search box.


Good reading.
 Putting prevention at the forefront of HIV/AIDS (comment)
 (Horton, R. and Das, P; THe Lancet, Volume 372, Number;
 From the very beginning of the global response to the AIDS pandemic,
 prevention has been marginalised. Treatment has dominated. This systematic
 imbalance in clinical and public-health programmes is largely responsible
 for the fact that around 2·5 million people become newly infected with HIV
 each year. The publication of a Series by The Lancet on the state of the
 science of HIV prevention—together with a call for action by leading
 academics, UNAIDS, and the World Bank—signifies a new commitment to stop
 the virus and its consequences.

 "Know your epidemic, know your response": a useful approach, if we get it
 right (comment)
 (Wilson, D. and Halperin, D.T. The Lancet, Volume 372, Number 9637; 9
 August 2008)
 Led by UNAIDS, Know your epidemic, know your response has become a rallying
 cry for an intensified focus on HIV prevention, spurred by the sobering
 realisation that for every person enrolled on antiretroviral treatment,
 many more become newly infected. The quest to better understand epidemics
 reflects growing recognition that there is no single global HIV epidemic,
 but rather a multitude of diverse epidemics. No single prescription can
 apply to countries as diverse as South Africa, Egypt, Russia, Thailand, or
 Papua New Guinea. The era of standard global prevention guidance is over.
 The Lancet's HIV Prevention Series #1 The history and challenge of HIV
 (Merson, M.H. et al; The Lancet, Volume 372, Number 9637; 9 August 2008)
 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.
 The Lancet's HIV Prevention Series #2 Biomedical interventions to prevent
 HIV infection: evidence, challenges, and way forward
 (Padian, N.S. et al; The Lancet; Article in Press, Corrected Proof; 6
 August 2008)
 Intensive research efforts for more than two decades have not yet resulted
 in an HIV vaccine of even moderate effectiveness. However, some progress
 has been made with other biomedical interventions, albeit on the basis of
 inconsistent levels of evidence. The male condom, if used correctly and
 consistently, has been proven in observational studies to be very effective
 in blocking HIV transmission during sexual intercourse; and, in three
 randomised trials, male circumcision was protective against HIV acquisition
 among men. Treatment of sexually transmitted infections, a public health
 intervention in its own right, has had mixed results, depending in part on
 the epidemic context in which the approach was assessed. Finally, oral and
 topical antiretroviral compounds are being assessed for their role in
 reduction of HIV transmission during sexual intercourse. Research on
 biomedical interventions poses formidable challenges. Difficulties with
 product adherence and the possibility of sexual disinhibition are important
 concerns. Biomedical interventions will need to be part of an integrative
 package that includes biomedical, behavioural, and structural
 interventions. Assessment of such multicomponent approaches with moderate
 effects is difficult. Issues to be considered include the nature of control
 groups and the effect of adherence on the true effectiveness of the
 The Lancet's HIV Prevention Series #3 Behavioural strategies to reduce HIV
 transmission: how to make them work better
 (Coates, T.J. et al; The Lancet; Article in Press, Corrected Proof; 6
 August 2008)
 This paper makes five key points. First is that the aggregate effect of
 radical and sustained behavioural changes in a sufficient number of
 individuals potentially at risk is needed for successful reductions in HIV
 transmission. Second, combination prevention is essential since HIV
 prevention is neither simple nor simplistic. Reductions in HIV transmission
 need widespread and sustained efforts, and a mix of communication channels
 to disseminate messages to motivate people to engage in a range of options
 to reduce risk. Third, prevention programmes can do better. The effect of
 behavioural strategies could be increased by aiming for many goals (eg,
 delay in onset of first intercourse, reduction in number of sexual
 partners, increases in condom use, etc) that are achieved by use of
 multilevel approaches (eg, couples, families, social and sexual networks,
 institutions, and entire communities) with populations both uninfected and
 infected with HIV. Fourth, prevention science can do better. Interventions
 derived from behavioural science have a role in overall HIV-prevention
 efforts, but they are insufficient when used by themselves to produce
 substantial and lasting reductions in HIV transmission between individuals
 or in entire communities. Fifth, we need to get the simple things right.
 The fundamentals of HIV prevention need to be agreed upon, funded,
 implemented, measured, and achieved. That, presently, is not the case.

 The Lancet's HIV Prevention Series #4 Structural approaches to HIV
 (Gupta; G.R. et al; The Lancet; Article in Press, Corrected Proof; 6 August
 Recognition that social, economic, political, and environmental factors
 directly affect HIV risk and vulnerability has stimulated interest in
 structural approaches to HIV prevention. Progress in the use of structural
 approaches has been limited for several reasons: absence of a clear
 definition; lack of operational guidance; and limited data on the
 effectiveness of structural approaches to the reduction of HIV incidence.
 In this paper we build on evidence and experience to address these gaps. We
 begin by defining structural factors and approaches. We describe the
 available evidence on their effectiveness and discuss methodological
 challenges to the assessment of these often complex efforts to reduce HIV
 risk and vulnerability. We identify core principles for implementing this
 kind of work. We also provide recommendations for ensuring the integration
 of structural approaches as part of combined prevention strategies.
 The Lancet's HIV Prevention Series #5 Making HIV prevention programmes work
 (Bertozzi, S.M. et al; The Lancet; Article in Press, Corrected Proof; 6
 August 2008)
 Even after 25 years of experience, HIV prevention programming remains
 largely deficient. We identify four areas that managers of national HIV
 prevention programmes should reassess and hence refocus their
 efforts—improvement of targeting, selection, and delivery of prevention
 interventions, and optimisation of funding. Although each area is not
 wholly independent from one another, and because each country and epidemic
 context will require a different balance of time and funding allocation in
 each area, we present the current state of each dimension in the global HIV
 prevention arena and propose practical ways to remedy present deficiencies.
 Insufficient data for intervention effectiveness and country-specific
 epidemiology has meant that programme managers have operated, and continue
 to operate, in a fog of uncertainty. Although priority must be given to the
 improvement of prevention methods and the capacity for the generation and
 use of evidence to improve programme planning and implementation,
 uncertainty will remain. In the meantime, however, we argue that prevention
 programming can be made much more effective by use of information that is
 readily available.
 The Lancet's HIV Prevention Series #6 Coming to terms with complexity: a
 call to action for HIV prevention
 (Piot, P. et al; The Lancet; Article in Press, Corrected Proof; 6 August
 A quarter of a century of AIDS responses has created a huge body of
 knowledge about HIV transmission and how to prevent it, yet every day,
 around the world, nearly 7000 people become infected with the virus.
 Although HIV prevention is complex, it ought not to be mystifying. Local
 and national achievements in curbing the epidemic have been myriad, and
 have created a body of evidence about what works, but these successful
 approaches have not yet been fully applied. Essential programmes and
 services have not had sufficient coverage; they have often lacked the
 funding to be applied with sufficient quality and intensity. Action and
 funding have not necessarily been directed to where the epidemic is or to
 what drives it. Few programmes address vulnerability to HIV and structural
 determinants of the epidemic. A prevention constituency has not been
 adequately mobilised to stimulate the demand for HIV prevention. Confident
 and unified leadership has not emerged to assert what is needed in HIV
 prevention and how to overcome the political, sociocultural, and logistic
 barriers in getting there. We discuss the combination of solutions which
 are needed to intensify HIV prevention, using the existing body of evidence
 and the lessons from our successes and failures in HIV prevention.

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