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HIV Prevention Around the World

What smart guys are wearing condom poster, Zimbabwe

Since the early 1980s, most countries have attempted to prevent the spread of HIV, but some have been much more successful than others. This page looks at some of the more interesting examples of HIV prevention from around the world.

The USA

Although in the USA, as in many other countries, there have been HIV prevention campaigns aimed at the general population, many of the most notable programmes have concentrated on the groups at highest risk of infection. This is regarded as the best approach for a country with relatively low HIV prevalence.

Gay men

The world’s first major HIV prevention campaigns targeted gay and bisexual men in US cities. They began around 1984 and were run by non-governmental organisations such as the San Francisco AIDS Foundation, AIDS Project Los Angeles and Gay Men’s Health Crisis in New York. These community-based groups had for some time been teaching people about AIDS and how it was most likely acquired, but they found that this was not enough. Even men who saw friends suffer and die of AIDS found it difficult to make long-term lifestyle changes.

The pioneering AIDS organisations found that the most effective approach was to provide men with explicit information and skills training in how to practise safer sex, and how to negotiate safer sexual relationships. This type of programme proved very popular and helped many thousands of men, initially with little support from the federal government. Largely because of this community-led response, levels of high-risk sexual behaviour plummeted among urban gay communities in the mid- to late 1980s, and the rate of new HIV infections fell substantially. 1 2

Recent studies in the US (as well as other Western countries) have found that levels of high risk sex between men who have sex with men have started rising again. This may be partly because new HIV & AIDS drugs have made HIV less frightening. 3 There is therefore a real need for more prevention projects targeting this group. It should also be noted that the decline in HIV has been much smaller among black and Hispanic men than among white men. 4

Other prevention programmes

America’s most dramatic success in HIV prevention has been the reduction in transmission from mother to child. The estimated rate of infections among babies peaked at 1,650 in 1991 and fell to around 144-236 in 2002. 5 This decline was caused by the use of antiretroviral drugs and avoidance of breastfeeding. Routine (opt-out) screening of pregnant women for HIV helped to maximise the impact of these interventions.

Many US politicians object to harm reduction, despite its proven benefits, because they think it involves condoning illegal drug use

The success of routine screening of pregnant women has encouraged the US to move towards routine HIV testing in all medical settings, and to target more prevention work at people who are already infected with HIV, as part of an initiative called Advancing HIV Prevention. The Centers for Disease Control and Prevention – a US government agency – hopes that this change of approach will help to reduce the rate of new infections, which was around 54,000 in 2009. 6 Among the new developments is greater support for partner notification schemes.

One subject not included in the Advancing HIV Prevention strategy is harm reduction for injecting drug users. In particular, it does not advocate for more needle exchanges, even though studies have shown that these reduce the sharing of injecting equipment and reduce HIV transmission without encouraging drug use. Experts believe that an expansion of needle exchange services helped to reverse an extensive HIV epidemic among drug users in New York City during the 1990s. 7 A 21-year ban on using federal funding for needle exchange programmes was lifted in late 2009.

As of March 2009, 184 needle exchange programmes were operating across 36 states, Washington DC and Puerto Rico. 8 This is fewer schemes than in Scotland, where the population is around sixty times smaller. 9 Many US politicians object to harm reduction, despite its proven benefits, because they think it involves condoning illegal drug use.

Ideological objections also hamper HIV prevention for young people. Much federal money is spent teaching “ abstinence only”, which studies have found to be less effective than comprehensive sex education at preventing sexually transmitted infections. 10

Europe

Like the USA, most Western and Central European countries have greatly reduced the rate of HIV transmission in medical settings (through blood screening and universal precautions) and from mother to child (through routine screening, use of preventive drugs and avoidance of breastfeeding). Countries that have implemented comprehensive harm reduction programmes, such as the UK, Germany and the Netherlands, have also maintained a very low rate of infection among injecting drug users. In some cases, the mass media have been used to reach the general population - for example in the UK's "Iceberg" and "Tombstone" campaigns, which were launched in 1987.

Yet despite these successes, the rate of new HIV diagnoses in Europe has risen over recent years. In Eastern Europe, most infections are among injecting drug users. Ukraine has the highest prevalence in Eastern Europe with around 1.1% of Ukrainian adults living with HIV. 11 Nevertheless, Ukraine has one of the most developed harm reduction programmes in the region with over 1,323 needle exchanges and it has offered opioid substitution therapy since 2004. 12 13

Though there are still barriers to accessing HIV prevention in Ukraine, it is a vastly better picture compared to Russia, another country where injecting drug use is driving the HIV epidemic. Only 70 needle exchanges serve an IDU population of 1.8 million and substitution therapy is illegal. 14

Africa

Africa is the continent worst affected by AIDS, and because most new infections occur during unprotected heterosexual sex, the main goal in HIV prevention is to persuade people to change their sexual behaviour – to delay first sex, decrease casual relationships, and increase condom use. This is always a difficult task, and in Africa it is made harder by poverty, lack of resources and weak infrastructure. A high proportion of people don't know their HIV status, misconceptions about transmission routes are widespread, and access to condoms is very low. As a result, most countries have yet to see any decline in their epidemics. However, a few notable exceptions prove that such declines are achievable.

Uganda

An Ugandan abstinence posterThe response was characterised by strong political leadership, open communication and involvement of numerous grassroots organisations

Of all African countries, Uganda has won the most praise for its HIV prevention efforts. HIV prevalence among adults fell from around 15% in the early 1990s to about 7% in 2001, and most experts believe this was largely because of concerted efforts to encourage safer sexual behaviour. The response began in the mid-1980s, and was characterised by strong political leadership, open communication and involvement of numerous grassroots organisations, as well as expanded condom distribution, HIV testing and treatment of sexually transmitted infections. 15 16

In recent years, HIV prevalence in Uganda has failed to decline much further and has been stable at between 6 percent and 7 percent since 2001. 17 A national survey in 2010 found that only one in six men and one in eleven women who had reported having sex with more than one partner in the past 12 months, also used a condom during their last sexual intercourse. 18 The epidemic is still very severe and there is much room for improvement.

Other African “success stories”

HIV incidence in urban Zimbabwe fell from an extremely high peak of almost 6% in 1991 to less than 1% in 2010. 19 The rate among women attending antenatal clinics in Zimbabwe fell from 32.1% in 2000 to 23.8% in 2004. Other large surveys have found similar trends among different population groups. Part of this decline is likely to have been due to rising death rates, but a drop in new infections is also thought to have played a part. Studies have found increased condom use, longer delays before first sex and fewer casual sexual relationships compared to earlier years. This behaviour change may have been partly due to prevention campaigns, but it may also have resulted from other factors such as increased fear of AIDS, or decreased mobility at a time of high unemployment. Political conditions in Zimbabwe now make it extremely difficult for overseas agencies to run prevention projects. 20

In Kenya, the proportion of adults living with HIV fell from around 10% in the late 1990s to about 7% in 2003, and surveys show similar behaviour changes as in Zimbabwe and Uganda. Although Kenya has recently scaled up its prevention efforts, it did so too late to account for the beginning of the decline in HIV prevalence. The causes of the behaviour change and its role in this decline are still not fully understood. 21 Kenya’s first lady Lucy Kibaki has been accused of endangering the progress made so far by making negative remarks about condoms. She has even been reported as saying that condoms are “causing the spread of AIDS in this country". 22

The belief that abstinence and marital fidelity are the only ways to prevent HIV infection is common among conservative politicians and religious leaders throughout Africa, as in many other parts of the world. Some commentators accuse the US of encouraging this view and of undermining condom promotion. Through its PEPFAR initiative, the US provides substantial funding for HIV prevention in Africa, giving it a strong influence over what activities are carried out. The US still supplies many millions of condoms to Africa, but it prefers to market them only to “high risk” population groups.

Another country often cited as a “success story” is Senegal, in West Africa. This nation has been praised for mobilising its people in an early and vigorous prevention campaign. Since the late 1980s, Senegalese have taught each other about HIV and AIDS through school curricula, peer education, community groups and cultural and sporting events. In this mostly Muslim country, religious authorities have helped by promoting abstinence and fidelity, while others have encouraged condom use and helped sex workers to set up support groups. Businesses and the army have supported the response. 23

Thanks to these efforts, the age of first sex rose, casual sex declined, and condom use increased dramatically. As a result, HIV prevalence in Senegal has yet to exceed 2%. However, much higher rates are found among sex workers and other groups. A survey in Senegal in 2004 found that 21.5% of men who have sex with men were infected with the virus, and almost all of them reported also having sex with women. Interventions to help this group are virtually non-existent; sex between men is highly stigmatised in Senegal and, as in half of African countries, it is also illegal. 24 Furthermore, researchers have recently found evidence of “a dramatic weakening of AIDS preventive attitudes” among the people of Senegal, including reduced perception of risk, less behaviour change and increased stigmatisation of people living with HIV. This suggests that the effects of earlier prevention programmes may be wearing off. 25

Less successful prevention programmes

Other African countries, such as Botswana, Namibia and South Africa, continue to harbour extremely severe, generalised epidemics that show no signs of abating. Mass media and social marketing projects have been launched in an attempt to change behaviour, alongside condom distribution and other interventions. These efforts do seem to have had some effect – particularly on levels of condom use – but so far they have not made a significant dent in infection rates. In late 2005 the Global Fund withdrew funding for South Africa’s largest HIV prevention project, loveLife, due to concerns that it was not cost effective. 26

Many activists believe that weak political leadership has severely hampered the response to HIV in South Africa

Many activists believe that weak political leadership has severely hampered the response to HIV in South Africa, where more than 5 million people are already infected. In particular, President Mbeki’s government was very slow to begin providing nevirapine and other drugs to help prevent mother-to-child transmission of the virus. In 2005, only around 14.6% of pregnant women with HIV received preventive treatment, according to UNAIDS (though the government’s own estimate is much higher). 27 This rate is quite typical for an African country, but is surprisingly low given South Africa’s relative wealth and resources.

Most children born with HIV in Africa die before their fifth birthday. The few who receive antiretroviral treatment can expect to live longer, but it would be much better if they were never infected in the first place. The vast majority of the two million children living with HIV in Africa would have been born healthy had their mothers received the kind of preventive care found in Western countries. At present, most African women are not even tested for HIV, let alone offered the drugs, counselling and infant formula that would help protect their babies.

Although all African countries have facilities for screening blood for HIV, most cannot guarantee the degree of safety found in the developed world. Because voluntary donors are rare, blood is often collected from family members and paid donors, which increases the risk of transmitting HIV. Use of poor quality test kits, unreliable supplies of equipment, and lack of trained staff can all compound this risk. Thirty-three of forty African countries surveyed in 2004 reported that they did not have fully operational quality systems in the blood transfusion service, including HIV testing. These countries collected around 2.7 million units of blood during that year, of which 88.5% were not tested for HIV in a quality-assured manner. Nevertheless, the blood safety measures already in place avert an estimated 500,000 HIV infections each year. 28

Latin America and the Caribbean

Latin America and the Caribbean are currently less badly affected by AIDS than is Africa. Still, in some countries more than 2% of adults are infected with HIV. Across the region the virus is spreading from established high-risk groups – sex workers, injecting drug users and men who have sex with men – into the general population.

Brazil

Brazil is seen as having one of the developing world’s best record of HIV prevention; the adult HIV prevalence has remained stable at around 0.5% in recent years. The response started in the early 1980s, at a time of great political change, and was led by newly formed non-governmental organisations. The Brazilian authorities cooperated with these groups and supported a strong programme of integrated HIV prevention and care, with special attention paid to marginalised communities. The government has vigorously promoted condom use – often through very explicit mass media campaigns – and has distributed hundreds of millions of free condoms. At the same time it has worked hard to combat homophobia and stigma related to HIV. Needle exchanges and other harm reduction programmes were established in key cities in the early 1990s, and were later expanded nationally. Prisoners are helped to access clean needles as well as condoms. 29 Although an exact figure is unavailable, between 76 percent and 95 percent of HIV-positive pregnant women received drugs to help prevent mother-to-child transmission in 2010. 30

In recent surveys, 90% of female sex workers reported condom use with their most recent client. Amongst injecting drug users condom use is high (70% used a condom last time they had sex), whereas just over half used sterile injecting equipment last time they injected. 31 Regular condom use among adults with more than one sexual partner is higher among men (43%) than women (34%). In 2009, HIV prevalence among MSM was very high at 12.6%. 32 HIV testing needs to be improved among high-risk groups in Brazil, as 2009 figures show that a very small percentage of individuals from across all high-risk groups have been tested in the last 12 months and know the result. 33

Cuba and Jamaica

Discrimination stops HIV prevention measures from reaching many of those at highest risk of infection

Cuba also has had remarkable success in controlling HIV, though it has taken a very different approach to Brazil’s, with much less emphasis on human rights and education. In 1986 the island began routinely screening its citizens for HIV, and within seven years around 12 million tests were performed. 34 To begin with, those who tested positive were quarantined indefinitely in sanatoriums, where they would receive medical care and education about how to avoid transmitting the virus, while authorities set about tracing their sexual partners. Since 1993 the rules had been less strict. Someone diagnosed with HIV still has to attend an eight-week course at a sanatorium, but after that they can choose whether to stay (and receive free care) or go home (and get less help from the state). Many have chosen to remain in sanatoriums. 35 Authorities maintain a database of everyone diagnosed with HIV and all of their sexual partners. 36

Although most experts and activists believe that Cuba’s heavy-handed approach is not a good example for other nations to follow, it has certainly been successful. Adult HIV prevalence at the end of 2009 was around 0.1% - the lowest in the Americas. 37 Drugs to prevent mother-to-child transmission have been universally available for many years, and infection among children is almost unheard of. Nevertheless, Cuba cannot afford to be complacent. One of the factors that previously helped to protect the island from HIV was its social isolation from countries with high prevalence. Recently tourism has grown substantially, and so has the sex industry. Many Cubans believe that HIV is not a threat to them, and the government, keen to celebrate its success so far, has done little to challenge this view. The need for education and condom promotion has never been greater. 38

Homophobia is much less of a problem in Cuba than it once was, but elsewhere in the Caribbean it is still rife. In Jamaica – where around 1.7% of adults were living with HIV at the end of 2009 – any act of physical intimacy between men is illegal, and punishable by up to ten years hard labour. 39 Gay men are shunned by society, and in some cases violently attacked because of their sexuality. Such discrimination stops HIV prevention measures from reaching many of those at highest risk of infection. 40 Attempts to distribute condoms to prisoners have been vigorously opposed by inmates and prison officers. 41

Asia and Australia

Thailand and Cambodia

In 1991, Thailand had a rapidly growing HIV epidemic, fuelled by an illegal yet thriving sex industry. In the same year a change of government heralded a new, pragmatic response to the problem. At its core was the world’s first “100 per cent condom use” programme. Instead of trying to eliminate commercial sex, the government chose to distribute tens of millions of free condoms to brothels and massage parlours, and to clamp down on those that failed to insist on condom use. Men were discouraged from visiting sex workers, and the rights of women were promoted. At the same time, anti-AIDS messages were broadcast hourly on all radio and television stations, encouraging open debate about HIV and sexual issues. As in Uganda and Senegal, many diverse sectors of society became active partners in fighting HIV, including sex workers, community groups, schools, religious leaders, businesses and the military. 42

Following the start of this campaign, the number of Thai men paying for sex fell substantially, and reported condom use in brothels rose from 14% in 1989 to over 90% in 1994. The effect on the HIV epidemic was spectacular, with annual diagnoses plummeting from 143,000 in 1991 to around 19,000 in 2003, and Thailand has rightly been praised for this success. Nevertheless, Thailand’s record is not perfect. In recent years, funding for HIV prevention has fallen by two thirds and public concern has dwindled. The virus is widespread among injecting drug users and men who have sex with men, who have been largely neglected by prevention campaigns. Condom use has declined again among sex workers, who are increasingly working in non-brothel settings, where they are largely unaffected by the 100 per cent condom use programme. 43

Cambodia has also seen a drop in new infections after introducing a 100 per cent condom use programme. However, as in Thailand, HIV remains a major problem for Cambodia, and an increasing number of infections are among the partners of men who acquired the virus during commercial sex. Unless they revamp their prevention programmes, both countries face the risk of HIV becoming widespread among the general population. 44

India and China

India harbours two quite separate HIV epidemics. In the south, where heterosexual sex is the main transmission route, prevention projects have largely focussed on sex workers and their clients. This approach is credited with reducing HIV prevalence among all young women in southern states from 1.7% in 2000 to 1.1% in 2004. 45 By contrast, the main driver of HIV in the northeast is injecting drug use, and responses there have been lacking. As in many parts of Asia, men who have sex with men have also been neglected.

Neighbouring China has a much lower HIV prevalence than India, but some parts of the country are much worse affected than others. In central China, tens of thousands of people became infected during the 1990s when they sold their blood to commercial agencies. Authorities eventually reacted by enforcing tighter regulations, and the blood donation system causes far fewer new infections than before. In 2005, around 94.5% of blood came from volunteer donors, compared to just 22% in 1998. Today, most HIV transmission takes place during drug use or unprotected sex. 46

China has traditionally taken a zero tolerance approach to drugs; the police are used to arresting drug users and sending them to compulsory rehabilitation centres. Recently, however, that attitude has started to change, and schemes providing methadone treatment and clean needles have been set up in several provinces. Some regions have also altered their approach to sex workers by introducing a 100 per cent condom use programme, peer education and treatment for sexually transmitted infections. 47 On a national scale, the government has introduced routine HIV testing of people thought to be at high risk of infection, including drug users, sex workers, former blood donors and patients at sexual health clinics. This has led to many more people being diagnosed, though some experts have voiced concern that some people may be pressured not to refuse testing. 48 Overall, China’s response to HIV is improving, but coverage is still too patchy to have a substantial impact.

Russia

Drug use is the main cause of HIV’s spread in Russia, where around 2% of adults have injected narcotics. As in China, authorities have concentrated on persecuting drug users and done little to protect their health. In 2003, Russia’s entire HIV prevention budget was just $1 million, and funding for harm reduction fell by 29% between 2002 and 2005. 49 Foreign donors have helped to support outreach programmes and needle exchanges in some regions, but they are few and far between. As of June 2006 the country had just 60 needle exchanges – fewer than in 2002 – and none were in Moscow. Substitution treatment – an effective way to help people give up drugs – does not exist in Russia.

In 2006, President Putin increased the federal budget for HIV and AIDS programmes, and promised to do more to tackle the epidemic. While this is encouraging news, it has coincided with increased hostility towards non-governmental organisations, and with criticism of “foreign” ideas such as condom promotion and harm reduction. Moral objections to homosexuality, drug use and commercial sex are major hindrances to HIV prevention in Russia. 50

Australia

Harm reduction is taken much more seriously in Australia, where federal funding enables a wide range of outlets – including drug treatment centres, hospitals, health centres, chemists and vending machines – to distribute many millions of clean needles each year. These and other harm reduction services have been supported since the 1980s, and have been highly effective at controlling HIV. According to official estimates, the $100 million spent on needle exchanges by state and federal governments between 1990 and 2000 prevented around 25,000 HIV infections and reduced health spending by around $1.8 billion (in US dollars). 51 Australia also has a strong history of peer outreach programmes for sex workers and men who have sex with men. 52

Conclusion

A survey of low- and middle-income countries found that in 2009, among the countries which reported, HIV prevention services reached around 58% of sex workers, 32% of injecting drug users, and 57% of men who have sex with men. 53 Just 53% of HIV-positive pregnant women received drugs to help prevent their babies becoming infected. Globally, it has been estimated that a condom was used in only 9% of sex acts with a non-marital and non-co-habiting partner in 2005. The global supply of public-sector condoms is less than half of what is needed to ensure adequate condom coverage. 54

There is no single best approach to HIV prevention; the response must be designed to fit local conditions and the state of the epidemic

As these statistics show, HIV prevention around the world needs much improvement. Progress is slowly being made in some areas, but there is still a very long way to go. As governments and other agencies try to develop better programmes, they would do well to consider some of the examples outlined in this page.

There is no single best approach to HIV prevention; the response must be designed to fit local conditions and the state of the epidemic. Nevertheless, most of the successful programmes – whether in Uganda, Senegal, Thailand, Brazil or among gay men in America – do have at least three features in common.

Firstly, these programmes encourage open communication about AIDS and the activities that put people at risk of infection, while at the same time combating stigma and discrimination. Secondly, they are pragmatic. Rather than just trying to eliminate certain types of sexual behaviour or drug use, they recognise that some people will continue to do these things, and that they should be helped to do so more safely. Thirdly, they involve the affected communities themselves in programme design and implementation. This ensures that the programme is carefully tailored to the communities’ needs, and that it is seen as something done “with them” rather than “to them”. The work of small community-based organisations has been vital to each of these successful programmes.

The only obvious exception is Cuba. However, that country’s system of more or less mandatory testing and quarantine is widely believed to violate human rights, and it would not be feasible in a country where HIV is already widespread.

Last but not least, strong leadership is essential for HIV prevention campaigns to have a far-reaching and sustained impact. This means that politicians, religious leaders and others in authority must become actively involved in the response, and must ensure that it receives adequate resources. If all of the world’s leaders truly committed themselves to this cause then a great many lives would be saved.

 

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