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“The only thing necessary for these diseases to the triumph is for good people and governments to do nothing.”


 
    

Bringing comprehensive
    HIV prevention to scale

 http://www.unaids.org/bangkok2004/GAR2004_html/GAR2004_06_en.htm

Prevention needs of girls and women

Despite women’s higher biological vulnerability, it is the legal, social and economic disadvantages faced by women and girls in most societies that greatly increase their HIV vulnerability. Therefore, gender-sensitive approaches are key when designing prevention programmes.

Not as easy as ABC

For years, prevention programmes for the general population have focused on the ‘ABC’ strategy—abstain and delay sexual initiation; be safer by being faithful or reducing the number of sexual partners; and use condoms correctly and consistently. For many women and girls, this approach is of limited value. They lack social and economic power, and live in fear of male violence. They cannot negotiate abstinence from sex, nor can they insist their partners remain faithful or use condoms.

Ironically, trust and affection within marriage and other long-term relationships are sometimes part of the problem. Studies from various parts of the world suggest married couples have sex more frequently than unmarried individuals, but use condoms less often. Global studies of relationships between sex workers and their clients show a similar pattern: condom use was less consistent if sex workers felt a level of intimacy with their regular clients. For example, in Kenya’s Nyanza Province, surveyed clients of sex workers reported using condoms less consistently if they were with their usual sex worker (Helene et al., 2002).

A range of approaches needed

Many women are denied the knowledge and tools to protect themselves from HIV. Surveys in 38 countries found extremely low HIV-transmission knowledge among 15–24-year-old women (UNFPA, 2002). It is vital to implement comprehensive strategies, including gender-specific and culturally specific services that help women counteract discriminatory social and economic factors. Key components include: access to education (particularly secondary education); strengthening legal protection for women’s property and inheritance rights; eradicating violence against women and girls; and ensuring equitable access to HIV care and prevention services. Men are often regarded as a major part of the problem. However, they need to be a substantial part of the solution by: taking responsibility for fidelity and safer sex; committing themselves to their daughters’ education; alleviating women’s burden of care; and embracing a zero-tolerance attitude towards violence against women.

In June 2002, the World Health Organization (WHO) and the International Center for Research on Women led a consultation of experts to rethink classic HIV prevention based on women’s and girls’ distinct needs. They also aimed to improve HIV interventions that target men (WHO, 2003). The experts described a continuum of approaches to integrate gender into prevention programmes:

  • Gender-sensitive approaches, at a minimum, recognize that women and men have different prevention, care and support needs. For example, diagnosing and treating sexually transmitted infections need to be integrated into family planning/reproductive health clinics. Then women will be able to gain access to these services without fear of social censure. Another example is promoting female-controlled prevention tools, such as female condoms or microbicides.
  • Approaches that transform gender roles. These work with men and women to overturn gender norms that create HIV vulnerability. Involving men in these approaches is critical to fostering constructive roles for men in sexual and reproductive health. One of the best-known examples is the ‘Stepping Stones’ participatory approach to HIV, sexual health and gender. It was first developed in Uganda in the mid-1990s, and is now used in more than 100 countries. Peer groups of 10 to 20 people of the same sex and similar age are formed to discuss gender roles, money, attitudes to sex and sexuality and attitudes to death. These peer environments encourage women and men of all ages to explore their social, sexual and psychological needs, analyse the communication blocks they face and make changes in their relationships.
  • Interventions that empower women and girls attempt to equalize the power balance between women and men. Examples include increasing women’s access to assets and resources, such as land and inheritance rights, and facilitating women’s networks and strengthening grassroots community organizations. Other projects go beyond immediate gender-specific needs. They are based on the belief that empowerment can only be achieved when women take control of all aspects of their lives. For instance, India’s Sonagachi Project involving sex workers has a self-governing structure and uses peer educators, making it an international empowerment model for HIV prevention among sex workers and their clients.

Gender-sensitive programming can often be achieved in the short term since national policy-makers and international donors understand and accept it. Developing more discrete, female-controlled prevention tools, such as microbicides, will greatly enhance these approaches. In the longer term, modifying the gender-based realities that drive the epidemic will require wide-scale transformative and empowering approaches. The effects of doing this will take longer to become evident, but are essential to halting the epidemic.

 

Prevention is the mainstay of the response to AIDS, but is seldom implemented at a scale that would turn the tide of the epidemic. Effective, inexpensive and relatively simple HIV prevention interventions do exist, but the pace of the epidemic is clearly outstripping most country efforts towards effective prevention programming. Globally, less than one-fifth of people who need it have any access to prevention services (Policy Project, 2004).

Today, expanded access to antiretroviral therapy is bringing hope to millions of people living with HIV; it is vital that this be matched by expanded prevention programming. Dramatically expanding prevention programmes would have a profound impact on HIV infection levels. Comprehensive prevention could avert 29 million of the 45 million new infections projected to occur this decade (Stöver et al., 2002) (see Figure 17). Moreover, without sharply reducing HIV incidence, expanded access to treatment becomes unsustainable. Antiretroviral therapy providers will be swamped by demand.

Projected new adult infections given current degree of intervention and a timely scale up of the comprehensive interventions package

Figure 17

In the 2001 UN Declaration of Commitment on HIV/AIDS, countries around the world committed themselves to massively scaling up prevention programmes. The Declaration’s goal is to reduce HIV prevalence among young people (15–24 years old) by 25% in the most affected countries, and to reduce the proportion of infants infected with HIV by 20%, both by 2005.

If current trends continue, many countries will fall short of these targets. In the hardest-hit countries of sub-Saharan Africa, few people have access to prevention programmes despite extraordinarily high infection rates. In other regions where the epidemic is rapidly emerging, opportunities to stop its expansion still exist—but only if prevention efforts are accelerated.

Progress update on the global response to the AIDS epidemic, 2004

Prevention programmes reach fewer than one in five people who need them

  • According to estimates from 70 countries responding to a 2003 coverage survey, the proportion of pregnant women covered by services to prevent mother-to-child HIV transmission ranges from 2% in the Western Pacific, to 5% in sub-Saharan Africa, and 34% in the Americas.
  • The proportion of adults needing voluntary counselling and testing who received it ranged from almost none in South-East Asia, to 7% in sub-Saharan Africa, and 1.5% in Eastern Europe.
  • Condom use in sex acts with a non-cohabiting partner ranged from 13% in South-East Asia, to 19% in sub-Saharan Africa.
  • Fewer than 10% of surveyed countries with significant HIV transmission among injecting drug users have access to harm-reduction programmes.
  • In the Americas, nearly 30% of men who have sex with men have access to prevention services, compared with 6% in sub-Saharan Africa. In South-East Asia, 16% of the estimated 2.2 million sex workers benefit from basic prevention services, compared with around 32% of the estimated 2.5 million sex workers in sub-Saharan Africa.
  • In sub-Saharan Africa, nearly 60% of primary school students receive basic AIDS education, compared with 13% in the Western Pacific region.

Source: Progress report on the global response to the HIV/AIDS epidemic, UNAIDS, 2003; Coverage of selected services for HIV/AIDS prevention and care in low- and middle-income countries in 2003, Policy Project, 2004.

 

Meeting new prevention challenges

Fortunately, a number of countries are demonstrating results in reducing HIV infection rates. Senegal, Thailand and Uganda pioneered early HIV prevention successes. In recent years, similar progress has been recorded in countries as diverse as Brazil, Cambodia and the Dominican Republic. The global community can learn from these prevention successes and adapt them. An overall lesson is that an effective response is anchored in three strategies, which are highly inter-related (UNAIDS, 2002):

Figure 18

Figure 18

·        decreasing the risk of infection to slow down the epidemic;

·        decreasing vulnerability to reduce both risk and impact; and

·        reducing impact in order to decrease vulnerability.

At the same time, HIV prevention needs to evolve and be more innovative in addressing changes in the epidemic. For example, in several industrialized countries, risk behaviours and new infections are rising again among populations in which prevalence had stabilized or declined—particularly among young men who have sex with men. This has been linked to the promise of antiretroviral therapies (Ostrow et al., 2002; Suarez et al., 2001) as well as ‘prevention fatigue’ and the fact that many young people are now coming of age without having experienced the epidemic’s devastations.

New or greatly increased efforts are needed to prevent HIV in women and girls, as even the best-designed interventions will have limited success unless supported by sustained efforts to attack the root causes of their vulnerability (see box on page 68). Equally, the challenge of ‘keeping the next generation HIV-free’ means that far more resources must be invested in prevention among young people of both sexes.

Expanded access to antiretroviral therapy and other treatment offers a critical opportunity to strengthen prevention efforts, by encouraging vastly more people to learn their HIV status. This is likely to occur both because the promise of treatment should stimulate greater use of voluntary counselling and testing, and because health-care providers will increasingly make the offer of diagnostic testing a routine practice in clinical settings. This, combined with visible treatment successes, should encourage more open dialogue about HIV. Messages of care and compassion from political, religious and community leaders will also help reduce stigma towards people living with HIV.

Reducing vulnerability among mine workers

Most of South Africa’s 300 000 gold and platinum miners work far from home and see their families only once a year—a system that originated under colonialism and flourished under apartheid. This system is one of the factors driving the country’s HIV epidemic, exposing miners to a host of risk situations. Today, that is changing for many men as companies work to replace crowded, all-male hostels with low-cost, family housing, often working with local governments to build houses and convert old hostels.

Lonmin Platinum is one of the leaders in these efforts. It is the world’s third-biggest platinum group metals producer and employs 16 000 regular mine workers. It has built more than 1000 dwellings to date and aims to build an additional 2000 in short order. And the company has gone even further. On World AIDS Day 2003, it started providing HIV-positive employees with antiretroviral treatment, and is considering the possibility of extending the programme to their families.

Reducing vulnerability

Effective prevention requires policies that help reduce the vulnerability of large numbers of people—in effect, creating a social, legal and economic environment in which prevention is possible. An effective response to AIDS goes hand in hand with basic socioeconomic development. Studies in sub-Saharan Africa show that men and women living in areas with higher indicators of development such as life expectancy and literacy are significantly more likely to use condoms (Ukwuani et al., 2003). Boys in Zimbabwe who remain in school and have intact families are more likely to practise safer sex (Betts et al., 2003). Studies in sub-Saharan Africa and the Caribbean indicate that women are less likely to use condoms than men due to gender-related power dynamics, which make it more difficult for women to request the use of condoms (Norman, 2003).

Initiatives that enhance economic and social development and empower women and girls also contribute to effective AIDS responses. Such prevention-friendly efforts take many forms and can often be implemented by both public and private sectors. For example, in South Africa, mining companies are building migrant mine workers family housing to replace the overcrowded, single-sex hostels that have been an important contributor to HIV transmission in the region (see box above). Eliminating school fees in Uganda and Kenya helps get new poor pupils into school and keep young people, notably girls, in school. Legislation legalizing the purchase and possession of sterile injecting equipment can reduce HIV transmission among injecting drug users without contributing to increased drug use. Similarly, international cooperation to prevent human trafficking for sexual exploitation reduces the number of young people exposed to an extremely high risk of HIV, violence and other human rights abuses.

Comprehensive prevention

Comprehensive prevention addresses all modes of HIV transmission. Since HIV epidemics are extremely diverse across regions, within countries and over time, programme planners need to place different emphases on the mix of strategies:

·        in low-prevalence settings, prevention among key population groups (e.g., sex workers and their clients, injecting drug users, men who have sex with men) can be effective in keeping HIV at low levels in the general population;

·        in high-prevalence settings, prevention among key populations continues to be important, but broad strategies reaching all segments of society are needed to turn the epidemic around; and

·        in all countries, prevention is impeded if universal access to treatment, as well as impact and vulnerability-reduction measures, are not clearly parts of the response.

Vulnerability to HIV exposure—an individual or community’s inability to control their risk of infection—is multifaceted, so no single prevention intervention will be effective on its own. Key elements in comprehensive HIV prevention include:

·        AIDS education and awareness;

·        behaviour change programmes, especially for young people and populations at higher risk of HIV exposure, as well as for people living with HIV;

·        promoting male and female condoms as a protective option, along with abstinence, fidelity and reducing the number of sexual partners;

·        voluntary counselling and testing;

·        preventing and treating sexually transmitted infections;

·        primary prevention among pregnant women and prevention of mother-to-child transmission;

·        harm reduction programmes for injecting drug users;

·        measures to protect blood supply safety;

·        infection control in health-care settings (universal precautions, safe medical injections, post-exposure prophylaxis);

·        community education and changes in laws and policies to counter stigma and discrimination; and

·        vulnerability reduction through social, legal and economic change.

Preventing sexual transmission through ‘combination prevention’

The term ‘combination prevention’ is sometimes used to mean comprehensive prevention. However, more frequently it refers to the combination of strategies required to prevent sexual transmission. Combination prevention includes various strategies that individuals can choose at different times in their lives to reduce their risks of sexual exposure to the virus.

Countries that have achieved sustained progress against HIV transmission have pursued an array of complementary prevention approaches, from the ‘ABC’ options for preventing sexual transmission at the individual level (see box on page 73) to the integration of prevention and care efforts. Brazil, Thailand and Uganda exemplify very different but effective responses: they emphasized getting the right combination of interventions to fit the specific risk factors and vulnerabilities that characterized the epidemic in each country.

Uganda is one of most inspiring examples of an effective national response, having successfully reduced overall prevalence of HIV since its peak in 1992. This was done through a variety of prevention approaches including community mobilization,pioneeringnongovernmental organization (NGO) projects and public education campaigns emphasizing delayed sexual initiation, partner reduction and condom use. Strong political leadership, destigmatization and open communication were key aspects of the Ugandan response to AIDS. Behavioural changes in the early 1990s—in particular, delayed sexual debut and reduced numbers of casual partners—were pivotal in reducing new infections. Following these initial changes, increased condom use appears to have played an important role in stabilizing the epidemic, which preserved and accelerated the response’s momentum over the past decade (Singh et al., 2003; Shelton et al., 2004).

The ABCs of combination prevention

Just as combination treatment attacks HIV at different phases of virus replication, combination prevention includes various safer sex behaviour strategies that informed individuals who are in a position to decide for themselves can choose at different times in their lives to reduce their risk of exposing themselves or others to HIV (Global HIV Prevention Working Group, 2003). These are often referred to as the ABCs of combination prevention.

  • A means abstinence—not engaging in sexual intercourse or delaying sexual initiation. Whether abstinence occurs by delaying sexual debut or by adopting a period of abstinence at a later stage, access to information and education about alternative safer sexual practices is critical to avoid HIV infection when sexual activity begins or is resumed.
  • B means being safer—by being faithful to one’s partner or reducing the number of sexual partners. The lifetime number of sexual partners is a very important predictor of HIV infection. Thus, having fewer sexual partners reduces the risk of HIV exposure. However, strategies to promote faithfulness among couples do not necessarily lead to lower incidence of HIV unless neither partner has HIV infection and both are consistently faithful.
  • C means correct and consistent condom use—condoms reduce the risk of HIV transmission for sexually active young people, couples in which one person is HIV-positive, sex workers and their clients, and anyone engaging in sexual activity with partners who may have been at risk of HIV exposure. Research has found that if people do not have access to condoms, other prevention strategies lose much of their potential effectiveness.

A, B, and C interventions can be adapted and combined in a balanced approach that will vary by cultural context, the population addressed and the stage of the epidemic.

Thailand also applied a variety of approaches, with high-profile critical leadership beginning in the early 1990s. As well as mass media campaigns, Thailand pioneered a ‘100% Condom Use’ policy for sex workers and their clients. This led to an increase in condom use, particularly in sex work, and a decrease in the number of sexual partners (UNAIDS, 2000).

Brazil reduced national infection rates by investing in mass media campaigns on AIDS awareness, harm reduction programmes for injecting drug users, behaviour change programmes for sex workers and men who have sex with men, and by promoting voluntary counselling and testing (Levi and Vitória, 2002). Strong civil society advocacy was an essential element, including by organizations of HIV-positive people. This advocacy effort supported and strengthened government-administered prevention activities and encouraged integrating care and treatment in the National AIDS Programme, including universal access to antiretroviral therapy.

The responses of these three countries were based on correct assessment of the unique mix of factors driving their respective epidemics. For example, Thailand’s primary emphasis on condom use in sex work settings would have been less successful in Uganda since sex work was not the main factor driving its epidemic.

    

AIDS education and awareness

Although the epidemic is well into its third decade, basic AIDS education remains fundamental to the response. For instance, in India, behavioural survey data showed that 30% of women had not heard of HIV or AIDS (NACO, 2003). Rural women were the least informed: less than 25% of rural women in the states of Bihar (18.7%), Gujarat (22.7%) and Uttar Pradesh (24.3%) were aware that HIV could be transmitted sexually. Figure 19 indicates the difference in knowledge about transmission of HIV between men and women, and between urban and rural respondents.

Most studies of prevention programmes in low- and middle-income countries indicate that effective behaviour-change projects include educational and communications components, using a range of media, from traditional theatre and music, to global television and radio networks (Merson et al., 2000). Countries that have significantly reduced rates of new infections have typically invested heavily in AIDS education and awareness initiatives.

Media campaigns have become increasingly involved in HIV and AIDS programming. National broadcasters such as China’s CCTV and the South African Broadcasting Corporation have made strong efforts, as have global media organizations such as the British Broadcasting Corporation, France’s TV5 and the international music broadcaster Music Television (see ‘Young People’ focus).

Proportion of respondents stating that HIV can be transmitted through sexual contact, selected states in India

Figure 19

However, information alone is not enough to produce sustained behaviour change. A recent study in Zimbabwe found that many young people who were educated about AIDS and sexually transmitted infections still did not use a condom during sexual intercourse (Betts et al., 2003). Clearly, as a prevention tool, HIV education alone has its limits. Nevertheless, information is critical to helping people gain an accurate understanding of how HIV is transmitted and how it can be prevented—the first step towards reducing risk.

National youth councils, health-care provider networks, religious networks and other structures can provide established communication channels for conveying facts. In China, Anhui province launched a ‘train the trainers’ approach to diffusing HIV-related information among health-care workers. Fifty-five staff were initially trained at various health institutions, and follow-up workshops were conducted in local provincial health-care settings. Eighteen months after the training, surveys found that basic HIV-related knowledge was up to 100% higher in counties where the training occurred, compared with counties where staff received no training (Wu et al., 2002).

China moves ahead with prevention among populations

China has 840 000 people living with HIV, with over 50% of infections acquired through contaminated drug injecting equipment. More recently, there has been a large increase in the number of people infected through commercial sex, especially in coastal areas in east and south China, and in big cities. In response, the government has declared a policy of vigorous behavioural intervention among groups at higher risk of HIV exposure. Although some of the measures—which include condom promotion, needle exchange and methadone maintenance therapy—have proved controversial with some government departments and the public, the new policy actually supports activities already under way in various parts of the country. For example, in 2001, the cities of Wuhan in Hubei Province and Jingjiang in Jiangsu Province began a pilot study with World Health Organization (WHO) support to promote 100% condom use in entertainment establishments. In 2002, a pilot project for marketing syringes and needles was conducted in Guangxi Zhuang Autonomous Region and Guangdong Province, using staff of local centres for disease control (Ministry of Health/UN Theme Group, 2003).

Programmes to change HIV risk behaviour and sustain healthy behaviour

Dozens of studies have demonstrated that a variety of strategies can help individuals initiate behaviour change and sustain healthy behaviour to reduce risk. Evaluations of programmes have documented sexual behaviour change among adolescents and adults, men and women, people in low-, middle- and higher-income countries, and among groups that are especially vulnerable to infection (Global HIV Prevention Working Group, 2003).

Behaviour change and maintenance programmes provide essential health information, motivate people to reduce risk and increase individuals’ skills in using condoms and negotiating safer sex. Effective approaches for young people and children involve life-skills-based education that promotes the adoption of healthy behaviours. These include taking greater responsibility for their own lives, making healthy choices, gaining strength to resist negative pressures and minimizing harmful behaviours.

Successful behaviour change programmes are usually accompanied by the other components of comprehensive prevention mentioned earlier. They are also supported by collecting solid information on the behaviours, attitudes, and social networks of the target population. A variety of techniques can be used, from surveys to sophisticated geographic information systems. For example, a recent South African study in three townships and a business district demonstrates how formative research plays a potentially useful role in developing prevention strategies. Researchers found that social networks in these areas were relatively diffuse, but that respondents were broadly able to identify public sites where people meet new sexual partners. The study showed that most of these sites lacked condoms, and helped identify potentially important venues for interventions (Weir et al., 2003).

Promoting male condom use

HIV prevention efforts have long focused on encouraging correct and consistent condom use as part of a combination prevention strategy. Scientific data overwhelmingly confirm that male latex condoms are highly effective in preventing sexual HIV transmission (CDC, 2002). Evidence also indicates that the polyurethane female condom is comparably effective in protecting against sexual transmission (WHO/UNAIDS, 1997). In addition, condoms prevent other sexually transmitted infections associated with increased risk of acquiring and transmitting HIV.

Nepal’s unique prevention efforts

In Nepal, Population Services International has implemented an awareness campaign that takes advantage of the reach of the national postal service. The campaign places a sticker saying ‘Protect yourself and others from HIV/AIDS’ on every letter or package entering and leaving the country. The stickers have the logo of the Number One brand of condoms which Population Services International has been distributing in Nepal since 2003. Other promotion efforts have focused on non-traditional outlets serving populations at higher risk, including people in entertainment establishments such as various types of restaurants and massage parlours. In the first year of operation, this resulted in almost four million condoms being distributed, far exceeding the first-year target of one million.

Condoms have always played a key role in successful national prevention programmes. Yet despite clear public health benefits, condom use is still low in many countries. Studies of nearly 4300 adults in Kenya, Tanzania and Trinidad found that only 19% had used a condom with their most recent sex partner (Norman, 2003). The United Nations Population Fund (UNFPA) has identified more than 200 myths, misperceptions and fears that hinder access to and use of condoms (UNFPA/UNAIDS, 2004).

Effectively promoting condom use requires clear messages that dispel myths and misperceptions, such as the idea that only promiscuous people use them or the fallacy that HIV is small enough to pass through latex. However, it requires more than just education. Individuals—particularly women and girls—who wish to use condoms often experience difficulty in negotiating their use with sex partners (Norman, 2003). These findings underscore the need to address gender issues within condom promotion efforts (see Figure 20).

Globally, condom distribution has increased substantially in recent years, but a large supply gap remains. In South Africa, between 2000 and 2002, condom distribution rose by almost 70%. In Brazil, between 1996 and 2000, total condom sales increased by about 62% (Levi and Vitória, 2002). In India, condom sales increased by 13% during 2003–2004. Meanwhile, the Chinese government currently purchases 1.2 billion condoms a year from domestic sources, primarily for free distribution as contraceptives.

Trends in sexual behaviour among young people in selected sub-Saharan African countries, 1994–2001

Figure 20

Despite the clear need, there are still not enough condoms available in many regions where HIV is rampant. UNFPA estimates that the current supply of condoms in low- and middle-income countries falls 40% short of the number required. Unfortunately, international funding for procuring condoms has declined in recent years. The World Bank’s Multicountry AIDS Programme and the Global Fund to Fight AIDS, Tuberculosis and Malaria are serving as important new channels of financial assistance for condom promotion. Despite this, a substantial condom gap remains and could grow much worse in coming years, unless all relevant stakeholders act to increase condom supply.

Female condoms

The female condom was launched in the early 1990s. Since 1997, more than 90 countries have introduced it. Promotion efforts have occasionally been resisted at the local level for a variety of reasons related both to providers and to users. But ministries of health in Brazil, Ghana, Zimbabwe and South Africa have been able to significantly increase the numbers of women using female condoms. The key ingredients of successful female condom introduction include training for providers and peer educators, one-to-one communication with potential users, a consistent supply, and combining private- and public-sector distribution. Other critical factors for scaling up female condom use include involving a broad range of decision-makers and influential people (programme managers, service providers, community leaders and women’s group members), as well as political leadership and funding by governments and donors.

Market factors also often prevent the effective promotion of female condoms. For one thing, they cost more than male condoms, which makes them inaccessible in many resource-limited countries. In response to these challenges, donor countries are working to obtain preferential prices, and increase financial assistance for promoting female condoms. A second-generation female condom that will cost one-third less than the current version has entered Phase II and III trials in South Africa.

Young people

Young people are a critical focus for behaviour-change programmes, since people 15–24 years old make up an estimated one-half of all new infections. However, young people in different parts of the world face different kinds of risks, and prevention programming must be designed accordingly. For example, interventions aimed at children who do not attend school are very different from those in school. In countries where injecting drug use poses a higher risk of HIV infection than sexual transmission, the curricula for life skills training have to be adjusted accordingly. Fortunately, a great deal of experience on prevention among young people has been built up in the past two decades and this is being applied in various parts of the world (see ‘Young People’ focus).

Women and girls

The special vulnerability of women and girls is well documented. For example, in sub-Saharan Africa overall, women are 30% more likely to be infected with HIV than men (see ‘Global Overview’ chapter). Among young people, the gender disparity in infection rates is particularly pronounced. In household surveys in seven countries in sub-Saharan Africa, 15–24-year-old women were found to be 2.7 times more likely to be HIV-infected than their male counterparts (WHO, 2002a) despite the fact that they were far less likely to report having non-marital, non-cohabiting partners in the previous 12 months (see Figure 21).

Trends in sexual behaviour among young people in selected sub-Saharan African countries, 1994–2001

Figure 21

Starting young is central to most prevention strategies, and one of the best means of protecting girls from HIV exposure is to keep them in school (see ‘Impact’ chapter). In line with the international initiative ‘Education for All’, three key action lines have been identified as being central to the education sector response to HIV and girls:

1.     Get girls into school, and ensure a safe environment that can keep them at school and learning.

2.     Ensure HIV prevention education is provided as part of the overall quality education that all children and young people deserve.

3.     Ensure special measures for those not in schools to extend the definition of education well beyond schools alone, and to consider the needs of working children, street children, and those who are exploited or made vulnerable by poverty and poor living conditions.

As girls grow older, other prevention activities become increasingly important. Reducing women’s vulnerability to HIV must address a variety of gender-related legal, social and economic disadvantages.

Married and cohabiting couples

Married and cohabiting couples have sex more frequently than people who are not living together, but they use condoms less often (Population Report, 1999). Some of this low condom use is certainly due to trust, but it also reflects women’s lack of power to negotiate safer sex, even when a woman suspects her husband has engaged in high-risk sex either before or during the marriage.

Being safer by being faithful to one’s partner is integral to ABC, but the idea that no protection is ever needed with regular partners can be dangerous. Faithfulness is only protective when neither partner is infected with HIV and both are consistently faithful. For example, a 1999 study in Thailand found that although three-quarters of HIV-infected women were most probably infected by their husbands, nearly half thought they were at no or low risk for HIV infection. Sex with their husband was the only HIV risk factor reported by these women (Xu et al., 2000).

This highlights the value of voluntary counselling and testing services for couples, which can increase knowledge of HIV status and assist partners to talk about sex and plan to reduce their risk. Studies have found that after voluntary testing and counselling, HIV sero-discordant couples (couples where only one partner is infected) and HIV-positive participants reduced unprotected intercourse and increased condom use at a greater rate than HIV-negative and untested participants (Weinhardt et al., 1999).

India: Condom use among men who have sex with men

The Humsafar Trust in Mumbai, which works with the Lokmanya Tilak municipal hospital, is one of India’s two HIV surveillance sites for men who have sex with men. In a survey among the Trust’s clients, 82% of men and 75% of transgendered people reported that their sex partners would be angry if they insisted on condom use. About half of both groups said that condoms were costly, difficult to find and embarrassing to purchase, and reported harassment by police for carrying them. Equally alarming, 85% of both groups believed condoms were unnecessary with someone who appears healthy (Mathur et al., 2002.)

Men who have sex with men

This population accounts for 5–10% of all HIV cases worldwide, including the largest share of infections in most industrialized countries and in Latin America. In Central and Eastern Europe, HIV prevalence among men who have sex with men is much higher than that of the general population (Hamers and Downs, 2003). In Indonesia, men who have sex with men represent 15% of reported AIDS cases; 29% in Singapore; 32% in Hong Kong; and 33% in the Philippines (Colby, 2003). Less is known about HIV prevalence in this population in sub-Saharan Africa.

In many parts of the world, men who have sex with men typically do not self-identify as gay, homosexual or bisexual. Incarceration or military service may also create contexts where there is sexual expression among men who are not gay-identified. Men who have unprotected sex with men may also have unprotected sex with women and thus serve as an epidemiological bridge to the broader population. In China, a survey of over 800 men who have sex with men found that 59% reported having had unprotected sex with women in the previous year (Ministry of Health/UN Theme Group, 2003).

Prevention programmes must take into account the fact that this group is highly stigmatized throughout much of the world. As of 2002, 84 countries had legal prohibitions against sex between men (International Lesbian and Gay Association World Legal Survey, 2002). In 13 Latin American countries, they receive a substantially smaller allocation of funds from national prevention programmes than their representation among all those infected would merit (see ‘National Responses’ chapter).

In the 1980s, men who had sex with men in North America, Western Europe and Australia were early HIV-prevention pioneers. They developed community-based programmes that forged safer sex norms and contributed to substantially reducing new HIV-infections. Such leadership is also apparent in low- and middle-income countries, through groups such as Malaysia’s Pink Triangle, Gays and Lesbians of Zimbabwe, and the Dominican Republic’s Amigos Siempre Amigos (‘friends always’), to name only a few.

In many countries, NGOs play a critical role in delivering HIV-prevention services to men who have sex with men. For example, the Indonesian government and Family Health International have implemented specially designed peer education among waria (transvestite sex workers), more than one in five of whom tested HIV-positive in 2002 in Jakarta (Ministry of Health, 2003).

Peer-based interventions that target social networks of men who have sex with men can be highly effective in promoting risk reduction. Recently, prevention workers recruited and trained young men in St Petersburg, Russia, and Sofia, Bulgaria, to deliver HIV prevention interventions to 14 social networks of men who have sex with men in these cities. An evaluation found that the programme promoted discussion of HIV and AIDS within the networks, and increased both knowledge levels and condom use (Amirkhanian et al., 2003).

Sex workers

HIV prevalence is generally higher among sex workers than in the general population. Surveys of sex workers in some urban areas between 1998 and 2002 detected extraordinarily high rates of infection: 74% in Ethiopia, 50% in South Africa, 45% in Guyana and 36% in Nepal (UNAIDS, 2002). Rising levels of HIV among sex workers can provide early warning of increasing probability that the epidemic will expand into the general population.

Trafficking of women and girls

Trafficking for the sex trade is a growing threat to women and girls. The International Labour Organization’s 2002 report, Unbearable to the human heart: child trafficking and action to eliminate it, states that an estimated 28 000 to 30 000 children are in prostitution in South Africa, with half between the ages of 10 and 14. In Europe, the International Organization for Migration estimates that between 2000 and 6000 women and girls are trafficked each year into Italy, while France, the Netherlands, Switzerland and the United Kingdom are also destination countries. Viet Nam faces widespread trafficking of rural children into prostitution in large cities. In the Americas, Mexico has considerable internal trafficking of girls for sex at Mexican tourist resorts (ILO/IPEC, 2002).

At the same time, there is substantial evidence that prevention programmes for sex workers are highly cost-effective, and that sex workers can be strong partners in prevention if programmes are based on recognizing their human rights. Acknowledging the broad diversity of sex workers is important in creating prevention programmes. In addition to women, sex workers can be male or transgender, young or old, and work in a range of settings from highly organized brothels to roadside bars and the street.

The most effective prevention programmes for sex workers include condom distribution, access to diagnosis and treatment of sexually transmitted infections and HIV, counselling and other services. Several such projects have had some success in increasing safer sex practices and reducing new cases of infection, as shown in studies in Benin and Côte d’Ivoire (Alary et al., 2002; Ghys et al., 2003). For example, the Clinique de Confiance in Abidjan has seen a marked reduction in prevalence of HIV and other sexually transmitted diseases among its clients since 1992 (see Figure 22), much of it attributable to prevention programming.

Annual prevalence of HIV and other sexually transmitted diseases at the Clinique de Confiance, Abidjan, Côte d'Ivoire (1992–2002)

Figure 22

The ‘100% Condom Use’ programme, first implemented in Thailand, is one of the best known sex-work-related interventions and has been replicated in other countries such as the Dominican Republic and Cambodia. Following implementation of the programme in Cambodia, adult prevalence, which had reached 3% in 1997, remained stable at that level through 2002. Meanwhile, HIV prevalence among sex workers who work in brothels declined from 43% in 1997 to 29% in 2002 (Cohen, 2003).

Recently, some sex worker organizations have criticized the way this programme has been applied in some countries (Wolffers and van Beelen, 2003). One study found that certain features of the Cambodian programme, such as lack of consultation with sex workers, reduced programme effectiveness, while its mandatory testing provisions raised significant human rights concerns (Lowe, 2002). A subsequent programme evaluation in 2003 led to the programme addressing some of these concerns. In contrast, the voluntary approach used in the Dominican Republic encourages condom use by mobilizing and educating sex workers, managers and other establishment staff (Kerrigan et al., 2003).

In many countries, a high percentage of sex workers are foreigners. An estimated 30% to 40% of sex workers in European Union countries are from Eastern Europe (Brussa, 2002). In Abidjan, Côte d’Ivoire, most sex workers come from neighbouring Ghana, Liberia and Nigeria (Ghys et al., 2002). In these circumstances, prevention programmes need to be carefully tailored to address the heightened vulnerability of foreign workers—particularly those who have been trafficked against their will (see box on page 80). One example is the European Network for HIV/STD Prevention in Prostitution. It operates in 24 European countries, including nine in Central and Eastern Europe. Its ‘cultural mediators’ work to contact sex workers from low- and middle-income countries and link them with health providers and other services (Brussa, 2002).

Human rights violations against sex workers (including high levels of violence) by police and by criminals are as pervasive as the sex trade itself, and seriously undermine prevention efforts (Human Rights Watch, 2003). Strategies to address this include education and awareness training for police officers, protective regulations, and enforcement of existing laws and workplace sanctions that prohibit discrimination and punish violence.

Prisoners

At any given time, there are approximately 10 million people imprisoned worldwide. This has serious implications for the global epidemic, since prisons and other custodial settings are breeding grounds for infectious diseases such as HIV, tuberculosis and hepatitis. Prison populations come largely from the most marginalized groups in society—people in poor health and with chronic untreated conditions, the vulnerable and those who have engaged in activities with high risk of HIV exposure such as injecting drugs and sex work. The vast majority are released into the wider community at some point.

Evidence of high HIV prevalence in prison is widely available. In South Africa, where prevalence of HIV infection for adults is more than 20%, the level in prisons is double (Goyer, 2003). In the United States, the proportion of confirmed cases of AIDS in prison is estimated to be four times higher than that in the general population (Braithwaite and Arriola, 2003). In Europe, reported HIV infection levels are as high as 26% in Spain; 17% in Italy; 13% in France; and 11% in both Switzerland and the Netherlands. Many HIV infections have also been reported from prisons in countries in Eastern Europe, such as Ukraine and, more recently, Lithuania, while prisons in Brazil have infection levels varying from11%to22% (Jürgens, 2003).

Antiretroviral therapy coverage for adults, end 2003

Figure 23

Globally, most prisoners are men, but women prisoners are also at risk of HIV. In Brazil, Canada and the United States, women prisoners are more likely to be HIV-positive than their male counterparts, largely because a high proportion are incarcerated for drug use and sex work (De Groot et al., 1999; Human Rights Watch, 1998).

In the Russian Federation, as injecting drug use has increased in society, the proportion of prisoners who are injecting drug users has increased and the number of HIV-positive prisoners has grown, as Figure 23 demonstrates. HIV-positive inmates are now about 4.3% of the total prison population.

Prison authorities sometimes deny it, but behaviours which carry high risk of HIV transmission are common in prisons, including injecting drug use, tattooing, male-male sexual relations and violence (including rape). In South Africa, up to 65% of male prisoners have sex with other prisoners, and an estimated 80% of prisoners awaiting trial are robbed and raped by convicted prisoners with whom they share a cell (Goyer, 2003; International Centre for Prison Studies, 2003).

Fortunately, a growing number of prison systems are working to protect prisoners from HIV. Many EU countries now provide free access to condoms, substitution treatment, and needle and syringe programmes in prison. In Spain, for example, an estimated 60% of incarcerated drug users receive methadone (Stöver, 2001). The Russian Federation is working with the AIDS Foundation East-West to develop a model programme which includes prevention education for prisoners and staff, access to condoms and providing bleach to sterilize injecting equipment (AFEW, 2003). Among low- and middle-income countries, Uganda is a leader in providing HIV prevention training for prisoners and staff, and has shared this expertise with South Africa’s prison system.

Antiretroviral treatment and drug substitution therapy are now available in some European prisons. This reflects the principle that treatment and care for prisoners should be equivalent to that available outside the prison setting, as most recently stated in the February 2004 Dublin Declaration on HIV/AIDS in Prisons in Europe and Central Asia. Ultimately, however, some of the most effective interventions for this group will be those aimed at breaking the vicious circle of drug use, crime and imprisonment. These include expanded substitution treatment for drug users in general, and increased use of non-custodial sentences.

Migrant workers and mobile populations

In recent years, increasing numbers of people have been on the move—from place to place within their own country, or to different countries altogether. The International Organization for Migration estimates that the number of international migrants (those who crossed national borders) increased from 105 million in 1985 to 175 million in 2000 (IOM, 2003), while a similar number of people may move within national borders.

There is a strong link between various kinds of mobility and heightened risk of HIV (see ‘Global Overview’ chapter). However, while there is a widespread prejudice that migrants ‘bring AIDS with them,’ the fact is that many migrants move from low HIV prevalence areas to those with higher prevalence, increasing their own risk of being exposed to the virus.

Rights to entry, treatment and care

A growing number of HIV-positive people are migrating to countries in Europe. Recent studies show that these individuals are typically diagnosed late in the course of infection and consequently miss the benefits of early care and treatment (Haour-Knipe, 2002). Some countries have prioritized voluntary counselling and testing, care and treatment for HIV-infected migrants and asylum seekers. But other countries have opted for mandatory testing and exclusion. This is particularly the case for migrants planning to remain in the host country for longer than six to twelve months. Some countries exclude HIV-positive immigrants altogether, while others insist on evidence that the individual has the means to finance his or her own treatment and care while in the country.

In the United Kingdom, this debate came to a head in 2003 when it was revealed that an estimated 80% of new heterosexual HIV infections had been acquired in sub-Saharan Africa. Intense media coverage suggested that asylum seekers were absorbing too many public services, which led to calls for mandatory HIV testing for immigrants.

In response, the All-Party Parliamentary Group on AIDS and its counterpart group on refugees held a series of hearings to investigate the matter. The resulting report concluded that testing and exclusion were both impractical and undesirable on human rights and public health grounds. It recommended that the government adhere to recognized guidelines against mandatory testing, while encouraging voluntary testing to ensure improved access to treatment and care. The group also called for national guidelines on providing care to HIV-positive asylum seekers living in the United Kingdom (All-Party Parliamentary Group on AIDS, 2003.)

HIV-related risk often depends on the reason for mobility. A recent study in India found that 16% of truck drivers working a route in the south were HIV-positive, compared to adult national HIV prevalence of below 1% (Manjunath et al., 2002). In South Africa, HIV prevalence is twice as high among migrant workers (26%) than among non-migrant workers (Lurie et al., 2003). In Sri Lanka, housemaids who have returned from working in the Middle East account for about half of reported HIV cases (UNDP, 2001a). Armed conflicts can increase HIV risk in a very short time as thousands are forced to flee their homes and communities (see ‘Conflict’ focus).

Matching the intervention with local conditions

Governments often fear that providing access to clean needles and syringes might result in more injecting drug use. But there is no evidence to support this view. Studies in Australia, Canada, Sweden, the United Kingdom and the United States have all shown that such programmes (particularly in concert with other interventions) help reduce the use of non-sterile injecting equipment and the transmission of HIV. There was no evidence that they increased either the number of injectors or the frequency of injecting drug use (Riehman, 1996). However, programmes must fit local conditions. For example, research in Canada has shown that cocaine injectors tend to inject much more frequently than heroin injectors, and therefore require much greater quantities of needles and syringes than usually provided by needle-syringe programmes (Strathdee and Vlahov, 2001).

The wide variety of conditions facing migrants requires that HIV prevention be carefully tailored to the specific circumstances of different groups. On a global level, there is increasing attention on prevention among mobile populations that regularly cross international borders such as truck drivers, traders and sex workers. A recent review found that as many as 56 programmes are operating in Africa and 27 different organizations are working in this field in South and South-East Asia (IOM/UNAIDS/UNDP, 2002; UNDP, 2001). Five countries are participants in a recently launched joint subregional HIV prevention and AIDS care programme along the Abidjan-Lagos Migration Corridor (see Figure 24).

Participating countries in the joint subregional HIV prevention and care programme along the Abidjan-Lagos migration corridor

Figure 24

Cooperation across borders is increasing in various parts of the world. For example, in October 2003, ASEAN countries took a major step forward when they agreed to incorporate HIV prevention programmes within large construction projects. As a pre-condition to bidding on these projects, contractors’ bids must include HIV prevention for construction workers and surrounding communities.

Injecting drug users and their sex partners

Using contaminated injecting equipment to inject drugs is a highly efficient mode of HIV transmission and continues to play a major role in HIV epidemics in several regions of the world (see Figure 25). Worldwide there are more than 13 million injecting drug users, and in some regions more than 50% of them are infected with HIV. Today, drug injecting with contaminated equipment is the major HIV transmission mode in many countries in Europe, Asia and Latin America, and is also driving HIV transmission in North Africa and the Middle East. In recent years, transmission among injecting drug users has been responsible for the world’s fastest spread of HIV infection, which has occurred in Eastern Europe and Central Asia (see ‘Global Overview’ chapter).

However, experience shows that it is possible to prevent and even reverse major epidemics among injecting drug users through a mixture of interventions. Cities such as London, United Kingdom, and Dhaka, Bangladesh, have managed to keep HIV prevalence among injecting drug users to less than 5%. In New York City in the United States, Edinburgh, Scotland, and several Brazilian cities, prevalence among injecting drug users has actually fallen (Burrows, 2003).

The best responses are built on the three pillars of supply reduction,demandreduction and harm reduction. A range of programming options should be used: discouraging people from using drugs, making treatment available to users, providing appropriate substitution therapies and making sure that clean needles and condoms are available. A review comparing HIV prevalence in cities across the globe with and without needle and syringe programmes found that cities which introduced such programmes showed a mean annual 19% decrease in HIV prevalence. This compares with an 8% increase in cities that failed to implement prevention measures. In Australia alone, these programmes prevented an estimated 25 000 HIV infections, and saved hundreds of millions of dollars in HIV treatment costs (Drummond, 2002).

Currently, the proportion of injecting drug users reached by prevention interventions is extremely low—less than 5% of the total in countries where this is a significant mode of transmission (UNAIDS, 2003). In many countries, there are still policy and legal barriers to using proven approaches such as access to clean needles and substitution therapy. This is despite statements by international bodies such as the International Narcotics Control Board confirming that these measures do not contravene international drug control conventions (INCB, 2004). Moreover, few interventions take into account the sex partners of injecting drug users, a key consideration in avoiding further expansion of the epidemic.

Proportion of 15–24-year-old injecting drug users infected with HIV, various studies

Figure 25

    

Prevention efforts are also hampered by the stigma associated with drug use. In some countries, health-care providers actively avoid serving injecting drug users. In the Russian Federation, more than 90% of the estimated one million people living with HIV were infected through injecting drug use. Yet injecting drug users make up only 13% of people receiving antiretroviral therapy (Malinowska-Sempruch et al., 2003).

HIV testing

UNAIDS promotes expanded access to both client-initiated and provider-initiated voluntary, confidential HIV testing, conducted with informed consent and accompanied by counselling for both HIV-positive and HIV-negative individuals. With respect to provider-initiated testing, in all settings, individuals retain the right to refuse testing, i.e. to ‘opt out’ of a routine offer of testing. All testing needs to be accompanied by referral to medical and psychosocial services for those who receive a positive test result, and by community education and legal and policy reform to counter stigma and discrimination.

HIV testing

Knowledge of HIV status is the gateway to AIDS treatment and has documented prevention benefits; however, the current reach of HIV testing services is poor and uptake is often low, largely because of fear of stigma and discrimination.

The cornerstones of HIV testing scale up include strengthened protection from stigma and discrimination as well as assured access to integrated prevention, treatment and care services. Public health strategies to increase knowledge of HIV status and human rights protection are mutually reinforcing and should be integrated for greatest effect in reducing HIV transmission and improving the quality of life of people living with HIV. The testing process, regardless of context, must remain voluntary, with the confidential nature of the test result preserved. The ‘3 Cs’ are the underpinning principles advocated since HIV testing of individuals began in 1985. They are:

·        confidentiality

·        testing accompanied by counselling

·        testing only with informed consent, meaning that it is voluntary.

HIV testing options for individuals urgently need to be greatly expanded to enhance access to treatment and prevention. Client-initiated voluntary counselling and testing services which focus on increasing knowledge of HIV status, particularly of sexually active people, are run by NGOs or public services at freestanding or designated facilities. Rapid scale up requires:

·        effective marketing of knowledge of HIV status for people who may have been exposed to HIV through any mode of transmission;

·        pre-test counselling provided either on an individual basis or in group settings with individual follow-up;

·        the use of rapid tests that provide results in a timely fashion to permit immediate post-test counselling follow-up for both HIV-negative and HIV-positive individuals.

New strategies to enhance the effectiveness of both treatment and prevention programmes require a provider-initiated routine offer of HIV testing with assured referral to effective prevention and treatment services. Diagnostic HIV testing is indicated whenever a person shows signs or symptoms that are consistent with HIV-related disease, including tuberculosis, to aid clinical diagnosis and management. A routine offer of HIV testing by health-care providers should be made to all patients in:

·        sexually transmitted infection clinics—to facilitate tailored counselling based on knowledge of HIV status;

·        maternal and child health clinics—to permit antiretroviral prevention of mother-to-child transmission;

·        health-care settings where HIV is prevalent and antiretroviral treatment is available (injecting drug use treatment services, hospital emergencies, internal medicine hospital wards, etc.)

Figure 26

Changes in voluntary counselling and testing in South Africa: more sites = more tested

Referral to post-test counselling services emphasizing prevention, for all those being tested, and to medical and psychosocial support, for those testing positive, must be assured—whether diagnostic testing is being performed or testing is being offered routinely (see Figure 27). The basic conditions of confidentiality, consent and counselling apply but the standard pre-test counselling used for client-initiated testing is adapted simply to ensure informed consent, without a full pre-test education and counselling session.

To provide informed consent to a provider-initiated offer of HIV testing, patients need to be informed of the following:

  • the clinical and prevention benefits of testing;
  • the right to refuse;
  • the follow-up services that will be offered; and
  • the importance of informing others, if the result is positive, who are at ongoing risk and would not suspect they were being exposed otherwise.

For provider-initiated testing, whether for purposes of diagnosis, offer of antiretroviral prevention of mother-to-child transmission or encouragement to learn HIV status, patients retain the right to refuse testing, i.e. to ‘opt out’ of a systematic offer of testing. HIV testing without consent may be justified in the rare circumstance in which a patient is unconscious, his or her parent or guardian is absent, and knowledge of HIV status is necessary for purposes of optimal treatment. All blood donors should be advised that their blood will be tested confidentially for HIV, and HIV-infected blood donations should be removed from the blood supply.

Khayelitsha: Availability of decentralized antiretroviral therapy access, advocacy, and multi-disciplinary support services dramatically increases demand for testing and counselling

Figure 27

Preventing and treating sexually transmitted infections

Preventing, diagnosing and treating sexually transmitted infections are essential components of an effective HIV prevention strategy. Untreated sexually transmitted infections dramatically increase the risk of HIV transmission through unprotected sex. Most of these sexually transmitted infections can be prevented by using condoms and seeking treatment early. Moreover, many bacterial sexually transmitted infections (e.g., syphilis, gonorrhoea and Chlamydia) and parasitic infections (e.g., Trichomonas infection) can be treated easily and inexpensively with antibiotics.

Unfortunately, in many countries, poor sexually transmitted infection diagnosis and treatment is hampering HIV prevention efforts. In 2003 in Viet Nam, only 38% of sexually transmitted infection cases were properly diagnosed, counselled and treated. Comparable figures for Botswana and Kenya were 30% and 50% respectively (UNAIDS, 2003). However, in Cotonou, Benin, pharmacists trained to diagnose and recommend treatment for sexually transmitted urethritis in men were far more likely to identify cases and recommend effective treatment than other pharmacists.

While there is general agreement that sexually transmitted infection control efforts need to be significantly scaled up—in a variety of ways—there is debate among researchers about the relative impact of large-scale sexually transmitted infection treatment programmes on HIV incidence. In Mwanza, Tanzania, a large-scale community-based sexually transmitted infection treatment trial reduced HIV incidence at the community level. However, two other trials in Uganda (in Masaka and Rakai) showed no effect (Kamali et al., 2003). This is likely due to the relatively advanced stage of the epidemic when these latter trials were undertaken. Control of sexually transmitted infections may be more effective in reducing HIV incidence in low and slowly rising epidemics (Hitchcock and Fransen, 1999).

Preventing mother-to-child transmission

In 2003, an estimated 630 000 children worldwide became infected with HIV—the vast majority of them during their mother’s pregnancy, labour and delivery, or as a result of breastfeeding. Meanwhile, some 490 000 children died of AIDS-related causes in 2003.

At least a quarter of newborns infected with HIV die before the age of one. Up to 60% die before reaching their second birthday. Overall, most die before they are five years old (Dabis and Ekpini, 2002; Elizabeth Glaser Pediatric AIDS Foundation, 2003). In 1999, in Botswana, 40% of all children who died before their f