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

    

HIV Prevention is Achievable

Michael H. Merson, MD

Department of Epidemiology and Public Health

Yale University School of Medicine

60 College Street

New Haven, CT 06511

October, 1998

Introduction

Estimates at the end of 1997 indicate that, since the start of the pandemic, approximately 42 million adults and children had been infected with HIV and 11.7 million of them had developed AIDS. Ninety percent of all infections have occurred in developing countries. ' Despite these daunting numbers and the well-known fact that it is difficult to change well established behaviors, there is increasing evidence, worldwide, that AIDS prevention is possible.

In planning our prevention interventions, it must be borne in mind that HIV infection is a classical, sexually-transmitted disease. Worldwide, half of all infections are in youth 15-24 years of age and the average age of infections declines as the epidemic becomes more established in a country, reflecting the entry of newly, sexually active persons into the population. Transmission of the virus is more efficient from men to women than from women to men. However, like other sexually transmitted diseases, HIV can be spread parenterally (through blood) and perinatally (from mother to child). While the percent of infections transmitted parenterally through injecting drug use worldwide is relatively small (around 10%), this route is responsible for half of all new HIV infections in the United States and has been the major means of introduction of HIV into all Asian countries that now have a major epidemic, as well some countries in South America. Most perinatal infections occur in Sub-Saharan Africa and other under served areas where heterosexual transmission is common. While antiretroviral therapy is highly effective in reducing transmission from mother to child, there is little or no access to these drugs in many developing countries.

  

Prevention of Sexual Transmission

As the vast majority of HIV infections worldwide are sexually transmitted, international HIV prevention efforts have placed greatest emphasis on interrupting this means of transmission. In almost all settings, heterosexual transmission is the predominant mode of sexual spread. The main approach to prevention of sexual transmission has been the promotion of safer sex messages through a wide variety of channels along with the provision of condoms. When properly manufactured, stored and used, condoms are virtually 100% effective in preventing HIV transmission, as best evidenced in studies of discordant couples (when one member of a couple is positive). ' In many countries educational interventions have been successful in increasing safer sex practices, including in high-risk populations, such as men who have sex with men, commercial sex workers and their clients, truck drivers, factory workers and the military. Many of these projects have been undertaken by community-based organizations who deliver safer-sex messages and provide condoms.'

Because of the increasing rates of infections in youth and the declining age of first intercourse, prevention efforts have frequently been undertaken in schools. The most effective sex education programs in schools have emphasized abstinence from sex for those who have not been sexually active and prefer to remain so and use of condoms for those who are sexually active. Some schools make condoms available through health educators. Such programs have been successful in increasing condom use and reducing pregnancy rates and rates of new sexually transmitted diseases (STDs) without increasing sexual activity. '

Another type of effective prevention intervention has been condom social marketing programs. These programs use modem marketing techniques to promote and sell condoms at a low price to high-risk populations using multiple channels. They seek to make condoms popular and to decrease any inhibitions associated with their use. Condom sales in 37 developing countries with social marketing assistance from USA organizations increased from 20,000 sold in 1987 to 530 million sold in 1997. In Switzerland a national condom social marketing program directed at adolescents and young adults has been credited with slowing the epidemic in that country.

One other type of preventive intervention has been voluntary testing and counseling programs. These programs were originally used primarily to detect HIV-infected blood donors, but have become commonly used by those wishing to know if they were infected. They have been found to be effective in bringing about safer sex practices, when counseling is done effectively and both partners of a couple are tested and counseled. This is especially the case for discordant couples.

Beginning in the late 1980's, there has been acceptance that educational efforts directed toward safer sex behavior should be accompanied by more effective treatment of sexually transmitted diseases. This is because genital ulcer disease increases the risk of HIV transmission per sexual exposure 10 to 50 times for male to female transmission and 50 to 3 00 times for female to male transmission. ' Non-ulcerative STD)s (chalmydia and gonorrhea) similarly increase the risk two to five-fold. A recently conducted study in Tanzania demonstrated a 42% reduction in new HIV infections after two years of follow-up as a result of improved STD care.' This included training of primary health care workers in STD syndromic case management, making available effective antibiotics and promoting health care seeking behavior by those infected. The positive impact of comprehensive STD case management and targeted condom promotion has been demonstrated in a number of clinic-based and community settings in Africa and Asia, particularly in high risk populations. The greatest challenge in using this approach is to find means for identifying the 30-50% of women who have asymptomatic STDs, particularly those with chlamydia infection.

The above-mentioned behavioral and STD treatment interventions are directed toward individuals. Interventions that change laws, policies or administrative procedures (structural interventions) or alter living conditions, resources, opportunities or social preserves (environmental interventions), and thus are directed toward societal change, are also effective in preventing sexual transmission. One of the most effective of these has been the 100% condom use policy in brothels in Thailand! This intervention, which has brought about nearly universal condom use in brothels, has been responsible for the dramatic decline in HIV and STD infections in that country between 1990 and 1995. Other similar type of interventions include the removal of import taxes on condoms (to decrease their price) and the education of women so that they need not be sex workers to earn income.

  

Prevention of Transmission Through Injecting Drug Use

Most the experience in programs to reduce HIV transmission among injecting drug users (IDUs) has been in developed nations. The most effective programs are based on the principle of harm reduction, i.e., reducing the risk of HIV infection in these injecting drugs. Such programs also reduce the incidence of other parenterally transmitted infections, particularly hepatitis. One type has been community outreach programs, which involve the recruitment of outreach workers who seek out IDUs and provide them education on safe injection practices, bleach to disinfect injection equipment, and condoms, while offering them access to voluntary and counseling services and drug treatment. These programs have been particularly effective in providing services for hard-to-reach drug users. ' A second type of program is syringe- exchange. These programs exchange dirty needles and syringes for clean ones and provide preventive messages and access to health care and drug treatment. Their effectiveness in reducing HIV transmission without increasing drug use has been clearly demonstrated. ` A third type of effective intervention (which is a structural intervention) is the making of clean needles and syringes readily available to IDUs through pharmacies or vending machines. This allows IDUs to obtain injection equipment in a more anonymous manner and has been shown to decrease needle sharing and purchase of needles and syringes on the street. I'

To achieve their maximum impact, all three types of interventions should be carried out simultaneously in order to give IDUs options for prevention. Simultaneously, drug treatment, particularly methadone maintenance programs, should be established and sufficient opportunities made available for those needing treatment. The federal government has recently proposed that methadone be made available in physician offices, not only in special clinics, in order to expand access to the drug.

How to Achieve Successful Prevention

There are increasing numbers of countries that have mounted successful prevention efforts.' Countries like Thailand, Uganda, Tanzania, Zambia, Senegal and Switzerland have implemented programs that have decreased sexual transmission. So have gay men in this country. Countries like Australia and New Zealand have illustrated the achievements possible through harm reduction programs in decreasing transmission through injection drug use.

One reason why these countries have been successful is that they have formulated prevention policies on the basis of sound science. This has enabled them to combat the many myths that have characterized this pandemic. This includes the myth of complacency ("we won't / don't have the problem), the myth that condoms are not effective, that sex education in schools leads to youth having more sex, that syringe exchange programs increase drug use, that sexual behavior cannot be changed and that we need to wait for a vaccine before I-HV will be prevented (a vaccine will help, but all experts agree that it is at least a decade away). Overcoming some of these myths is often not easy, even in the presence of solid scientific data, because they are based on moral beliefs and teachings. Indeed, HIV prevention is "counter-cultural" in that it requires that we discuss sexuality openly, admit that adolescents have sex, recognize sexual diversity and delink condom use to distrust of one's partner.

Successful prevention programs have also combated the discrimination and stigmatization often associated with HIV and AIDS. Because AIDS is contagious, disfiguring and presumed to be fatal, it elicits fears about our own mortality. Society may respond to these fears by stigmatizing those infected with HIV and populations with high rates of infection. Such stigmatization and the resulting discrimination are particularly difficult for populations that are already stigmatized, such as gay men, drug users, commercial sex workers and, in this country, communities of color, which because of their increased vulnerability, have high rates of HIV infection. Successful programs have also resisted efforts, often generated by discriminatory policies, to try and prevent HIV infection through mandatory testing and quarantine which can never be effective in controlling this disease.

To overcome the myths of AIDS and combat discrimination requires strong political leadership from government, the private (business) sector, and leaders in other sectors of society (including from sports, entertainment, academia and religion). Countries that have achieved successful prevention have had such leadership. They also have encouraged "grass root" action by community based groups, including persons infected and affected by HIV who often are the best carriers of prevention messages.

Perhaps the greatest challenge now facing HIV prevention has been the advent of new and improved anti-retroviral therapy. The new combination therapy has been shown to have the potential to greatly prolong the life of HIV-infected persons and to markedly improve the quality of their lives. However, it is making HIV prevention more difficult, as it gives the impression that there is a "cure" for AIDS, thereby discouraging the need to practice safer sexual behavior. This situation is made even more dangerous by the increasing prevalence of HIV strains resistant to these drugs due to poor adherence or intolerance to the drug therapy. Because of these concerns, it is essential that health care providers emphasize the importance of prevention when administering anti-retroviral drugs and that the media and pharmaceutical industry not exaggerate the benefits of this therapy.

Role of Religious Leaders

Throughout the world religious leaders have played an important role in AIDS care. In particular, they have provided much needed support and compassion for HIV-infected persons and have spoken out against the stigmatization and discrimination HIV-infected persons frequently face in their daily lives. Church leaders need to continue to help safeguard the rights of persons affected by HIV/AIDS and to participate actively in discussions of ethical issues posed by the epidemic at local, national and international levels. In the United States and elsewhere there are efforts underway to enact measures that will limit the rights of HIV-infected persons based on the mistaken belief that such measures can enhance prevention efforts.

Even greater participation is needed among religious leaders in addressing their congregations about HIV prevention and in working more closely with community-based prevention programs. This task is often difficult because of the behaviors associated with HIV infection. Experience has shown beyond doubt that successful prevention requires acknowledging that these behaviors exist and addressing them in a frank, realistic and non-judgmental manner. Gay men, commercial sex workers and injecting drug users are often rejected by society, yet they are among those most vulnerable to HIV infections. Churches should help to educate these populations as to how to prevent HIV infection, and to develop locally relevant responses. Similarly, churches should have special programs to inform youths about how HIV infection is transmitted and how to protect themselves. They should also work with women as they seek to attain equality with men socially and economically, since this equality is essential to reduce their vulnerability to HIV infection.

Heavily affected communities need to feel empowered to cope with the challenges of the epidemic. They need to believe that they are not rejected by their religious communities. Religious leaders can thus play a key role in engendering this empowerment so that these communities can obtain the prevention and care services they need. In some circumstances this will require that religious communities confront their own fears and prejudices about those populations that are most vulnerable to MV infection. If churches can provide a climate of love, acceptance and support for those who are vulnerable to, or affected by, HIV and AIDS, other sectors of society are likely to follow.

References:

1.UNAIDS: Report on the Global HIV/AIDS Epidemic. 1997 World Health Organization: Geneva.

2.De Vincenzi, 1. (1994). A Longitudinal Study of Human Immunodeficiency Virus Transmission by Heterosexual Partners. New Engl J Med, 331:341-346

3.Merson, M., Dayton, J., (1998). Effectiveness of HIV Prevention Interventions in Developing Countries. (TJnder review).

4.Kirby, D., Short, L., Collins, J., et al (1994). School-Based Programs to Reduce Sexual Risk Behaviors: A Review of Effectiveness. Public Health Reports, 109 (3):339-359.

5.Dubois-Arber, F., Jeannin, A., Konings, E., et al (1997). Increased Condom Use without Other Major Changes in Sexual Behavior among the General Population in Switzerland. American Journal of Public Health, 87 (4): 558 566

6.Hayes, R.J., Schulz, K.F. & Plummer, F.A. (1995). The Cofactor Effect of Genital Ulcers on the Per-Exposure Risk of HIV Transmission in SubSaharan Africa. J Trop Med Hyg, 98:1-8.

7.Grosskurth, H., Mosha, F., Todd, J. et al. (1995). Impact of improved treatment of sexually transmitted diseases on HIV infection in rural Tanzania: Randomized controlled trial. Lancet, 346:530-536

8.Rojanapithayakom, W. & Hanenberg R. (1996). The 100 percent condom program in Thailand. AIDS, 10:1-7.

9.Coyle, S. L., Needle, R., Normand, J. (1998) Outreach-Based HIV Prevention for Injecting Drug Users: A Review of Published Outcome Data. Public Health Reports, 113(l):19-30.

10.Vlahov, D. & Junge, B. (1998). The Role of Needle Exchange Programs in HIV Prevention. Public Health Reports, 113(l):75-80.

11.Groseclose, S.L., Weinstein, B., Jones, T.S., et al. (1995). Impact of Increased Legal Access to Needles and Syringes on Practices of Injecting-Drug Users and Police Officers-Connecticut, 1992-1993. Journal of Acquired Immune Deficiency and Human Retro virology, 10:82-89.

 

 

 

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