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With over 33 million people infected with HIV worldwide and over 7,400 new infections every day, universal access to comprehensive HIV prevention services is essential.  In 2007, roughly 3 million people became newly infected with HIV, including 470,000 children under the age of 15, most of whom were infected through mother-to-child transmission of the virus.  HIV prevention does not have to be complicated in order to have a real impact on the spread of HIV/AIDS.  But it does have to address the various needs of all populations at risk—from injection drug users to adult married women.

Understanding HIV Infection and Prevention
HIV can only be transmitted in a few ways: through sex, blood, and mother-to-child transmission.  Educating people about HIV and about the behaviors that put them at risk—such as unprotected sex and injection drug use—and enabling them to adopt safer behaviors are at the core of HIV prevention.  Yet, preventing HIV requires a thorough understanding of the complex social, cultural, and economic factors that make some people more vulnerable to HIV infection than others.  Worldwide, HIV is a disease of poverty and gender inequality.  HIV prevalence statistics prove this: the highest rates of HIV occur in the poorest countries, where more women than men are infected, and young women are most at risk of acquiring HIV.

Lack of Access to Basic Prevention Services
According to UNAIDS, less than 20% of people at risk of HIV infection have access to basic prevention.  In countries with a generalized epidemic (meaning that the virus is not restricted to a particular population, such as sex workers or injection drug users), everyone is at risk. In addition, only 11% of the world’s pregnant women have access to services to prevent mother-to-child transmission (PMTCT), despite the fact that this is one of the cheapest and easiest prevention interventions available. Scaling up available prevention strategies in 125 low- and middle-income countries would prevent over 28 million new HIV infections between now and 2015—the target date for achieving the Millennium Development Goals.

Stopping Sexual Transmission of HIV
HIV prevention includes a wide range of programs and interventions that have been scientifically proven effective.  One common approach to HIV prevention—the one endorsed by the US government through the President’s Emergency Plan for AIDS Relief (PEPFAR)—is the “ABC” model. ABC—abstinence, be faithful, use a condom—is potentially quite effective at preventing the spread of HIV.  But it is essential that all three components be undertaken in a balanced and culturally-appropriate manner.  For ABC to work, programs that promote abstinence and fidelity must work together to delay sexual debut—the first time someone has sex—and limit the number of sexual partners.  At the same time, condom education programs teach adolescents and adults about safer sex practices and provide them with access to male and female condoms (and hopefully someday to microbicides, too).&nsbp; The reality is that most people become sexually active in their late teens, young girls in the global South are often forced into early marriages, and extramarital affairs are not uncommon.  This means that everyone needs complete and accurate information about how to protect themselves against HIV when they do have sex, whether high-risk or not.

In addition to comprehensive HIV and condom education, people need to understand their sexual and reproductive health (SRH), including sexually transmitted infections, which increase the risk of acquiring HIV.  One very important SRH service is prevention of mother-to-child HIV transmission, a highly cost-effective and successful intervention that must be made accessible to all pregnant women.  Another element of SRH, male circumcision, has proven effective at protecting men from HIV, and should be carefully offered along with SRH and HIV counseling in a culturally appropriate setting.  Violence against women and violence against children (VAW/C) is another important driver of the HIV pandemic.  Sexuality and violence education programs can help people negotiate safer, consensual sex, which can dramatically reduce the risks of HIV transmission.  In addition, harm reduction is a fundamental HIV prevention approach for commercial sex workers and those engaged in transactional sex—often called poverty-driven sex or survival sex, because it involves people trading sex for things they need, like school fees, food, medicine, or money.  For this vulnerable population, harm reduction includes education about HIV/AIDS and related risk factors, provision of condoms, and economic empowerment programs.

Poverty and HIV/AIDS Prevention
Because AIDS is a disease of poverty and because women are almost 70% of the world’s poor, economic empowerment efforts are an important element of HIV prevention.  Foremost among these is universal access to a free basic education.  Primary education can reduce the impact of poverty, particularly on girls and women, decrease early marriage, facilitate family planning, and increase gender equity and awareness of human rights—all of which can slow the spread of HIV.  Programs like microfinance schemes can have a direct impact on economic independence for those past schooling age, with benefits that are passed on to younger generations.

Stopping Intravenous Transmission of HIV
Although unprotected sex remains the primary cause of HIV transmission worldwide, blood and injection safety—both in health care settings and among drug users—is also a critical component of HIV prevention.  Hundreds of thousands of HIV infections are caused each year through unsafe injections in health care settings, for example, through accidental needle pricks during vaccinations.  Laboratory safety and access to clean syringes in health care settings are essential to prevent this method of HIV transmission.  But harm reduction with injection drug users (IDUs) is also key, and often overlooked.  Nearly one-third of all HIV infections outside Africa are attributed to injection drug use, yet only 5% of IDUs worldwide receive any HIV prevention services.  Injection drug use is a particularly important factor in the HIV/AIDS epidemics of extremely populous, so-called “second wave” countries like Russia and China, and in Vietnam, the newest PEPFAR focus country.  Clean needle exchange and programs to help people who wish to stop using injection drugs are best practices endorsed by the World Health Organization and should be made widely available.

Prevention Technologies
Finally, as HIV and AIDS continue to spread, decimating entire communities, it is urgent that increased resources be invested into new and underutilized technologies to prevent HIV.  Female condoms should be made available at low cost around the world.  Research into microbicides, which would allow women to protect themselves against HIV without their partner’s knowledge or cooperation, and into a vaccine for HIV should receive greater investment from the global community.

For more detail on comprehensive HIV prevention, take a look at GAA’s fact sheet.

What needs to be done?

In order to meet the Millennium Development Goals by 2015, much greater attention will need to be paid to the AIDS pandemic.  As a result, United Nations member states have committed to achieving specific targets for universal access to HIV/AIDS services by 2010.  The prevention targets include reducing AIDS cases by 25%. reducing the number of HIV-infected children by 50%, and increasing to 95% the proportion of young people who both correctly identify ways to prevent HIV and reject major misconceptions about HIV.  These commitments must be kept if we are to slow and ultimately reverse the spread of HIV/AIDS.

Governments and multilateral agencies need to support comprehensive and fully funded HIV prevention programs that do not impose ideological beliefs and that reflect the realities of people’s lives.  First and foremost, this means that ABC programs must be conducted in a balanced manner, according to scientific evidence of what works and what doesn’t. US law currently requires that one-third of all money spent on HIV prevention overseas supports abstinence-until-marriage programs.  Yet, a number of experts have reported that this requirement contradicts scientific evidence and is actually undermining efforts to stop the spread of HIV.  For more information, take a look at reports on PEPFAR from the Government Accountability Office and the Institute of Medicine, both of which recommend that PEPFAR promote a comprehensive approach to HIV prevention.

Thankfully, the Global Fund to Fight AIDS, Tuberculosis and Malaria is providing much-needed balance to PEPFAR’s emphasis on abstinence in poor, AIDS-affected countries.  The Global Fund supports comprehensive ABC programming, as well as harm reduction for sex workers and IDUs, anti-violence programs, comprehensive sexual and reproductive health services, health system strengthening, and other important components of HIV prevention. But the Global Fund must be fully funded, with the US and other wealthy donors increasing their contributions each year to help the Fund continue its current work and scale up programs that have proven effective.

All HIV/AIDS programs must adopt a model similar to the Global Fund’s—one that integrates the diverse factors driving the spread of HIV.  Many such programs exist, and they need to be scaled up through national-level programs so that everyone can benefit.  Promising efforts include integration of HIV/AIDS and SRH services and social marketing for condoms.  At the same time, stronger health systems are needed to ensure universal access to comprehensive HIV prevention services.  This means more trained health care workers and adequate supplies and equipment, including condoms and HIV tests.  Finally, mass media campaigns, such as Soul City in South Africa, that spread HIV awareness and prevention messages and combine SRH and VAW/C information with stigma reduction and promotion of safer sex, must reach all members of the population.


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