Prevention is achieveable Michael H. Merson
	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. 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 lives 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 ÒcureÓ 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. A classic STD In planning prevention interventions, it must be borne in mind that HIV infection is a classic sexually transmitted disease (STD). 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 percent), this route is responsible for half of all new HIV infections in the U.S. and has been the major means of introduction of HIV into all Asian countries that now have major epidemics, as well as some countries in South America. Most perinatal infections occur in Sub-Saharan Africa and other underserved 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. Preventing 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 percent 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 without increasing sexual activity. Another type of effective prevention intervention has been condom social marketing programs. These programs use modern 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 U.S. 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 there. 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 are 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. Structural interventions Beyond behavioral and STD treatment interventions directed toward individuals, interventions that change law, 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 percent 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 types 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. Injected drugs Most of 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 those 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 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. 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. These include the myth of complacency (ÒWe wonÕt/donÕt have the problemÓ), 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 HIV 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 Òcounter-culturalÓ 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. 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. 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. Countries that have achieved successful prevention have had strong political leadership from government, the private (business) sector, and leaders in other sectors of society (including sports, entertainment, academia and religion). They also have encouraged grass roots action by community-based groups, including persons infected and affected by HIV who often are the best carriers of prevention messages. Physician Michael H. Merson is Dean of Public Health at Yale University School of Medicine. This piece is adapted from Merson's presentation to the AIDS & Religion in America conference in Atlanta, Georgia, November 1998. sponsored by the AIDS National Interfaith Network <http://www.anin.org>. Illustration: The Apartment Series, by Joe Bussell, 1985 Back to top Back to current issue