Peter R. Lamptey, director of the FHI/IMPACT Project, delivered this presentation on how prevention can deter the spread of HIV/AIDS at the 2000 XIII International AIDS Conference on AIDS in South Africa.
Introduction (slide 2)
It is a privilege and an honor to address the Thirteenth International Conference on HIV/AIDS/STD. I would like to thank the organizers for affording me the opportunity to speak here today.
The title of the presentation I've been asked to give today may seem overly optimistic at best. How can we make the statement that "Prevention works," especially in Africa, where over 4 million people become infected with HIV every year? How does prevention work for tens of millions of individuals living with HIV without any real hope for survival?
What we can say, I believe, is that prevention can work. And there is evidence, from several research studies, numerous interventions and some national programs, that it does work. But we cannot claim success until we make prevention work globally, controlling the pandemic and drastically reducing the rate of new infections in most populations all over the world.
Successes in HIV/AIDS prevention (slide 3)
Despite the lack of global success in HIV prevention, we have made tremendous strides in prevention, care and support. The epidemic has slowed in several industrialized countries and some developing countries. Effective, though expensive, new drugs for the management of HIV disease have improved survival, reduced AIDS mortality, and enhanced quality of life. We have dramatically reduced mother-to-child transmission of HIV in industrialized countries.
Progress against HIV is most evident in countries with the resources to mount comprehensive programs and subsidize the cost of antiretroviral therapy. My presentation will focus primarily on some of the documented successes in developing countries, where 90 percent of HIV infections occur.
During the past decade, we have greatly improved our understanding of the HIV/AIDS epidemic and the interventions needed to contain it. The next two slides show the types of approaches currently being used in various programs around the world. These approaches reduce individuals' risk and vulnerability to HIV and help create an environment that supports HIV prevention and care.
Slide 4: Programs to reduce the transmission of HIV
Slide 5: Contextual interventions for HIV/AIDS prevention and care
In recent years, a number of studies and programs have confirmed the value of some of the interventions used to reduce risk and vulnerability to HIV. Others have identified new interventions that may be feasible in resource-poor settings.
Blood safety is the most effective of all interventions in AIDS prevention and has been successful in most countries. In industrialized countries, infection through blood transfusion is a very rare occurrence. However, in developing countries, the quality of blood screening for HIV varies widely between and within countries as a result of periodic shortages of test equipment and supplies as well as poor quality assurance.
The Mwanza trial showed that improved clinical services for sexually transmitted disease, using the syndromic or symptom-based approach, reduced the incidence of HIV infection by about 40 percent over two years. We have also learned from the Rakai study that mass treatment of all sexually active adults for STD is not effective in the prevention of HIV. The Lesedi study, however, showed that mass treatment of sex workers is effective in reducing the STD burden in both sex workers and their clients. Despite the findings of the Rakai study, STD management is still one of the most important interventions to control HIV.
Another randomized controlled trial, conducted in Kenya, Tanzania, and Trinidad, demonstrated the efficacy of voluntary HIV counseling and testing, or VCT, in promoting behavior change. Couples who received VCT reduced unprotected intercourse with partners significantly more than couples who did not receive VCT.
The percentage of individuals reporting unprotected intercourse with casual partners also declined significantly more among those receiving VCT than those who did not.
This trial provides further evidence of the value of VCT and the urgent need to expand access and improve the quality of VCT services.
Several clinical trials have demonstrated the efficacy of various regimens of antiretroviral therapy in preventing mother-to-child transmission, or MTCT. These include long-course AZT, short-course AZT, a combination of AZT and 3TC, and nevirapine. In the U.S, since the implementation of a nation-wide program in 1994, the number of infants who acquire HIV from MTCT has declined by 73 percent. Many experts believe that with the success of ARV in preventing MTCT and the relative accessibility in the industrialized countries, elimination of pediatric HIV infection is a realistic goal.
The lower cost of nevirapine (at 4 dollars per treatment) makes prevention of MTCT more affordable in developing countries. However, the results of the UNAIDS-funded PETRA study in breastfeeding populations has shown that ARV prophylaxis alone is not sufficient for the prevention of MTCT. The study, conducted in Tanzania, Uganda and South Africa, confirmed the early efficacy of ARV, but found no differences in HIV transmission rates and mortality among the infants at 18 months between the intervention arms and the placebo group. The loss of efficacy in all three intervention arms has been attributed to transmission of HIV through breastfeeding.
Even though IDUs are one of the most marginalized and difficult populations to reach with interventions, there have been successes in the prevention of HIV among this population. Several successful harm reduction programs have been reported in some industrialized countries, including Australia, Switzerland, U.K. and the U.S. For example, in New York, HIV risk behavior has declined by 40 percent among IDUs, and HIV prevalence has declined from 50 percent to 30 percent since 1991, as well as a four-fold decline in HIV incidence. These changes have been attributed to the expansion of needle exchange programs. In developing countries, there has been limited success in the prevention of HIV in IDUs. The explosive increases in HIV prevalence among IDUs in China and more recently in Nepal suggest that we are not doing enough for this population.
One intervention that is already widely implemented throughout the developing world -- condom social marketing -- has made an effective means of prevention more accessible, affordable and attractive to millions of people.
Condom availability and use have increased dramatically in several countries as a result of condom social marketing. For example, in Brazil condom sales increased from 70 million in 1993 to 320 million in 1999.
Slide 6: Condom sales in selected countries
The next slide shows some of the successes in male latex condom sales in a number of countries.
A recent UNAIDS-sponsored trial of the microbicide, Nonoxynol-9, showed that it does not protect against HIV and may actually enhance its transmission. The female condom will therefore continue to be the primary female-initiated mode of protection.
The results of these interventions offer possibilities for strengthening HIV prevention efforts. But we need to find better mechanisms for translating these results into large-scale interventions in order to have impact at the national level.
National program successes (slide 7)
Most HIV programs in developing countries are limited in scope and coverage, under-funded, and have inadequate data to assess their impact. I have no doubt that many of them are saving lives, and that the epidemic would have been far worse without them. But for this presentation, I have chosen only programs that have adequate behavioral and biological outcome data to assess program effectiveness. I will present data demonstrating that some national programs may have contributed to a decline in the epidemic through prevention efforts.
Over the last few years, a number of national programs have reported significant declines in the prevalence of HIV at the country level. These countries include several industrialized countries, such as the United States, Canada, Australia, and some Western European countries. Among developing countries, Thailand, Uganda and, more recently, Senegal, have been cited extensively as national program successes. There are encouraging signs that the Cambodia, Zambia and the Democratic Republic of the Congo epidemics may also be stabilizing.
The success of the Thai program
Much has been written about the success of the Thai AIDS prevention program. From negligible prevalence in 1988, HIV spread very quickly through the Thai population, initially through IDU and later through heterosexual transmission. The Thai government set up an extensive national sentinel surveillance system to monitor the epidemic, followed by an aggressive HIV/AIDS prevention program.
Slide 8: HIV prevalence in sex workers in Thailand
The next slide shows that HIV prevalence among brothel-based sex workers increased to about 30 percent, and has been declining since the mid-1990s.
The prevalence in Thai military recruits peaked at about 4 percent and has been slowly declining.
Slide 9: HIV prevalence in pregnant women and blood donors in Thailand
Similarly, HIV prevalence in antenatal women increased to a peak of a little over 2 percent before slowly decreasing. In the last two years, a small rise in prevalence has been reported. This increase has been attributed to the decline in program resources as a result of the Asian economic crisis, and possibly to complacency.
Slide 10: HIV prevalence among IDU in Thailand
In contrast, HIV prevalence in the IDU population has continued to rise, reaching over 50 percent in 1999.
Slide 11: Factors contributing to the success of the Thai program
The decline in the spread of HIV in Thailand has been attributed to 1) an effective STD control program, 2) early monitoring for decision making, 3) an aggressive education campaign, 4) promotion and enforcement of a 100 percent condom-only brothel policy, 5) the availability of and access to affordable condoms and 6) the political and financial commitment of the government to HIV prevention, and 7) the involvement of the business community.
Thailand is an excellent example of a country that responded early and aggressively, committed adequate resources, and implemented large-scale, technically sound interventions.
The continuing rise of infection in IDU suggests that harm reduction programs have not been successful. The recent rise in HIV prevalence in pregnant women is a warning that even in successful programs, complacency can reverse the progress that has been achieved.
Early signs of success in Cambodia
Cambodia has the most serious epidemic in Asia, with prevalence of up to 52 percent in sex workers and an average of 33 percent. In pregnant women, the range is 0 percent to 8.6 percent, with an average of 2.6 percent. The government's response includes a comprehensive and multi-sectoral strategy that includes a 100 percent condom-only brothel program.
The epidemic in Cambodia has progressed rapidly in both the high-risk and general populations, following a pattern not unlike that of Thailand.
The following slides show HIV prevalence in various sentinel population groups.
Slide 12: HIV seroprevalence in sex workers in Cambodia
The trend in HIV prevalence among sex workers appears to have stabilized in recent years, and even shows a slight decline between 1998 and 1999.
Slide 13: HIV seroprevalence in sex workers by age in Cambodia
This decline is more pronounced in sex workers younger than 20 years old.
A similar trend is observed among policemen.
Slide 14: HIV seroprevalence among policemen in Cambodia
The serological trends are supported by behavioral trends. Behavioral data show reductions in risk behavior in Cambodia over the last four years.
Slide 15: Always condom use with clients
This slide shows that the percentage of sex workers reporting that they always use condoms with their clients has risen steadily, and has reached a high level.
Even though we need more data points for the HIV prevalence before we can conclude that Cambodia's epidemic is stabilizing, these data are encouraging because they indicate that high levels of condom use between sex workers and their clients can interrupt transmission. Similar trends were observed in Thailand earlier in the course of that country's epidemic.
The Cambodia example is unique in showing what can be achieved with relatively limited resources and with an infrastructure crippled by years of civil war.
Low and stable HIV infection rates in Senegal
Senegal has maintained one of the lowest rates of HIV infection in sub-Saharan Africa. Since 1998, the prevalence of HIV in Senegal has remained relatively low in both urban and rural populations.
The next two slides show the rapid and progressive spread of HIV among pregnant women in South Africa and other African cities.
Slide 16: HIV prevalence in pregnant women in South Africa
Slide 17: HIV prevalence in pregnant women in selected African countries
In contrast, data from sentinel sites in four urban areas in Senegal, collected from 1989 to 1996, show that the prevalence of HIV in pregnant women has remained low: between 0.1 percent and 1.6
Slide 18: HIV prevalence among pregnant women in Senegal
Slide 19: HIV prevalence among sex workers in Senegal
HIV prevalence was higher in female sex workers over the same period, but is still much lower than sex worker prevalence rates in other African countries. Both HIV-1 and HIV-2 show the same trends over time.
Results of a cohort study revealed that there were almost no new infections among pregnant women between the ages of 15 and 24 in the capital, Dakar.
There is no corresponding data to monitor changes in behavior over this period, but condoms are reported to be readily available. Sex workers report over 90 percent usage of condoms with clients.
The low levels of HIV infection in Senegal have been attributed to an early and comprehensive prevention program. Other factors may account for the lower risk and vulnerability to HIV found in Senegal.
These include high rates of male circumcision and reported low consumption of alcohol. One of the unique aspects of the Senegal program is the legalization of commercial sex and the use of registration as a non-punitive entry point for health services.
A declining epidemic in Uganda
Uganda is one of the most severely affected countries, with a total HIV prevalence among adults of almost 10 percent. It is also one of the countries where the epidemic was recognized early and where it has enjoyed tremendous political leadership, as well as commitment of adequate financial resources to the problem. Significant declines in HIV prevalence have been reported in young pregnant women in some urban areas.
The next slide shows the decline in HIV prevalence in antenatal clinics in selected sites in Uganda.
Slide 20: HIV prevalence in selected antenatal clinics in Uganda
The decline is even more marked in the 15- to 19-year age group. At one site, the prevalence in women ages 15 to 19 dropped from 22 percent to 10 percent, after reaching a high of 28 percent. The steady drop for the youngest women suggests a decline not just in HIV prevalence, but also in incidence.
Slide 21: HIV prevalence by age group, Nsambya, Uganda
Behavioral data appear to support the changes in prevalence. Reported condom use among both men and women increased for all age groups between 1989 and 1995.
Slide 22: Condom use in urban men in Uganda
Slide 23: Condom use in urban women in Uganda
Discussion (slide 24)
How successful are HIV prevention programs? I believe that prevention efforts are having a greater impact on the global epidemic than we realize. The studies and programs I have described simply represent the few with adequate evaluation data to demonstrate the impact of prevention efforts. However, we need to ensure that all prevention efforts are technically sound, represent successful approaches and have adequate coverage to have any real impact.
Slide 25: Factors common to successful programs
What does it take to have a successful prevention program ?
What can we learn from the success of national programs in these four countries? This slide shows some factors common to successful programs: political leadership and financial commitment; an early start to interventions; adequate resources; large-scale interventions involving all relevant sectors; sound technical strategies; and a good source of evaluation data to guide implementation and document progress.
One of the major reasons for the continuing spread of HIV is the lack of adequate resources to support prevention and care programs in developing countries.
In 1999, the U.S. government spent about $800 million on its domestic HIV prevention programs and $7 billion for domestic care and assistance programs out of a total HIV/AIDS budget of nearly $10 billion.
In contrast, the total amount spent in developing countries on both prevention and care was about $600 million. Of this total amount, about 50 percent was contributed by national governments. World Bank loans constituted 23 percent, 19 percent was provided by bilateral and multilateral donors, and 9 percent by UN agencies.
The 1996 Harvard study found that four countries -- Brazil, Thailand, India and Uganda -- accounted for over two-thirds of the total national government expenditures of 266 million dollars. Brazil accounted for over half, due to the government policy of providing antiretroviral therapy to all HIV-positive persons. Thailand spent 74 million dollars and Uganda, 38 million dollars. It is no surprise that Thailand and Uganda have had program successes in prevention as a result of the substantial investment of resources in their HIV/AIDS programs.
The Harvard/UNAIDS study revealed large differences in spending for HIV/AIDS activities among countries -- differences that are often unrelated to the severity of the epidemic or to the ability to pay.
Slide 26: Global HIV incidence and program expenditures
The next slide shows the relation between the incidence of new infections and the level of funding from the United States, the largest international donor to HIV/AIDS programs. It demonstrates that the level of U.S funding has not kept pace with the growth of the epidemic. Actually, when adjusted for inflation, the funds made available by all the major donors per HIV-positive person, were more than halved between 1988 and 1997.
Unless we allocate enough resources to control the epidemic, country success stories will be the exception rather the rule. UNAIDS estimates that we need at least 3 billion dollars a year for prevention in developing countries, a lot more if care needs are included.
Recommendations (slide 27)
There are a number of recommendations I could make to improve the impact of HIV prevention programs on the global HIV/AIDS pandemic. I will limit these recommendations to the five most important ones that will make the most difference.
Slide 28: Recommendations
The first is: Increase resources available for HIV prevention. Program resources may be enhanced in several ways.
Slide 29: Increasing program resources
Community involvement: Involving both those living with and affected by HIV, as well as those living without HIV, in interventions in their own communities is one of the most important ways of sustaining an HIV prevention program, both in terms of resources and sustaining lower risk and vulnerability to HIV.
Private sector involvement: Especially in developing countries, the public sector cannot afford to bear the cost of the HIV/AIDS epidemic alone. Industry and the business sector -- especially the multinational corporations -- should share this burden
Increases in public sector resources: Governments facing competing pressures for resources must recognize that HIV prevention is a good investment. Providing adequate human and fiscal resources to prevent HIV today will reduce the cost of care and management later.
Increase donor support: HIV prevention will not be possible in most developing countries without donor support. Donor support is grossly inadequate in the face of a rapidly growing epidemic.
Resources from loans: Countries that cannot raise adequate resources for HIV prevention should "bite the bullet" and obtain "soft loans." Given the devastating social and economic impact of HIV/AIDS, this approach is justified for economic as well as public health reasons.
Debt relief: is essential, especially for the heavily indebted poor countries, to free resources from the servicing of debts for HIV/AIDS prevention and care as well as much needed development programs.
My second major recommendation is to develop large-scale, comprehensive and sustainable prevention programs. A comprehensive program should consist of both prevention and care, including access to therapy. Programs should cover a large segment of the at-risk population to be effective. We know what works, but we need to do more of it and on a larger scale to have any significant impact on the epidemic.
My third recommendation is to develop and enforce public policies that will enhance and support HIV/AIDS prevention and care and help eliminate stigma. The AIDS epidemic is an urgent and serious public health problem and cannot be treated "as business as usual." We need bold, innovative and aggressive public health measures to slow the epidemic. This will take measures that are unpopular and even controversial, such as making condoms available to youth, selective mass treatment for STD in high-risk populations, access to ARV, supportive environments for harm reduction programs and harsh penalties for discrimination and violence against people living with HIV.
Prevention efforts will not be successful until we are able to eliminate the stigma associated with HIV and the resulting discrimination against people living with the virus.
Fourth, we need to increase the resources for, and improve the availability and access to, therapies for the treatment of STD, TB, and HIV disease.
Fifth, HIV/AIDS prevention and care programs need to develop linkages with development programs and ensure that we are able to modify the environment to reduce the risk and vulnerability of society to HIV. I would like to endorse Roy Anderson's call for us to do a few things well for most of the populations at risk. It is nave for us to think that with our limited HIV/AIDS resources, we can change overnight the developmental and societal inequities that exist in developing countries.
Conclusion (slide 30)
In 1993, at the Ninth the International Conference on AIDS in Berlin, I gave a presentation entitled: "HIV prevention: Is it working?" I'm sorry to say that my recommendations today are almost identical to the recommendations I made seven years ago. The HIV/AIDS epidemic continues its relentless spread, and the response is still woefully inadequate in most countries. More than 5 million people become infected every year, yet denial and discrimination still prevail.
The program experiences that I reviewed today suggest that success in HIV prevention is achievable, even in resource-constrained settings. We need to apply the lessons learned from successful programs to other settings and expand the coverage of prevention programs.
We need to double our research efforts to find a cure, or at least more effective and affordable therapies, to find vaccines for both AIDS and STDs and to find more effective microbicides. We also need to improve our understanding of the factors -- behavioral, epidemiological and contextual -- that contribute to the differences between the epidemics in Senegal and the Philippines compared to those in Cote d'Ivoire and Thailand.
New and more effective antiretroviral drugs have reduced AIDS morbidity and mortality and the transmission of HIV from mother to child. They may even have reduced sexual transmission of HIV -- but only in industrialized countries. These drugs are still beyond the reach of most people in the developing world.
The human race is capable of the greatest acts of kindness and compassion. Yet we spend more resources fighting each other than saving each other. If a neighboring country were to attack another and kill 700 people every week, there would be international outrage -- especially if that country was in Europe. Yet that's how many people die every week from AIDS in Zimbabwe, a country with a population of only 11 million. The Western world spent several billion dollars on the wars in Iraq and Kosovo to stop aggression and injustice. Yet we cannot provide enough resources to fight an aggressive virus that has already killed more people than two world wars. African countries with devastating AIDS epidemics and struggling economies also spend their scarce resources on military conflicts and on defense against imaginary enemies, while the real enemy, the HIV epidemic, rages on in their countries.
We know what we need to do. We know that HIV prevention can work. How many more people must die before we find the will and the resources needed to make prevention and care work for everyone?
