Report of the Strategic Meeting on Prevention (HIV and STDs)
Geneva, 5-7 October 1994
Introduction
By mid-1994, a cumulative total of over 17 million men, women and children
globally were estimated to have contracted HIV infection. WHO estimates that
every 24 hours more than 6000 people become infected. By the year 2000, a
further 14 to 24 million people worldwide may acquire HIV infection, bringing
the total to 30-40 million, and the epidemic is projected to continue well
into the next century.
HIV had a head start, spreading widely in a few countries in 1970s and early
1980s. But now we know what causes AIDS and how HIV is transmitted. We have
learned from a decade of experience that certain approaches to prevention can
and do work.
Situation analysis
A comprehensive HIV prevention programme should include approaches which
address immediate HIV transmission mechanisms and approaches which address the
underlying factors in the environment. There is no standard, universally valid
package of approaches. Rather, these need to be selected according to the
local context and tailored to the needs of the target population. However, there
is evidence that approaches have a better chance of producing the desired
result when a number of them are combined.
A supportive environment
One of the most important lessons learnt over the past decade is that a
supportive environment is vital to the success of efforts to prevent the
transmission of HIV through sex and drug use. A supportive environment is one
in which safer behaviour is made easy, accepted and even routine. It is an
environment with:
- no barriers to the dissemination of information on HIV prevention (e.g. national policy
prohibiting sexually frank messages in the mass media)
- no barriers to people effectively receiving and understanding this information (e.g. illiteracy,
lack of access to printed or other media)
- no barriers to people acting on the information they receive (e.g. economic necessity for a sex
worker to accept clients who refuse to use a condom).
Such an environment is rare. The typical backdrop to HIV prevention includes
sexual and socioeconomic subordination of women; economic factors fuelling
migration; discriminatory practices; poverty; intolerance; lack of AIDS/STD and
sexual health education in schools; inaccessible health (and especially STD)
services; and laws that heighten the vulnerability of marginalized populations.
It is even claimed that in many countries, only affluent, well educated
city-dwelling males may be capable of protecting themselves from HIV. While
almost certainly an exaggeration, this reflection points up how far we have to
go in building a supportive environment.
Some effective approaches
A number of approaches have been shown to reduce sexual transmission of the
virus. Communication to promote safe behaviour needs to offer a range of
options, from abstinence and mutually faithful relationships to non-penetrative
forms of sex and intercourse protected by condom use. This approach needs to be
coupled with condom promotion and provision. A similar harm-reduction approach
combining communication to promote safe behaviour along with support services
is effective in reducing HIV transmission through injecting drug use.
The prevention and treatment of other sexually transmitted diseases (STDs) is
important as well. WHO estimates that 150 to 300 million curable sexually
transmitted infections occur annually. If left untreated, they can increase
HIV transmission as much as 5 to 10-fold. STDs cause both acute illness and
serious long-term complications such as infertility and ectopic pregnancy. In
developing countries, the World Bank ranks STDs as the second greatest health
problem (after maternal mortality) for women aged 15 to 44. STDs are thus a
public health priority in their own right.
Communication to promote safer sexual behaviour
The main approaches under this heading are communication through the media and
interpersonal communication.
The role of the media in promoting family planning is well documented. More
recent evidence shows that communication through the media can also improve
AIDS knowledge and attitudes and increase safe sexual practices. The "Stop
AIDS" campaign in Switzerland contributed to a 42% rise in condom use among
young people aged 17 to 30.
Institution-based interpersonal communication is important,
especially in schools and workplaces. WHO has evidence suggesting that half of
all new infections and 60% of female infections in mature African epidemics
may now be occurring before age 20, which underscores the importance of school
AIDS programmes. A recent WHO review demonstrates that school education about
sexual and reproductive health promotes more responsible sexual behaviour
without increasing sexual activity. Indeed, many studies have shown it has the
contrary effect, i.e. a delaying in the onset of sexual intercourse in many
studies. In a recent review of 7 Zimbabwean workplace AIDS programmes, a
reduction in STDs was reported by each of the 5 programmes for which STD data
were available (median reduction 59%, range 47%-80%).
Community-based interpersonal communication has proved effective
in many contexts. Within one year, a peer education programme in the United
Republic of Tanzania increased condom use among truck drivers from 54% to 74%
and another programme in Mexico increased condom use among sex workers from
50% to 80%.
Condom promotion and provision
Laboratory, clinical and epidemiological studies prove that condoms are an
effective and practical way of reducing transmission of STD and HIV. There are
4 complementary approaches to condom promotion: private sales, public
distribution (e.g. in family planning clinics), social marketing, and community-based
distribution.
Condom social marketing, which borrows from market research, marketing
techniques and communication research, is an effective approach to promoting
the sale of subsidized condoms through existing commercial and informal channels.
For example, sales in Zaire increased from 100 000 in 1987 to over 18 million
in 1991. Overall in Africa, condom social marketing sales soared from under
1 million in 1988 to 77 million in 1993.
Community-based distribution usually involves free distribution of
condoms to socially or epidemiologically vulnerable groups, women as well as
men. In Thailand from 1992 to 1993, the government supplied condoms to the sex
industry and initiated sanctions against sex establishments (not sex workers)
where condoms were not consistently used. From 1989 to 1993, condom use among
sex workers increased from 14% to 94% and monthly STD incidence declined from
between 15% and 25% to between 0.3% and 0.5%. Between 1989 and 1993, reported
STDs among men declined by four-fifths nationwide.
Communication and services for safer drug-related behaviour
The harm-reduction options that need to be communicated to injecting drug users
range from stopping drug use to switching to safer forms (e.g. smoking), to
injection with sterile or cleaned equipment only. The accompanying services
include detoxification programmes, outreach, and needle exchange or other forms
of access to clean equipment. A recent study presents strong confirmation that
HIV epidemics in injecting drug users can be prevented by: (i) launching HIV
prevention efforts early, before 5% of drug injectors become infected; (ii)
providing community outreach to communicate about safer behaviour and build
trust between users and health care workers; (iii) ensuring legal access to
sterile injection equipment. Of the 22 cities studied, only the five cities
that used all three approaches still have infection levels under 5% in their
drug-injecting population. This is a good example of a supportive environment.
In contrast, repressive measures such as jail sentences or forcible isolation
will drive users away from harm-reduction programmes and hamper efforts to
keep them and their sex partners free of infection.
STD prevention and care
A study in Zaire provided STD care, condoms and one-on-one education to 531
women. Over 3 years, HIV incidence declined from almost 12 per 100 woman years
in the first six months to under 5 per 100 woman years in the last six months,
demonstrating how much impact comprehensive STD services can have on HIV
transmission. An effective STD prevention and care programme should include
safer sex promotion in the general population, encouragement to seek care
quickly if an STD is suspected, treatment for symptomatic individuals,
detection of syphilis in pregnant women, and prophylaxis for neonatal eye
infection.
Barriers to more effective HIV prevention
If effective prevention approaches exist, why are more than 6000 people a day
still becoming infected with HIV? The reasons range all the way from human
rights infringements to political reluctance to engage the epidemic with the
frankness and decisiveness needed.
Unsupportive environment
HIV spreads along the fault-lines of society, pointing up the myriad social
and economic problems that remain unsolved. In the broadest sense, therefore,
building a supportive environment requires measures to: improve the status of
women; protect the human rights of individuals with HIV and socially
marginalized groups; improve the stability of families by reducing displacement
and homelessness; and increase access to health, social and legal services. In
the context of HIV/AIDS, what matters is to implement simultaneously approaches
that are capable of yielding short-term results (e.g. collective action by sex
workers to raise their charges so that they can afford to refuse clients
unwilling to wear a condom) alongside approaches which will bear dividends
only over the long term (e.g. improving women's legal status, educational
access and income-generating potential).
Reluctance to accept need for harm reduction
Some believe that safer-sex and other harm-reduction messages condone and even
encourage transgressions from the moral code. They would prefer to encourage
only abstinence from drugs, sexual abstinence and fidelity. However, there is
no doubt that a proportion of people cannot or will not restrict themselves to
these options. Giving people the full range of safer behaviour options can
only be described as a life-saving measure in the AIDS era.
Reluctance to acknowledge risk behaviours
A related problem is failure to acknowledge the existence within a country of
certain lifestyles or behaviours, such as drug injecting, sexual intercourse
among young people, or homosexual or bisexual practices. This creates barriers
to the introduction of the kinds of prevention programmes that have slowed the
spread of HIV in other countries.
Inadequate appreciation of the community's central role
The importance of community leadership, participation and activism has been
amply demonstrated, for example by the pioneering prevention efforts of the
gay community in developed countries. Not all countries have risen to the
challenge of providing helpful outside support to their communities.
Delayed response
The earlier a society responds to AIDS, the more cost-effective its efforts.
Very early prevention programmes can concentrate their resources on the
empowerment and protection of groups at highest risk of HIV, preventing an
initial explosion of infections among these groups and thus averting the
subsequent increase in transmission in the larger community. Notwithstanding
the benefits of early action, many countries delay vital programmes, losing
opportunities that will never return.
Piecemeal and small-scale prevention approaches
Few countries have programmes which concurrently combine communication to
promote safer sexual behaviour, condom promotion, and STD prevention and care.
Yet mathematical models suggest that combining partner reduction, condom use
and STD treatment magnifies their individual effects. This synergism is not
yet exploited to the full in HIV prevention strategies. Even successful local
and community initiatives remain limited to specific communities or geographic
areas, instead of being transformed into comprehensive, large-scale,
nationwide programmes. Relatively few countries have revamped their legislation,
policies and enforcement practices to provide a supportive environment for HIV
prevention.
Misguided prevention approaches
The evidence indicates that compulsory HIV testing is neither required nor
helpful for effective HIV prevention. Being a violation of human rights, it can
even have a chilling effect on prevention programmes. Yet many societies
continue to advocate this inappropriate approach.
Insufficient funding
WHO estimates that US$2.5 billion annually could fund basic prevention programmes
in developing countries and thereby avert 10 million infections by the year 2000. While
this is 10 times more than is spent today, it is not a prohibitive amount. For example,
basic prevention in Asia would cost approximately US$1.5 billion annually, which
represents 0.03% of Asia's economic output. However, the lowest-income countries are
unable to mount even this effort without external assistance.
Inadequate political commitment
A few countries have shown decisive political commitment in terms of acknowledging the
extent of real HIV/STD risk, endorsing the need for harm reduction, and allocating
sufficient national resources to prevention, but such commitment is needed urgently from
all.
Priorities for action
Enough is known about HIV prevention approaches to save millions of lives in the coming
years. The Paris AIDS Summit could endorse the following principles and national
priorities and launch the global initiatives outlined below.
Basic principles
1. AIDS is a global problem in every sense of the word, affecting people of both sexes and all
ages, and transcending geographical boundaries, cultural identities and social classes.
2. The HIV/AIDS epidemic has spotlighted the need for sweeping reforms of the health and social
sectors in many countries. This opportunity should not be missed, for these reforms promise to be
of lasting benefit to society at large.
3. If the spread of HIV is to be effectively reduced, people living with HIV/AIDS must be actively
involved in planning and implementing prevention programmes.
4. HIV prevention flourishes in a climate of freedom from discrimination, respect for human rights,
and tolerance of individuals regardless of sex, race, class, or sexual orientation. Where there is
good governance and an environment marked by consensus instead of divisiveness, individuals can be
empowered to adopt and sustain protective behaviour.
5. Because of the power of language to reflect and convey values, concepts and distinctions, the
language used in this epidemic needs to be non-discriminatory, non-alienating and inclusive. It should
be the language of choice of those most affected.
6. Community leadership and participation are essential elements in building a climate where safer
behaviour is the norm. Governments must encourage the diversity of responses that emerge within
communities, while respecting their autonomy of action.
7. External assistance to community action against HIV/AIDS must be supportive, not directive. It must
supplement, not supplant, community responses.
8. Individuals should have access to voluntary, confidential (or anonymous) HIV testing and counselling,
and be protected from mandatory testing. There is no rationale for mandatory HIV testing, whether for
the general population or for individuals or groups believed to be at higher risk of infection, and
whether for domestic purposes or in connection with travel, work or study abroad.
9. People who are stigmatized or excluded for whatever reason are especially vulnerable to HIV infection
and need special support to be able to protect themselves. Society must strive to reach out to them
with prevention activities. Because HIV never remains confined to a given group, we will never
successfully protect the larger community unless we protect our most vulnerable populations.
10. All people have the right to the enjoyment of the highest attainable standard of physical and mental
health, including the right to be able to protect themselves from AIDS and other STDs. Therefore:
- no taboo must be allowed to interfere with the diffusion of life-saving information about HIV
prevention, including to children and young people;
- there should be universal access to reproductive and sexual health care services, including a
reliable supply of high-quality condoms;
- no woman must become infected with HIV because economic dependence or social subordination
prevents her from negotiating safer sex or refusing unwanted sex.
11. HIV/STD prevention spending is among the best investments countries can make, returning billions
of dollars in health care savings, production and income.
Priorities for national action
1. Governments in partnership with communities, private and nongovernmental organizations, and
the academic and research community should develop national policy to guide and facilitate all HIV
prevention activities in the country.
2. To ensure rapid, decentralized countrywide implementation of effective HIV/STD prevention
programmes, governments should:
- involve all sectors of society in prevention
- allocate substantial national resources
- provide financial or technical support to community initiatives
- tailor prevention activities to the frame of reference of the population they are intended for
- link them closely with care so that they are credible
- strengthen the training of health care workers and others
- expand the capacity for quality prevention and care across all levels of the health system.
3. Governments should review and revise laws and policies to ensure that they uphold human rights,
prohibit discrimination, and make it as easy as possible for both men and women to take protective
action against HIV transmission.
4. Governments should ensure universal access to an essential package of complementary approaches
that prevent the sexual, drug-related and bloodborne transmission of HIV infection and the other
STDs (including multiple options and technologies for protective sexual behaviours). One hundred
percent of individuals should have access, at a minimum, to prevention information, condoms
(including through social marketing) and effective, non-stigmatizing STD care.
5. To facilitate this access, governments should:
- identify mechanisms for reaching both men and women, whether literate or not, including those
without access to mass media
- remove all barriers to large-scale communication and education programmes
- make time and space available in government-controlled media
- ensure that journalists are adequately informed and allowed to operate without interference
- eliminate any legal and policy barriers to condom promotion, including media restrictions
- abolish duties, taxes and licensing fees for condoms, ensure their inclusion in all essential
drug lists, and safeguard quality control for condoms and other protective products
- offer incentives for private-sector employers who invest in HIV/STD prevention and care
activities
- ensure that prevention programmes reach people who are incarcerated.
6. Research programmes on sexuality are needed to:
- document sexual behaviour
- help develop prevention options/technologies related to specific contexts of risk for HIV
infection.
7. Governments should initiate or strengthen nationwide school AIDS education programmes
emphasizing:
- attitudes that are respectful of women and girls as equals
- good communication and shared responsibility between the sexes on issues of sexuality and
family life
- the specific skills required for HIV/STD prevention.
8. Governments should recognize the specific needs of groups at higher risk of HIV infection and
invest a commensurate level of resources in their protection, being sensitive to the risk of
discrimination inherent in targeted HIV prevention. Focused activities should complement those
intended for the general public. Community initiatives to provide prevention, care and support for
such groups should not be impeded.
9. Governments should establish harm-reduction programmes for injecting drug users and facilitate their
utilization wherever injecting drug use takes place.
Global initiatives
1. Global initiative on greater involvement by people living with HIV/AIDS
The Paris AIDS Summit could launch an initiative to help ensure the success of HIV
prevention through greater participation by people living with and affected by HIV/AIDS,
who are an integral part of the response to the epidemic.
To date, the methods used for preventing HIV transmission have not succeeded in bringing
the epidemic under control. Communities around the world, who are affected to varying
degrees, are seeking new and effective approaches to the fight against HIV.
In 1994, more than ever, the world needs a fresh approach to curtailing the spread of
HIV. The Paris AIDS Summit is convinced that increased participation in prevention by
people with a close personal connection to the epidemic is the approach that has been
missing the approach that can bring success within reach.
Through their commitment during the past decade, based on their unique life experience,
people living with HIV/AIDS and their networks and organizations have given a human face
to HIV/AIDS. By taking an active part in prevention they help safeguard the principle of
non-exclusion in these programmes, increasing their effectiveness. And because they share
the same values as their communities of origin, they have special credibility in helping
create a favourable climate for attitudinal and behavioural changes. As more PWAs have
become involved in prevention, their visibility has encouraged others living with the
virus to be open about their infection status, making it possible for them in turn to
contribute openly to prevention, care and support programmes.
Given the importance of strengthening and accelerating this involvement, the Paris AIDS
Summit could call on WHO (in anticipation of the joint and cosponsored UN programme on
HIV/AIDS) to develop a new global initiative aimed at helping people whose lives have
been touched by HIV/AIDS to be open about their connection with the epidemic, join
together at national level, and work together publicly to stop the spread of HIV and
alleviate the impact of HIV/AIDS.
The global initiative could take the form of a federation of national organizations/groups
working openly in the planning and implementation of prevention, care and support, and
comprising people living with HIV/AIDS and others directly affected, such as their
mothers, fathers, spouses, partners and children. In countries with no public organization
of this kind, the federation could work directly with individuals with the aim of
enabling them to establish one, perhaps by first creating a confidential support group.
The federation could thus:
- work with confidential support groups at the national level to identify individuals
interested in publicly affirming their connection with the epidemic
- provide technical, organizational and start-up financial assistance to nascent national
organizations
- help national organizations to acquire the necessary expertise to defend the rights of
their members, particularly the right to work and not be fired despite disclosure of their
connection with the epidemic
- serve as a safety net of last recourse for national organizations encountering difficulty
in protecting their members
- ensure that violations of the rights of national organizations or their members are promptly
brought to the attention of the Council on Human Rights, Ethics and HIV/AIDS (as proposed by
the Strategic Meeting on Vulnerability to HIV/AIDS)
- facilitate communication between existing national organizations, represent them at
international fora, and help identify and disseminate information about innovative prevention,
care and support approaches devised by member organizations and others.
2. Global mobilization of youth on HIV/AIDS
(An initiative similar to this one was proposed by the Strategic Meeting on Vulnerability to HIV/AIDS)
In an era when half of all HIV infections occur in people under 25 years old and when
the world's youth faces an uncertain future, a worldwide initiative on HIV/AIDS and youth
would focus on a message of hope, solidarity and prevention.
This initiative would mobilize and organize an urgent and worldwide response, building
on leadership by youth and working within local and international youth cultures.
This initiative could operate through collaborative efforts between youth organizations,
communities, NGOs, governments, international groups, the international sports community,
and the private sector, particularly the media, entertainment and publishing industries.
The initiative would be a sustained effort that uses all available resources and
opportunities, such as sports events, concerts and other media events.
It would:
- build on and magnify the scope of national efforts by scaling them up worldwide
- encourage the exchange of ideas and programmes cross-culturally, including south-south collaboration
- facilitate the international production and exchange of information and communication materials, such
as audio and video products, public service announcements, footage and scripts for media programming
- facilitate the easing of copyright restrictions on specific AIDS-related materials
(e.g. documentaries) and find ways of ensuring access to distribution through the media
- build solid and sustainable links between HIV/AIDS programmes, both national and international, and
the mass media and entertainment industries.
The Summit could set this initiative in motion in partnership with youth organizations,
media representatives and communications experts.
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