Archives
There is strong agreement that HIV prevention should
There is strong agreement that HIV prevention should focus on approaches that are evidence based, but there is disagreement about how to obtain such rigorous evidence and whether this should refer only to randomised study designs. Pickles and colleagues\' report provides a concrete example of an effectiveness assessment of a large-scale programme that uses a non-randomised design. The investigators make a plausible and convincing case for the effectiveness of the programme with mathematical modelling and data from a series of population-based biobehavioural surveys. They also provide a valid alternative to experimental designs, which are often impossible or inappropriate for complex combination prevention programmes.
The report also presents a convincing case that classic prevention approaches, including peer-led outreach and behaviour change supported by calcium channel mobilisation, and some structural interventions to address stigma or violence, are feasible and effective in preventing HIV. The recent breakthroughs and excitement caused by antiretroviral-based prevention have overshadowed the fact that prevention basics for and by key populations can be highly effective. In southern India, Bradley and colleagues showed that the proportion of sex acts between female sex workers and their clients protected by condoms increased from 16–24% to 81–89% in 5 years, resulting in a decline in HIV and other sexually transmitted diseases in sex workers and in the general population. Condoms are the cheapest, simplest, safest, and most effective instruments to reduce sexual transmission of HIV, but their effectiveness at the population level is determined by adherence. New, promising antiretroviral-based prevention will have to be promoted in combination with condoms, and adherence support will be key. The data from Avahan remind us to bring behavioural approaches and condom promotion back to the centre of the debate for HIV prevention and programming.
Evidence-based prevention planning is also about understanding the HIV epidemic within a country, and providing services to the people at highest risk of acquiring and transmitting HIV. In most countries, key populations such as female sex workers and men who have sex with men have a disproportionate share of the HIV burden, both in concentrated epidemics and generalised epidemics in sub-Saharan Africa. In Kenya, for example, 33% of new infections are attributed to transmissions by these two populations. But, despite these data and the availability of effective approaches, the coverage of prevention programmes is highly inadequate. Worldwide, less than half of countries report to UNAIDS on prevention programmes for female sex workers and men who have sex with men, and the median coverage of programmes is 55%. Whether the non-reporting countries still have no programmes or their programmes are too small in scale to be mentioned is unclear. There are many explanations for this inaction, including cultural or legal barriers, poor leadership and planning, and the fact that same-sex intercourse is highly stigmatised, even criminalised, in many parts of Africa. But this implementation gap remains an unacceptable shortcoming of the worldwide response to HIV.
This report should help to convince policy makers and programme managers worldwide to address this unfinished agenda of targeted HIV prevention. Investments in programmes for key populations and creation of a conducive environment for HIV prevention and human rights can make a great difference to the future course of the HIV epidemic. The evidence from India is overwhelming. The time for scaling up in the rest of the world is now.
With the target date of 2015 for meeting the Millennium Development Goals (MDGs) nearing, studies that examine trends in target indicators by subgroups are valuable contributions to the understanding of whether targets will be met, and can help to identify inequities in indicator trends for certain at-risk populations. For the nutritional target within MDG 1, target 2 aims to halve the proportion of undernourished people between 1990 and 2015. Within this target are two measurable indicators—the prevalence of underweight children younger than 5 years of age and the proportion of the population below the minimum level of dietary energy consumption. Improving trends in average indicator values for national or regional groups can mask substantial lags in vulnerable populations within these larger geographical areas. In the paper by Christopher Paciorek and colleagues in this issue of , differences in trends in under-5 underweight between rural and urban populations are examined by countries and regions from 1985 to 2011. On the basis of the data presented in this paper, it seems that, on average, children in urban areas fare better than their rural counterparts. The urban–rural differences are greater in some regions than others and the trends show variability in the narrowing of the urban–rural gap by regions.