Risky Behaviors Must Change For HIV Prevention To Succeed

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Radical behavioral changes need to be adopted and sustained by enough people at risk of HIV infection - and they must be part of a comprehensive combination prevention package - if HIV-prevention strategies are to have any chance of success, UCLA AIDS Institute associate director Thomas Coates and colleagues argue in a new paper in the medical journal The Lancet.

Coates and co-authors Linda Richter of the Human Sciences Research Council in Durban, South Africa, and Carlos Caceres of Cayetano Heredia University in Lima, Peru, also call for new initiatives based on behavioral science to be included as part of a future combination prevention framework.

"The radical behavioral change that is needed to reduce HIV transmission requires radical commitment," write Richter, Caceres and Coates, who is also a UCLA professor-in-residence of infectious diseases and director of the UCLA Program in Global Health. "Prevention strategies will never work if they are not implemented completely, with appropriate resources and benchmarks, and with a view toward sustainability. The fundamentals of HIV prevention need to be agreed upon, funded, implemented, measured, and achieved. That, presently, is not the case."

There are far more varieties of sexual expression than are generally acknowledged or sanctioned by the defined legal and moral systems of most societies, the authors say. And substance use — to the point of intoxication — is not only allowed, but is central to many countries' economies, leaving little wonder that attempts to control such substances, especially alcohol, stimulants and injecting drugs, have met with little success.

In addition to decreasing substance abuse, behavioral strategies aim to delay first intercourse; decrease the number of sexual partners; increase the use of protection in sexual acts; provide access to male circumcision; decrease the sharing of needles and syringes; and provide counseling, testing and access to treatment for those who are infected.

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The authors recommend that new initiatives based on behavioral science be added to those based on communications, peer education and other such efforts as part of a combination framework. It is essential that the right programs are initiated, they say.

In the paper, Coates and his co-authors discuss programs such as the U.S. President's Emergency Plan for AIDS Relief, which until recently required that a third of its funds be spent promoting abstinence before marriage rather than on areas evidence suggested needed the most funding. And while these restrictions have been reduced in the recently passed 2008 version of the plan, many advocates feel that the changes are not enough to ensure that all the money is appropriately directed.

There are many challenges facing behavioral-change strategies, according to the authors. Because many people with HIV don't know they are infected, a major task in the developing world must be to ensure that those who carry the virus are made aware of their status. Risk compensation — in which advances in HIV prevention are undone by increases in risky behavior — must also be addressed. And HIV prevention counseling and services need to be a regular part of treatment for HIV-positive patients.

In addition, there is a shocking lack knowledge about HIV among young people, with indications that the target set by the UN General Assembly Special Session — comprehensive HIV knowledge among 90 percent of young people around the globe by 2010 — will not even be half-met.

"Nothing should be more important than a major focus on young people, not only in sub-Saharan Africa but in many other parts of the world as well," the authors write.

Injecting-drug use remains another controversial area, they say. While many governments will not object to their HIV-infected population receiving antiretroviral drugs, a large number, including the U.S., refuse to implement harm-reduction policies to prevent HIV transmission in injecting-drug users.

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