Preventing sexually transmitted diseases and HIV infection

World Health • 51st Year, No. 6, November-December 1998 3 Preventing sexually transmitted diseases and HIV infection Thierry E. Mertens & Michel Carael F aith in biomedical technology could lead us to wait for a vac-cine or cure for HIV I AIDS. However, even with tremendous increases in commitment and re- sources for a vaccine, tens of mil- lions of new infections will occur before one is widely available. What has prevention involved so far? Preventing new HIV infections involves changing people's behav- iour related to sex, drug injection and medical practice. Most HIV preven- tion efforts to date have attempted to influence the choices that individuals . make about risk-taking behaviour. · The theories that have informed prevention programmes until re- cently have identified the basic interventions needed to prevent sexual transmission of HIV: firstly, promoting safer sex and condom use, and secondly, encouraging people to seek care for sexually transmitted diseases (STDs) while trying to improve STD case management and services. Additional approaches to sustaining individual behavioural change have included training in prevention skills, decision-making, problem-solving and resisting social pressures. These efforts still need to be expanded and strengthened. The effectiveness has been shown of comprehensive and early sex education, community action, wide coverage of advertising and market- ing, and drug treatment for injecting drug users, with access to clean needles as part of a prevention and care package. First and foremost, condoms and voluntary testing and counselling services need to be made widely available and accessible. Meanwhile AIDS has become an established disease in much of the world, exerting heavy pressure on health systems and development. New vulnerable populations continue to emerge, especially among young people and marginalized groups, calling urgently for both targeted and general population prevention strategies. Threats to prevention Denial, complacency and discrimina- tion continue to be the greatest threats to effective prevention of HIV infec- tion and STDs. In Thailand, a policy aimed at 100% condom use in broth- els was initiated as early as 1988 by the Ministry of Public Health, and led to a dramatic increase in condom use by men. Unfortunately, many coun- tries continue to go through a period of denial that HIV poses any prob- lem, so they do not take an effective . approach early enough. Instead, they pay lip service to prevention and reassure themselves by focusing on inappropriate approaches such as monitoring population groups in which there is no epidemic (for example, among pregnant women and children) until HIV reaches them too. The dramatic changes and im- provements in HIV therapies could also threaten HIV prevention. Thanks to antiretroviral drugs admin- istered to pregnant women, it is possible to reduce significantly mother-to-child transmission of HIV in some settings. New combination therapies have changed the response to the epidemic in industrialized countries. But these therapies are unlikely to be available in many countries for a while, notwithstand- ing the expectations of people living with HIV. This uneven access has tremendously increased the pressure on governments to spend more At the World AIDS Conference in Geneva last June, a boy holds a poster oF the Famous Brazilian Football player Ronaldo, advocating safe sex to protect against HIV. Photo UNA/05/ IFCR/l Passah money on care. The advent of new therapies could effectively hijack the agenda for increased efforts in pre- vention, if prevention remains un- linked to care. Challenges to HIV prevention In this evolving environment, the paradigm of "integrating prevention with care" should be strengthened and put in the front line of future strategic planning. A flexible ap- proach is needed, with HIV preven- tion being integrated into all services in the health and other sectors, in- cluding those of private doctors, workplaces and pharmacists, and education targeted at vulnerable populations. As HIV continues to spread in developing countries, there is grow- ing recognition that individual be- haviour occurs in a complex social and cultural context. To remove sexual and drug-taking behaviour from its broader environment is to 4 ignore the role of peer influences, emotions, cultural beliefs, marriage systems, community structures and access to basic services. Individual risk factors may explain who is more likely to become HIV-infected in a given population, but may not indi- cate the determinants of HIV preva- lence in a particular community. Such determinants include poverty and poor access to information adapted to each sociocultural con- text. The risk ofHIV also dramati- cally increases with disasters, wars, and political and economic crises. HIV I AIDS prevention programmes are therefore focusing increasingly on social environments, gender relations, conflict resolution, human rights and socioeconomic inequalities as factors that encourage or prevent risky behaviour. A better understanding and modification of these factors will bring about socially desirable behaviour. In the medium and long term, changes in these factors are likely to have a large impact on HIV transmission. Changing norms and values with regard to risky sexual behaviour and injecting drug use requires the partic- ipation of community organizations and social movements. Intolerance of marginalized groups and discrimi- nation against them are immensely counterproductive as Jonathan Mann was already pointing out in 1989. In addition, the people themselves have to be involved and participate ac- tively in designing and conducting prevention activities. The human rights perspective- including respect for the rights of sexual partners - is too often hampered by laws and practices that restrict the participa- tion of the people most affected in making decisions that have an impact on themselves and their environment. Medical and paramedical profes- sionals need to enable community workers to reach out and deliver basic services including condoms and STD treatment. Medical and paramedical practitioners, and the whole range of community workers, need to take every opportunity in talking with men and women, be they patients or not, to foster behavioural changes and adoption of condom use. This is one of the most impor- tant challenges, since evidence from most parts of the world suggests that fewer than 20% of practitioners promote condom use during consul- tations for STDs, or encourage patients to send along their partners. It is also recognized that societies and cultures are changing and that epidemics evolve with those changes. The example of Eastern Europe has reminded us how an HIV epidemic can suddenly arise follow- ing drastic changes in socioeco- nomic conditions, such as those which followed the demise of the USSR. Increased labour migration linked with the post-industrial glob- alized economy is also an important factor in the spread of HIV, since mobility is a primary cause of changing behaviour and seeking new sexual partners. The HIV epidemic is dynamic, so prevention efforts must be dynamic as well. Finally, the single most important challenge for limiting the epidemic is reaching the largest possible vulnerable population with preven- tion programmes. In the past five years, evidence has accumulated to show that broad coverage based on community action and comprehen- sive service delivery, hand in hand with care and impact alleviation, lead to a decreased incidence of HIV. World Health • 51st Year, No. 6, November-December 1998 By dramatically increasing access to services and information in the short term and modifying the envi- ronment of risk in the longer term, the course of the global epidemic can be changed. Let us not forget that tuberculosis declined in the industri- alized countries (at least until vigi- lance declined) thanks to a very broad change in living conditions. • Or Thierry E. Mertens is the WHO Representative in Nepal, P.O Box 108, Kathmandu, he was formerly Director of the Department of H/V I AIDS and Other Sexually Transmitted Infections at WHO headquarters in Geneva . Or Michel Carael is Prevention Team Leader, Department of Policy, Strategy and Research, joint United Nations Programme on HIV I AIDS (UNA/OS), 121 I Geneva 27, Switzerland. "HIV is one of the most serious health problems facing the world, with the current si tuation worse than anticipated in the early 1990s. lt is a sign ificant obstacle to development, striking the workforce in its most productive years. Hard-won gains in child survival and adult hea lth are suddenly neutralized. Structures of entire soc ieties are threatened, health systems destroyed. Our choice is as simple as it is cri tical: WHO w ill increase its efforts on HIV / AIDS by ensuring a better integration of HIV-specific activi ties in all relevant programmes. Such activities wi ll be undertaken in a well- coordina ted fashion throughout the Organization , and core resources wil l be devoted to them. They wil l occur in close cooperation with other partners within the framework of UNAIDS. " Gro Harlem Brundtland, MD, MPH Director-General World Health Organization 21 July 1998