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HIV Prevention What have we learned, what remains to be done?

Peter Aggleton School of Education and Social Work, University of Sussex. HIV Prevention What have we learned, what remains to be done?. Thank you. Judy Auerbach, San Francisco Carlos Caceres, Lima Liviana Calzavara, Toronto Mary Crewe, Pretoria Gary Dowsett, Melbourne

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HIV Prevention What have we learned, what remains to be done?

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  1. Peter Aggleton School of Education and Social Work, University of Sussex HIV PreventionWhat have we learned, what remains to be done?

  2. Thank you • Judy Auerbach, San Francisco • Carlos Caceres, Lima • Liviana Calzavara, Toronto • Mary Crewe, Pretoria • Gary Dowsett, Melbourne • Geeta Rao Gupta, New York • Susan Kippax, Sydney • Ajay Mahal, Boston • Ted Myers, Toronto • Jessica Ogden, New York • Richard Parker, Rio de Janeiro • Justin Parkhurst, London • and many others

  3. Global ContextUNAIDS Report on the Global AIDS Epidemic 2010 • In 2009, estimated 2.6 million people became newly infected with HIV -- more than one fifth (21%) fewer than the 3.2 million in 1997, when annual new infections peaked • In 33 countries, HIV incidence has fallen by more than 25% between 2001 and 2009; 22 of these countries are in sub-Saharan Africa. • Largest epidemics in sub-Saharan Africa—Ethiopia, Nigeria, South Africa, Zambia, and Zimbabwe—either stabilised or showing signs of decline • But, between 2001 and 2009, incidence increased by more than 25% in seven countries, including five in Eastern Europe and Central Asia (including Bangladesh, Philippines, Uzbekistan)

  4. AIDS-related deaths decreasingUNAIDS Report on the Global AIDS Epidemic 2010 Number of annual AIDS-related deaths worldwide is steadily decreasing from the peak of 2.1 million [1.9 million–2.3 million] in 2004 to an estimated 1.8 million [1.6 million–2.1 million] in 2009 (Figure 2.3). The decline reflects increased availability of antiretroviral therapy, as well as care and support, to people living with HIV, particularly in middle- and low-income countries; it is also a result of decreasing incidence starting in the late 1990s.

  5. HIV prevention worksUNAIDS Report on the Global AIDS Epidemic 2010 • Dedicated efforts to promote and support combination HIV prevention are producing clear and impressive results. • HIV prevention programmes must include a combination of behavioural, biomedical, and structural responses, and these activities should operate in synergy.

  6. Here in the UK

  7. Here in the UK

  8. The present context – light and shade • Treatment optimism • De-prioritisation of HIV amidst other health concerns • Belief that AIDS has gone away (except in Africa)

  9. Gay men New diagnoses among men who have sex with men (MSM) remain high (3,080 in 2010 – highest number ever); four out of five probably acquired their infection in the UK . Over 110% increase since 1999 (1450 cases) One in six MSM, and one in sixteen heterosexuals newly diagnosed with HIV in 2009 had acquired their infection within the previous 4-5 months before diagnosis.  Half of adults were diagnosed with HIV at a late stage of infection in 2009 (CD4 counts less than 350 per mm within three months of diagnosis), the stage at which treatment is recommended to begin.  Source: HIV in the United Kingdom: 2010 Report. Health Promotion Agency

  10. Heterosexual contact The estimated number of people infected through heterosexual contact within the UK has increased from 540 new diagnoses in 2003 to 1,130 in 2009, and has increased, from 11% (540/4,800) in 2003 to 31% (1,130/3,560 in 2009, as a proportion of all heterosexual diagnoses during this period. Source: HIV in the United Kingdom: 2010 Report

  11. Young people In the UK in 2007, there were 702 new diagnoses of HIV among young people (10 per 100,000), which is nearly three times the number reported in 1998 (258)

  12. Injecting drug users The annual number of new HIV diagnoses among injecting drug users fell between 1992 and 2000, but has gradually risen over the past few years. 170 HIV diagnoses, where infection was thought to have been acquired through injecting drug use, were reported in the UK for 2009 Source: HIV in the United Kingdom: 2010 Report. Health Promotion Agency

  13. Older people • HIV infected adults aged 50 years and over accessing care more than tripled between 2000 and 2009, from 2,432 to 12,063, representing one in five of all adults seen for HIV care in 2009 • New diagnoses among older adults more than doubled between 2000 and 2009, and accounted for 13% of all diagnoses in 2009. Two-thirds (67%) were diagnosed late, with a CD4 cell count less than 350 per mm3 Source: HIV in the United Kingdom: 2010 Report. Health Protection Agency

  14. Official UK government position ‘The UK is a relatively low prevalence country for HIV infections as a result of sustained public education and health promotion campaigns’ http://www.dh.gov.uk/en/Publichealth/Healthimprovement/Sexualhealth/HIV/index.htm

  15. Political economy of HIV prevention • Increasing normalisation • Increasing biomedicalisation • Simplified view of drivers (e.g. lack of knowledge of HIV status) • Overly simple remedies (e.g. better health services) • Limited understanding of valid knowledge (e.g. RCTs) • Lack of memory of what has been learned in the past

  16. Some preconditions for success • Social solidarity • Sense of inequity and injustice • Generalised reciprocity • Dense and overlapping networks of communication • Community trust • Cultural templates for success • Properly comprehensive response

  17. Combination prevention • Need to • move beyond the search for ‘magic bullets’ • move beyond simplistic ‘interventions’ • value the importance of a programmatic approach • combine actions to maximise the likelihood of success

  18. Comprehensive prevention …… involves all the strategies required to prevent transmission of HIV. These include AIDS education; behaviour change programmes for young people and vulnerable populations; promotion of male and female condoms, along with abstinence, being safer through fidelity and reducing the number of partners; voluntary counseling and testing; prevention of mother-to-child HIV transmission; preventing and treating sexually transmitted infections; blood safety, prevention of transmission in health care settings; community education and changes in laws and policies to counter stigma; vulnerability reduction through social, legal and economic change; and harm reduction programs for injecting drug users. Adapted from http://data.unaids.org/Publications/Fact-Sheets04/FS_Prevention_en.pdf

  19. Effective prevention requires engagement with • Social vulnerability • Individual risk • Impact of HIV on communities • Generational continuity and change

  20. Structural approaches • Single policy or programmatic actions • Multiple structural actions to catalyse change • Regardless of type, structural approaches • Address factors that influence individual behaviour • Change social, economic, political and environmental factors affecting HIV-related vulnerability and risk in specific contexts

  21. Structural approaches • Syringe and needle exchange worldwide • So-called ‘100%’ condom use programmes in Dominican Republic, Thailand and other countries • Program H, working with young men in Brazil • IMAGE Project in South Africa

  22. Some notes of caution • Recognizing the importance of context cautions against • assuming there is any one ‘blueprint’ for success • assuming effects of a programme will be same in different settings • Context (time, place, group) really does matter

  23. Neither poverty nor wealth is a social driver per se; rather, it is the context in which some people are wealthy and some people are poor that can lead to relational patterns resulting in forms of sexual networking that can spread HIV. Poor people in some settings may be more likely to engage in particular practices—perhaps earlier onset of sexual activity, or occasional transactional sex—which may increase risk of infection. Wealthy people in some settings may find that their wealth permits greater social and sexual networking, or allows them to have a higher number of regular sex partners—a pattern that may place them at risk, as well. Context determines the nature of social/sexual arrangements, which interact with both poverty and wealth to contribute to greater or lesser vulnerability. J. Auerbach, J. Parkhurst, C. Caceres and K. Keller (2009) Aids2031 Social Drivers paper

  24. One way forward • Causes of social vulnerability • Distal (national policies and laws) • Proximal (being in prison or being in football/rugby/cricket team) • Focus of programmatic action • Individual • Group • Community as a whole

  25. In conclusion • Important to address social structure in HIV prevention • Changing political economy of HIV • Value of an inclusive and comprehensive approach to HIV prevention • New conceptual tools at our disposal • Importance of partnership for success

  26. Thank you

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