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Preventing HIV/AIDS
EXPANDING ACCESS TO TREATMENT. In the past two
years, pledges of expanded funding for treatment
efforts and the increased availability of generic
ARV drugs have changed the focus of HIV/AIDS programmes.
WHO and its partners in the Joint United
Nations Programme on HIV/AIDS (UNAIDS) have
undertaken the enormous challenge of treating 3 million
people with ARVs by 2005.(30) In Africa in 2003,
only 100,000 people were receiving ARVs, just 2
per cent of an estimated 4.4 million needing treatment.
In South and East Asia, 7 per cent of those
who need treatment were covered by ARV services.
The United States has pledged to provide funds to
15 African and Caribbean countries to treat 2 million
people over the next five years, as part of a new initiative
intended to prevent 7 million new infections
and to provide care and support for 10 million people
living with HIV/AIDS.
WHO and UNAIDS recognize that treatment initiatives
are a long-term commitment. “Lifelong provision
of therapy must be guaranteed to everyone who has
started antiretroviral therapy. Thus, 3 by 5 is just the
beginning of ongoing antiretroviral therapy scale-up
and strengthening of health systems.” (31)
Rapid expansion of treatment will require immediate
strengthening of health systems—which can
benefit sexual and reproductive health programmes
as well—and increasing the number of health care
providers (a goal of the 3 by 5 Initiative).
Wider availability of treatment will contribute
to HIV prevention efforts, as those on ARVs are less
likely to spread the virus, and their provision creates
opportunities to communicate prevention messages
and provide condoms. But it is imperative to increase
support for prevention programmes as well, and to
integrate prevention into treatment initiatives.
Another key need is to strengthen universal
precautions (including safety procedures and proper
disposal of gloves and sharp objects). Currently, even
when service providers know the precautions to take
against HIV transmission, they often lack protective
gloves and ARVs (in case of needle sticks or other accidents).
A recent study in Zambia found that clinics
had no safety guidelines or post-exposure prophylaxis
kits. When gloves were in short supply, clients were
told to buy them. Addressing occupational risk may
boost staff moral and improve client care.(32)
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REDUCING HIV RATES: LESSONS FROM UGANDA |
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HIV prevalence in Uganda peaked at
around 15 per cent in 1991 and then fell to 5 per cent by 2001. This decline has been
attributed to prevention efforts on several fronts, in a combined public health
approach to behaviour change described as “ABC”—promotion of abstinence, partner
reduction (also called “be faithful”), and consistent and correct condom use,
coupled with VCT services.
Abstinence. Data indicate that young Ugandans are increasingly starting sexual relations at a later age. Between 1989 and 2000, the age at onset of sexual relations increased from 15.9 to 16.6 years among young women and from 17.3 to 18.5 among
young men. Educational efforts promoting abstinence and increased knowledge about
the disease both played a part.
However, the proportion of people who were sexually active dropped substantially only among adolescent women aged 15-17 and not other groups. About half of all unmarried women were sexually experienced in 2000, the same proportion as in the late
1980s. Just over half of unmarried men were sexually experienced, a one third decline.
Be faithful (reduce the number of partners). Monogamy increased between
1989 and 1995, especially among sexually active unmarried women, but changed
little thereafter. The proportion of women with multiple partners was cut in half, but
from already low levels. In contrast, more than 25 per cent of active unmarried men
had multiple partners. Married men with multiple partners increased in some age
groups but decreased in others.
Condom use. Dramatic changes occurred in condom use, particularly among unmarried men and women, in the 1990s. Before 1989 use by either sex was negligible. By
1995 it increased to 8 per cent among women and 11 per cent among men. Later
increases have been striking, particularly among the youngest (and most vulnerable)
age groups.
Condom use by sexually active women aged 15-17 increased from 6 per cent to 25 per cent and by those 18-19 from 3 per cent to 12 per cent. For men aged 15-17, condom
use rose from 16 per cent to 55 per cent and in those 18-19, from 20 per cent to 33
per cent. Recent data suggest continued increases in condom use. See Sources
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PREVENTION PRIORITIES. A recent study of incidence
of HIV in Cambodia, Honduras, Indonesia,
Kenya and Russia suggests that the focus of prevention
activities should be based on a careful analysis
of where infections are occurring and not simply on
broad categories of at-risk groups.(33) For example, in
Cambodia, new infections acquired as a result of commercial
sex have fallen, while the proportion of new
infections acquired in marriage has increased from 11
per cent to 46 per cent. Yet the initial transmission of
HIV is still heavily linked to sex work and most people
becoming infected are those whose partners had high-risk behaviours in the past. Thus, prevention
needs to focus on both sex work and prevention
within marriage.
FAMILY PLANNING. It is also critical that an increased
emphasis on HIV/AIDS prevention and treatment
does not come at the expense of other sexual and
reproductive health information and services. Data
from the 2003 Demographic and Health Survey suggests
this has occurred in Kenya, where the family
planning programme made gains in the 1990s.
Contraceptive prevalence rose steadily from 27
per cent in 1989 to 39 per cent in 1998, but has not
increased since.
In the context of high HIV prevalence, it is critical
to continue support for family planning, which is a
key component of reducing mother-to-child transmission.
Recent studies in Kenya and Zambia found that
family planning providers, clients for antenatal care
and family planning, and HIV-positive women all
saw an increased need for family planning to avoid
unintended pregnancies.(34)
At the same time, providers need to respect the
rights of all people, including those infected, to make
their own decisions about having children and to have
access to accurate information and humane treatment
in order to do so. In many cases, HIV-positive women
are told that they should not have children. This discriminatory
treatment leads many such women not
to disclose their status to health workers.
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POSITIVE WOMEN: VOICES AND CHOICES |
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The Positive Women: Voices and Choices advocacy-research project developed by the International Community of
Women Living with HIV/AIDS is exploring the impact of HIV/AIDS on women’s sexual and reproductive lives, challenging the violation of their rights and advocating improvements
in policies and services.
The effort in Zimbabwe, one of three project countries, was
carried out from 1998 to 2001. HIV-positive women were generally unaware of their risk before they were tested. Gender norms and economic dependence on their husbands
or partners restricted the women’s control over their sexual and reproductive lives. In the face of prejudices about HIV-positive women being sexually active and having children,
they did not tell health workers about their status, making it difficult to address their needs. Using condoms in marriage was not considered appropriate.
The younger women wanted to have children, while
older women with several children wanted to limit childbearing after their HIV diagnosis. Condom use and contraceptive use increased markedly among women who attended support groups. The project affirmed that HIV-positive women need better economic opportunities, pregnancy and
delivery care integrated with family planning and STI/HIV-related services. See Sources
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INTEGRATION CHALLENGES. A recent study found
that “many health sector reforms have separated
sexuality education, [reproductive health services]
and STI/HIV/AIDS programmes from each other,
making different ministries or segments of health
ministries responsible for them, which also
creates potential rivalry for budgetary control
and funding.” (35)
An assessment in the Kaolack region of Senegal
in 2001 found little evidence of integration of family
planning or maternal and child health care with
STI/HIV/AIDS services. “The obvious lack of availability
of HIV/AIDS services in the districts’ health care
and community structures attests once again that
the lack of decentralization for these activities is
hindering any possibility of discussing integration on
these levels.” (36)
Reforms intended to strengthen health systems,
including the creation of minimum services packages,
should ensure that HIV/AIDS prevention and treatment
services are included along with family
planning.(37)
Health providers, who face mounting work loads
and often staff reductions, must be enabled not only
to provide contraceptives to clients, but also to identify
related reproductive health problems. They need
space to examine and counsel patients in private, and
need supplies and equipment that are often missing
from clinics in developing countries including gloves,
speculums, spotlights and syringes for contraceptive
injections.
Health providers also often need to be educated
about HIV/AIDS to overcome bias, and taught to communicate
prevention messages and to help individuals
accessing services assess their risk of infection.
CHANGING BEHAVIOUR. Combating HIV/AIDS calls
for addressing the underlying socio-economic, cultural
and behavioural factors that contribute to its spread—
including the lack of paid jobs, particularly for women,
employment and migration policies that force many
people to migrate for jobs, gender-based violence and
trafficking of women.(38)
Behaviour change is gradual, multifaceted and
needs to improve the health and reduce the risks of
diverse married and unmarried young populations. As
experience in Senegal and Uganda(39) shows, promoting
responsible, voluntary and safe behaviour requires
comprehensive and multisectoral efforts that foster
partnerships involving central and local governments,
the private sector, development partners, cultural
leaders and a wide range of civil society organizations.
A project in Zimbabwe is seeking to offer a financial
shield for girls to resist sexual liaisons with older
men, often called “sugar daddies”, who provide support
in exchange for sex.(40) The programme offers
vocational and life skills training, loans and jobs,
linked to education about reproductive health and
condom negotiation. A study will assess the impact
of the programme on HIV, STIs, the onset of sexual
activity and pregnancy.
REACHING HIGH-RISK GROUPS. Attention to
reaching high-risk groups with HIV/AIDS prevention
information, or treatment and care, has increased
substantially in recent years. Most of the countries
polled in the UNFPA global survey reported undertaking
programmes to reach groups such as sex workers,
injecting drug users, long-distance truck drivers, men
who have relations with men, street children, soldiers
and migrant workers, as well as adolescents and
youth.
NGOs are often key partners or initiators. In
Kenya, for example, a project that offers education
and counselling on responsible sexual behaviour and
condom use and provides economic alternatives has
reached 15,000 sex workers and their clients. In
Bangladesh, a variety of organizations provide sexual
health services to commercial sex workers.(41)
Countries in Latin America have been particularly
active in educating members of the armed forces to
stem HIV/AIDS infection and further transmission.(42)
COMBATING STIGMA AND BIAS. People living with
HIV/AIDS still face stigma and legal and social discrimination
in all regions. Ghana, South Africa and
Uganda are among the countries that have launched
programmes to combat this major obstacle to curbing
the epidemic. The Bahamas is one of a number of
countries that have outlawed discrimination against
HIV-infected people in the workplace.
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COMPREHENSIVE APPROACH TO HIV/AIDS PREVENTION IN SIERRA LEONE |
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Sierra Leone recently emerged from more than ten years of war that seriously disrupted all sectors of society. Almost two
thirds of the population was uprooted, rape and sexual abuse were widespread, and thousands of girls and women who lost their families have turned to sex work to survive. People’s
heightened vulnerability to HIV/AIDS has now become a priority concern.
UNFPA has responded through a coordinated initiative that
targets different groups and involves a range of national actors and government offices. The overall aim is to reduce the risk of HIV/AIDS and other STIs, reduce women’s need for commercial
sex work, alleviate poverty and enhance family life and community security.
Conducted in partnership with the Government, UNAIDS,
the UN Department of Peacekeeping Operations, UNIFEM and other partners, UNFPA’s comprehensive approach includes the following:
- Workshops and other initiatives to promote HIV/AIDS prevention among the Sierra Leone police force, the Sierra Leone military, international peacekeepers, and demobilized
soldiers;
- Promoting HIV/AIDS prevention among sex workers, through both health education and skills training to help them find other sources of income;
- Strengthening the capacity of partner NGOs;
- Promoting HIV/AIDS prevention among refugee and IDP populations;
- Creation of safe blood supply.
In 2003, the UN Security Council recognized the multiparty,
multi-pronged initiative as a potential breakthrough in responding to HIV/AIDS in post-war reconstruction, bringing everyone—including ex-combatants, military personnel and
international peacekeepers—together to promote improved health and HIV prevention. UNFPA and partners are applying similar approaches in neighbouring Liberia and in the
Democratic Republic of the Congo.
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