Series 78 www.thelancet.com HIV Prevention 6 Coming to terms with complexity: a call to action for HIV prevention Peter Piot, Michael Bartos, Heidi Larson, Debrework Zewdie, Purnima Mane A quarter of a century of AIDS responses has created a huge body of knowledge about HIV transmission and how to prevent it, yet every day, around the world, nearly 7000 people become infected with the virus. Although HIV prevention is complex, it ought not to be mystifying. Local and national achievements in curbing the epidemic have been myriad, and have created a body of evidence about what works, but these successful approaches have not yet been fully applied. Essential programmes and services have not had sufficient coverage; they have often lacked the funding to be applied with sufficient quality and intensity. Action and funding have not necessarily been directed to where the epidemic is or to what drives it. Few programmes address vulnerability to HIV and structural determinants of the epidemic. A prevention constituency has not been adequately mobilised to stimulate the demand for HIV prevention. Confident and unified leadership has not emerged to assert what is needed in HIV prevention and how to overcome the political, sociocultural, and logistic barriers in getting there. We discuss the combination of solutions which are needed to intensify HIV prevention, using the existing body of evidence and the lessons from our successes and failures in HIV prevention. Momentum for HIV prevention Although the gap between what is needed in HIV prevention worldwide and what has so far been achieved is huge, we should not neglect the momentum which has been generated, especially over the past decade. HIV prevalence has declined substantially in a growing number of countries and regions: Zimbabwe, Côte d’Ivoire, Burkina Faso, Thailand, Cambodia, southern India, and urban Haiti and Kenya. 1 These reductions represent the payoff from investments made throughout the 1990s and into this century. Commitment of political capital and other resources has been translated into major increases in programmatic effort that are now bearing fruit in improved outcomes—infections averted and lives saved. But worldwide the current degree of effort is not yet sufficient: the epidemic continues to extend its reach, and new infections continue at a rate which puts unsustainable burdens on countries for decades to come. To intensify HIV prevention, programme implementers need to know their epidemic, and to respond in at least three dimensions. The first—HIV rates and behaviours at a local level—is commonly used. The second—the state of HIV/AIDS spending and programming in relation to the levels of need, including in relation to each key subpopulation—is sometimes used. Bertozzi and colleagues in this Series 2 detail the mix of spending and programming required for an optimum response. The third—an appreciation of macro-level political, demographic, and economic changes—is rarely used, but unless responses take these changing social and cultural contexts into account, they will miss their mark. This combination of knowledge and context is what makes information strategic and the basis for action (panel 1). Only when it is applied in a comprehensive AIDS programming cycle can it create an effective feedback loop between information, programming, assessment of programme effectiveness, and back to improved information and programming (panel 2). 7 As Rao Gupta and colleagues note in this Series 8 other public-health efforts have shown the consequences of not conducting adequate analysis of the social and political environment. One of the more extreme examples has been in the global polio-eradication initiative, in which an overly top-down effort neither adequately assessed local cultural and political contexts nor adequately engaged local communities early in the effort, leading to a state-wide boycott of polio vaccination in Northern Nigeria, 9 community-level refusals in northern India, and pockets of refusals in other settings. To take another example, reproductive-health programmes have also recognised the need to understand social and cultural systems in planning any intervention—in-depth analysis from nine countries showed that “development entry points and constraints that derive from social and cultural systems and structures cannot be overlooked or underestimated”. 10 The epidemic could continue to surprise us As Bertozzi and colleagues argue in this Series, 1 HIV prevention responses must be informed by an analysis of where the next 1000 HIV infections are likely to come from in any given context. HIV/AIDS is highly dynamic. Initial HIV outbreaks in highly vulnerable populations might be followed by a slower spread which could nevertheless affect large numbers of people: 11 in Thailand or Uganda, for example, a large proportion of transmission is among serodiscordant long-term couples. Epidemics could resurge—as among gay men in western Published Online August 6, 2008 DOI:10.1016/S0140- 6736(08)60888-0 This is the sixth in a Series of six papers about HIV prevention Joint United Nations Programme on HIV/AIDS (UNAIDS), Geneva, Switzerland (P Piot PhD, M Bartos MEd); Department of International Development, Community and Environment, Clark University, Worcester, MA, USA (H Larson PhD); Center for Population and Development Studies, Harvard School of Public Health, Harvard University, Cambridge, MA, USA (H Larson PhD); The World Bank, Washington, DC, USA (D Zewdie PhD); and United Nations Population Fund (UNFPA), New York, USA (P Mane PhD) Correspondence to: Michael Bartos, Joint United Nations Programme on HIV/AIDS, 20 Avenue Appia, CH-1211 Geneva 27, Switzerland bartosm@unaids.org