Comment www.thelancet.com Vol 368 November 25, 2006 1851 From minuscule biomedical models to sexuality’s depths Nearly three decades of prevention interventions against HIV/AIDS have yielded little effect, with the few success stories heralded universally as potential blueprints in best-practice dossiers. Unprotected sex is still the most common mode of HIV transmission. Unintended or teenage pregnancies, sexually transmitted infections including HIV/AIDS, and sexual abuse, violence, and discrimination remain major public-health challenges, despite targeted strategies of redress. What is missing in available sexual-health programmes, policies, and activism? Why are they not as effective as they promise? What is wrong with these interventions? One possibility is foundational: interventions are premised on limited working definitions of sexuality as a concept. 1 The production of knowledge on sexuality in the AIDS era is a field rich with a complex array of social actors from diverse institutions, disciplines, political motivations, and funding agencies. However, biomedicine maintains the hegemony over what knowledge is valued and thereby implemented as policy and practice. 2 Before the advent of HIV/AIDS, human sexuality research was mainly a terrain for biomedicine—physiology, psychology, psychiatry, and epidemiology. 3 Sexuality was perceived in terms of deviance, disease, and abnormality, needing correction, control, punishment, and cures. Early sexuality scholars reproduced the theoretical and methodological commitments of biomedical research. Statistics and quantitative methods dominated their inquiry. The onslaught of knowledge, attitude, behaviour, and practice surveys to understand the dynamics of sexual behaviour responsible for transmitting HIV portrays the persistence of this trend in knowledge generation. This positivistic approach is good for measurements (eg, how much, how often, how many) but not for ex- ploring meanings (ie, how and why things occur). Despite advantages of such an approach (eg, quantification, representativeness, generalisability), there are problems such as over-simplification of complex, nuanced, and analyses and make recommendations based on evidence of what works best for children. Finally, JLICA does not seek to perpetuate itself or carve a permanent niche in the HIV/AIDS research landscape. It aims to get a specific job done by a defined target date. This time-bound approach should enhance JLICA’s focus and effect. The initiative consists of four themed learning groups, whose membership will be balanced by sex and geography, with disciplinary diversity and strong representation from high-burden countries (panel). Beyond reports and analyses, JLICA will: produce methods for programme planning, implementation, and evaluation; establish an interactive website and communications platform for practitioners; and sponsor national and regional workshops, at which policymakers and practitioners can share experiences, learn from one another, and build foundations for sustained collaboration. The initiative will identify successful models of local practice that might have been under the radar of international organisations, national governments, and donors. Learning groups might participate in operations research with specific projects at national and subnational levels to document, evaluate, and improve promising strategies in real time. For too long, children have been at the margins of the response to HIV/AIDS. But political momentum is shifting, and today an opportunity exists to place policies and programmes for children’s well being at the forefront of our struggle against the disease. In a world scarred by HIV/AIDS, JLICA is ready to make common cause with all people committed to children’s flourishing. *Peter Bell, Agnès Binagwaho The Carter Center, Atlanta, GA 30307, USA (PB); and Commission Nationale de Lutte contre le SIDA, Kigali, Rwanda (AB) peter.bell@emory.edu We declare that we have no conflict of interest. 1 The Lancet . The devastating effects of HIV/AIDS on children. Lancet 2006; 368: 424. 2 Horton R. A prescription for AIDS 2006–10. Lancet 2006; 368: 716–18. 3 UNICEF. Children: the missing face of AIDS—a call to action. New York: UNICEF, 2005. 4 UNICEF, Bernard van Leer Foundation, CARE, et al. The framework for the protection, care and support of orphans and vulnerable children living in a world with HIV and AIDS. July, 2004: http://www.unicef.org/ aids/files/Framework_English.pdf (accessed Oct 24, 2006). 5 UNICEF, UNAIDS, PEPFAR. Africa’s orphaned and vulnerable generations: children affected by AIDS. 2006: http://www.unicef.org/ publications/ files/AOVG_Report__prepublication_PDF.pdf (accessed Oct 24, 2006). 6 The Joint Learning Initiative on Children and HIV/AIDS (JLICA). http:// www.jlica.org (accessed Nov 21, 2006).