…the radical behavioural change that is needed to reduce HIV transmission requires radical commitment. Prevention strategies will never work if they are not implemented completely, with appropriate resources and benchmarks, and with a view toward sustainability. The fundamentals of HIV prevention need to be agreed upon, funded, implemented, measured, and achieved. That, presently, is not the case.
These are the closing comments from a review of behavioral strategies to reduce HIV transmission by Tom Coates, Linda Richter and Carlos Caceres in The Lancet (full text available with free registration).
They argue that in the absence of any definitive research suggesting the primacy of one approach over another (and indeed, reject such simplistic analysis), a combination of strategies is needed that includes strong leadership and community engagement that are sustained over time.
Using the experiences of Uganda and the Mbeya region of Tanzania to illustrate the common factors that contribute to the success of behaviorally-based interventions to reduce HIV transmission:
Our findings indicate that substantial HIV reductions in Uganda resulted from public-health interventions that triggered a social process of risk avoidance manifested by [radical] changes in sexual behaviours….Second, a mix of communication channels disseminated simple and clear messages about several risk reduction and health-seeking options (eg, delay of onset of first intercourse, reduction in number of partners, condom use especially with non-primary partners, HIV testing, and treatment for sexually transmitted infections). One risk reduction strategy (eg, abstinence or partner reduction) should not be emphasised over another (eg, condom use), since people like choice and the mix of strategies is essential… Third, local involvement in message design, production, and dissemination was essential. In fact, one of the most energising activities in many strategies and campaigns for HIV prevention involves using the creativity and energy of people who are most affected by the epidemic to develop messages and strategies to motivate behavioural change.
They do not propose an exclusive reliance on behavioral methods. Rather they place these interventions within a larger framework of highly active HIV prevention activities.
They propose an ongoing, strategic approach to reducing incidence that focuses on multiple HIV risk behaviors that will vary among various population groups in which HIV is spreading (and call to mind the adage: know your epidemic).
Behavioural strategy aims might involve increased knowledge about how to protect oneself from HIV infection; stigma reduction; encouraging access to services (eg, methadone maintenance, HIV counseling and testing, diagnosis and treatment of sexually transmitted infections, use of antenatal and reproductive health services); improving attitudes toward safer sexual practices; delaying onset of intercourse; decreasing number of partners; reducing use of sex workers; increasing condom sales; recognition of early symptoms of sexually transmitted infections or HIV; recognition of the benefits and limitations of male circumcision for protection against HIV; disclosure of HIV serostatus; harm reduction strategies; how to access treatment for HIV; the importance of adherence to antiretroviral drugs; and so on.
They underscore that HIV is ‘a social event’ that extends far beyond threat appraisal, knowledge and beliefs, intentions and social norms. Behavioral interventions should target a variety of social units including individuals, couples, families (especially for children), peer agents/educators, popular opinion leaders, social networks, social institutions (workplaces, prison, the military, faith-based organizations, and schools) and the community through mass media, social marketing, and community mobilization.
This call for a multifaceted approach has been echoed in the Disease Control Priorities Project’s paper on constructing an effective HIV prevention program [pdf].
It is essential for prevention packages to address both the biological and behavioral factors associated with transmission and the social and structural factors which can aid or impede the success of HIV prevention programming. For example, biomedical interventions (e.g., condom use, circumcision) should be integrated with behavioral approaches (e.g., voluntary counseling and testing, sexual behavior change) in a multi-component intervention. Simultaneously, structural interventions should address the underlying social, cultural, economic, physical, and policy aspects that can hinder prevention efforts. However, all components (biomedical, behavioral, and structural) must be clearly defined, replicable, and capable of being rigorously evaluated.
The DCPP paper also reiterates points that we have raised here:
Rigorous epidemiological methods for evaluating multicomponent prevention programs at scale have not yet been developed in detail. Large-scale comparison data of prevention interventions outside the trial setting are essential for future programs as they will provide “real world” glimpses into an intervention’s effectiveness.
Social marketing for behavior change, product access and distribution and improved health services quality and delivery can play a crucial role in translating these recommendations into effective prevention programs at the community and national level. In some cases the work has already begun. Let’s be sure to inform the policymakers and program managers around the world as to what works and what is not. And hopefully, with a pledge from President Obama to keep politics out of science, we can successfully implement what we know works, and can investigate what we need to know.