Important priorities for prevention and treatment of HIV/AIDS

11/24/04

NB. Please note that if you are outside North America, the embargo for LANCET press material is 0001 hours UK Time Friday 26 November 2004.

Ahead of World AIDS Day on December 1, a series of commentaries in this week's issue of THE LANCET outline the current and future priorities in the global effort to curb the HIV/AIDS pandemic.

The first commentary is a call to action for a renewed public-health strategy to prevent sexually transmitted HIV. Against a background of twenty years of debate over the value of different behaviour-change approaches, authors Daniel Halperin (University of California San Francisco, USA) and colleagues outline evidence-based objectives for the various populations at risk: an emphasis on abstinence for young people not yet sexually active, the importance of fidelity and consistent condom use for people already sexually active; and programmes and policies aimed at reducing the number of sexual partners and promoting correct and consistent condom use in high-risk groups. The commentary is a consensus statement signed by over 140 HIV/AIDS experts from 36 countries, and includes such notable endorsers as Archbishop Desmond Tutu, President Museveni of Uganda, Special UN Envoy Stephen Lewis, and representatives from the World Bank, Global Fund for AIDS/TB/Malaria, and five UN agencies, the heads of the HIV-AIDS programs in several countries including Ethiopia, India, Jamaica and Uganda, as well as prominent technical, religious and other organizations working on HIV-AIDS. The commentary concludes: 'The time has come to leave behind divisive polarisation and to move forward together in designing and implementing evidence-based prevention programmes to help reduce the millions of new infections occurring each year.'

With an estimated 5 million new HIV infections worldwide in 2003, the context in which people are vulnerable to HIV infection is discussed by Catherine Hankins (UNAIDS, Geneva, Switzerland). The commentary outlines how changing the social, legal, and economic environments in many populations--especially among women and children in developing countries--is critical if any future public-health interventions to reduce HIV transmission are to be successful.

The provision of contraception for women on antiretroviral drugs is seen as a priority, especially in Africa, write James D Shelton and E Anne Peterson (USAID). Compelling reasons for widespread availability of contraception include: prevention of maternal-to-child transmission of HIV, avoiding the potential risk of antiretroviral drugs harming the fetus, and avoiding the high risk of maternal and infant morbidity and mortality. The authors conclude: 'There are compelling human, medical, social, and programmatic reasons to make high-quality, highly accessible, effective, and voluntary contraception available to women on antiretroviral drugs in Africa. It is morally imperative and programmatically pragmatic. As programmes scale-up to the challenge of providing antiretrovirals, they should be designed to strengthen family planning and other integral and vital health services from the beginning. At USAID we have begun serious efforts to make contraception available to women on antiretroviral drugs. We call on providers and other partners in international health to do the same.'

Thomas Kerr (British Columbia Centre for Excellence in HIV/AIDS, Vancouver, Canada) and colleagues highlight the HIV/AIDS issues relating to injecting-drug users (IDUs), especially how 'Heroin dependence is the underlying condition fueling the HIV epidemic in many countries.' A March 2005 meeting is seen as crucial for the acceptance of two effective opiod substitutions (methadone and buprenorphine) to be recommended therapies by WHO to the Essential Drugs List. The authors conclude: 'Given what is now known about the effectiveness of opioid-substitution therapy in HIV prevention and treatment, a decision to add these drugs to the list is needed to help ensure greater access to substitution therapies and antiretroviral treatments, and in turn to help to bring the HIV/AIDS epidemic among IDU under control.'

The final commentary paints an ominous picture for South Africa and other African countries. Jerome A Singh (Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban) discusses a recent report highlighting the decline in South Africa's population growth because of HIV/AIDS, with future projections suggesting that the country's population may decrease by 5 million people (from a population of 45 million today) by the year 2050. This direct effect of HIV/AIDS on the South African population has serious implications for stability in other African nations. Dr Singh concludes: "The relative peace currently prevailing in conflict-riddled countries, such as Liberia, Burundi, and the Democratic Republic of the Congo has been attributed, in part, to the presence of about 2800 South African peacekeepers in these and other African hotspots. However, the South African Government's refusal to deploy HIV-positive troops on UN peacekeeping missions will likely become increasingly unsustainable because 17-22% of South Africa's defence force is HIV positive. The effect of AIDS-related natural attrition, combined with a rise in rates of infection with HIV among South African troops in the years ahead, can be expected to reduce the number of South African troops eligible for peacekeeping missions in troubled African regions. The downscaling of South African peacekeeping operations because of these factors could threaten peace and stability in regions where South African troops currently serve, or could be called upon to serve in."

Source: Eurekalert & others

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