The Lancet Calls for a New Prevention Movement

(good thing we're all working on that!)

The venerable medical journal the Lancet dedicated its pre-IAC issue to HIV-prevention, what editor Richard Horton called “the neglected issue in the AIDS response.” On Wednesday, contributing authors called for a reinvigorated movement for prevention that demands a comprehensive, multifaceted approach, including structural change. Mirroring the Caucus for Evidence Based Prevention critiques of narrow definitions of evidence, the distinguished panel also called for investment in flexibile, realistic monitoring and evaluation mechanisms.

Jeffery O’Malley, director of the HIV and AIDS group at the UN Development Program, opened with the history of HIV-prevention, urging us to remember when prevention and epidemiology were all the AIDS community had enough information talk about. In the early 80s, he recalled, “gay men and drag queens invented safe sex, and they still haven’t been given the Nobel Prize.”

The 80s saw not only immense fear and ignorance but also dedicated, honest political leadership in countries that became success stories: Thailand, Senegal, Uganda, the U.K., and Australia. The 90s: the decade of scientific advance and opportunities lost to bad politics, decreasing funding, and the transition from the WHO AIDS program to UNAIDS. In the new millennium, Dr. Peter Piot revitalized UN efforts and money began to flow through private foundations and bilateral programs. Later in the session, Dr. Piot argued that funding for treatment may have—in a paradox—jump started new investment in prevention.

New prevention funding, however, does not flow fast enough to the communities that need it. Today, fewer than half of men who have sex with men and injection drug users worldwide have access to prevention. Just over half of surveyed commercial sex workers reported knowing where to receive an HIV test and condoms, the measure for “being reached.” In fact, only 39 countries have reported on CSWs, 27 countries on MSM, and only 15 on IDUs. Assuming those countries not reporting are not reaching these populations, that pitiful proportion falls even lower.

HIV-prevention requires radical change in not only our behaviors but also our social structures, and that change can take a long time to generate. Human behavior is shaped and constrained by our environments, and programs have to provide solutions that make sense in the context of people’s everyday lives.

“We talk about sexual activity as an antiseptic act,” said Tom Coates, Director of the UCLA Program in Global Health. “People have sex for many reasons: procreation—and the U.S. government would like us to stop there, but some people do it for fun. And some people do it for money. Some people do not have a choice.”

“Choice” was the order of the day: we need a rich tool kit of myriad methods including biomedical interventions, behavior change initiatives, social marketing, and social change efforts. Jessica Ogden, consultant with the International Center for Research on Women, demonstrated how mapping the causal pathways from overarching social factors to the immediate risk can show us where interventions can break the chain.For example, gender inequity can manifest as men’s social and physical domination of women resulting in domestic violence, making condom negotiation frightening or dangerous which leads to unprotected sex. The struggle is to understand how and where to address the problem. In the example of gender-based violence, domestic violence shelters and services address immediate risks for individual women while programs for young people that teach gender equity and relationship skills provide long term solutions. Advocacy for policies and resources to support such programs are part of structural change. Clearly, such change is necessary to make prevention options meaningful.

Evaluating efforts to generate structural change presents challenges to monitoring and evaluation. Because structural changes like policy reform are “upstream” from immediate risk behaviors, it is difficult to demonstrate that this work causes positive (or negative) outcomes. Social change work also typically generates spontaneous activities impossible to predict at baseline. These challenges can be creatively overcome, but the resources for longitudinal studies that include ethnographic and other qualitative research methodologies are simply missing.

Echoing the language of the publication’s call to action, Dr. Piot concluded by saying prevention is about coming to terms with complexity.Programs have focused on short term results for 25 years. Social change takes time, so start now.