As the global financial crisis raises the spectre of cutbacks in AIDS funding, countries need to start being more strategic about how they spend their AIDS budgets.
"If funding is in doubt, how will treatment programmes stay ahead of the growing demand for antiretroviral therapies?" asks a UNAIDS report, AIDS Outlook/09, released ahead of World AIDS Day on 1 December, which aims to guide policymakers drafting or reviewing their national AIDS plans on how to get the most bang for their donor bucks.
The report acknowledges some of the significant gains made since the first World AIDS Day 20 years ago, particularly in the area of treatment, but notes that for every two people who start taking antiretroviral drugs (ARVs), five others are newly infected.
The authors suggest that countries improve their understanding of the dynamics characterising their particular epidemic, and point to insights gained from recent "modes of transmission" studies conducted in 11 sub-Saharan African countries.
By estimating in which population groups new HIV infections occurred in the past year, researchers have been able to pinpoint the groups that would benefit most from targeted prevention.
Earlier HIV prevention campaigns were often based on the assumption that young, single people who engaged in casual sex were most at risk of HIV, but an analysis of data from Uganda found that 43 percent of new infections occurred among discordant couples (in which one partner was HIV-positive and the other negative). Another 44 percent of infections occurred among those who had multiple sex partners besides their regular partners.
Contrary to the conventional wisdom, Uganda should therefore focus its AIDS spending on prevention campaigns aimed at people in marriages or long-term relationships.
Two similar studies in Kenya found that although most new infections occurred through casual sex or discordance, there were a significant number among injecting drug users and men having sex with men - groups that have largely been ignored by HIV interventions.
"My concern is not only that we have good studies, but the studies are used," said the outgoing UNAIDS Executive Director, Peter Piot. In five African countries where modes of transmission studies have been carried out, steering committees with representatives from various government and non-government sectors have been formed to review and act on the findings.
"With this information we have fine-tuned our behavioural change and communication strategy, and future programming of prevention interventions," said Keketso Sefeane, chief executive of the Lesotho National AIDS Commission.
The UNAIDS report also advises countries not to rely on a single "magic-bullet" approach to reducing new HIV infections, but to promote as many different prevention tools as possible.
A "combination prevention" approach, outlined in a series of articles published in The Lancet medical journal in August, is defined by UNAIDS as "choosing the right mix of behavioural, biomedical and structural HIV prevention actions and tactics to suit your actual epidemic and the needs of those most at risk".
Arguing that AIDS funding must continue to increase despite the global financial crisis, Piot noted that current funding levels had already shown a "high return on investments" in terms of the number of lives saved.
"If there's a decline in funding, the return on the investment will be much less," he pointed out. "Postponing action just increases the bill later on."
UN Secretary General Ban Ki-moon has appointed Michel Sidibé as the UNAIDS executive director, starting in 2009. Sidibé is currently UNAIDS deputy executive director of programmes and Assistant Secretary-General of the UN.
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