Time for prevention that works

An array of interventions aimed at slowing the rate of new HIV infections in Africa has been tried over the last two decades. Some were tested to see if they actually worked, but many were not.



In southern Africa "we were hit very quickly and very hard [by HIV/AIDS]," said Prof Geoff Setswe, chief research specialist in the Social Aspects of HIV/AIDS and Health at South Africa's Human Sciences Research Council (HSRC).



Prevention initiatives were developed and rolled out rapidly and often haphazardly. "We started doing anything we thought would help and said, 'We'll see later', so there was a lot of hit and miss."



Setswe was addressing delegates at the Social Aspects of HIV/AIDS Research Alliance (SAHARA) conference on 1 December in Johannesburg, South Africa, on the question of what constitutes evidence in the field of HIV prevention.



With the global economic crisis squeezing AIDS budgets, and a frustrating lack of progress in significantly reducing new HIV infections, donors and governments are under more pressure than ever to concentrate resources on prevention strategies that are known to work.



In science, the gold standard for demonstrating efficacy is randomized controlled clinical trials, with compared outcomes between one group that received an intervention and another that received a placebo. Such trials have been successfully used to provide strong evidence for bio-medical prevention strategies such as male circumcision and treatment to prevent mother-to-child transmission (PMTCT).



But clinical trials are not always appropriate for testing behavioural and social interventions, such as the ABC (Abstain, Be Faithful, Condomise) approach, or efforts to reduce multiple concurrent sexual partnerships.



Perhaps for this reason, no behavioural or social intervention has so far met the criteria for "best evidence", which Setswe defined as at least 80 percent effectiveness.



Counselling people living with HIV has been found to be 68 percent effective in reducing high-risk sexual behaviours, classified as "good evidence" by Setswe.



Other seemingly promising interventions, such as a microfinance programme in rural Limpopo Province that included raising awareness of gender-based violence and HIV education, failed to reduce new HIV infections.



Dr Olive Shisana, CEO of the HSRC, pointed out that even prevention strategies with a strong evidence base were not always implemented; funding and capacity limitations often created obstacles, as did social, cultural and political factors.



Despite compelling evidence that male circumcision reduces HIV infections among men, for example, South Africa has lagged behind other countries in the region in implementing a mass circumcision programme. "There are still people among us who say, 'We shouldn't implement because it's against our culture'," Shisana said.



Donors also often do not base decisions to fund prevention efforts on successful outcomes: the United States, guided by a conservative religious ideology, funded many abstinence-only initiatives without any evidence that they reduced infection rates.

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Meanwhile, programme managers are often forced to chase donor money rather than the evidence. As a result, said one delegate reacting to Setswe's presentation, programmes were sometimes changed to accommodate donor whims, creating a lack of consistency.



Dr Innocent Ntanganira, the World Health Organization's regional adviser on HIV prevention, commented that the time for small-scale, piecemeal interventions with little impact was over, and called for evidence-based, cost-effective interventions to be scaled up. "We know what works," he said. "We need to go to scale with national prevention programmes."



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