UNAIDS
Background The past 10 years have brought some remarkable successes in HIV prevention (27). Incidence rates fell more than 25% in 33 countries, including 22 countries in subSaharan Africa that carry the highest burden. Although the studies may not be definitive, such results suggest that HIV prevention can work—when young people are empowered to act on information and access services, when men and women have access to and choose to use condoms and when countries and communities are mobilized to invest in effective and comprehensive evidence-informed programmes around sex work and drug use.
“Know your epidemic, know your response”
However, during the past decade, the number of people newly infected with HIV has increased by more than 25% in seven countries. Further, despite reductions, in 2008, 1.9 million more people became infected with HIV in sub-Saharan Africa alone. Halting all HIV epidemics will require nothing short of revolutionizing the prevention of HIV transmission.
Gaps in prevention Combination prevention (28) approaches based on sound evidence of effectiveness and efficacy—“Know your epidemic, know your response”—have not been widely applied. As a result, national prevention efforts are often inadequate and poorly focused. Heterosexual exposure is the primary mode of transmission in sub-Saharan Africa. As epidemics have matured, the number of people in “low-risk” partnerships who are newly infected is often high. Nevertheless, programmes rarely focus on adults, married couples or people in long-term relationships or provide prevention services for serodiscordant couples. Most young people still have inadequate access to high-quality health services, including sexual and reproductive health and rights programmes, HIV testing and condom provision. Effective school-based sexuality education is still not available in most countries (29, 30). In many societies, attitudes and laws stifle public discussion of sexuality—for example, in relation to condom use, abortion and sexual diversity. Yet whether an HIV epidemic is generalized or concentrated, the most severely affected population groups include young people. Because their youth compounds other vulnerabilities, young women and men need additional information, services and social support. Although easily preventable at low cost, the vertical transmission of HIV in low- and middle-income countries remains unacceptably high. An estimated 53% of pregnant women living with HIV received antiretroviral drugs to reduce the risk of transmitting HIV to their infants in 2009 (31). In the same year, 379 000 babies acquired HIV (31). Progress is too slow, and programmes often offer far from an adequate standard of care—for example, the continued use of single-dose nevirapine instead of recommended combination therapy. The ability of young women to protect themselves from HIV is frequently compromised by a combination of biological, social, cultural, legal and economic
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