Need for Change in Social Norms to Prevent Spread of HIV

The global AIDS epidemic has touched the 25 year mark and this year has been heralded as the “least bad” year yet. With increasing access to lifesaving treatments last year even in developing countries , a few hard-hit countries have reported declining HIV infection rates. However Bill Gates addressing the International AIDS Conference in Toronto this week said that current trends don’t bode well for the future because estimates have shown that for each person who started anti-HIV therapy last year, 10 more contracted the virus.

Gates noted, “When you extrapolate five to 10 years, you quickly see that there is no feasible way to … treat everyone …. unless we dramatically reduce the number of new infections.”

According to Dr. Helene Gayle, the president and CEO of CARE, a humanitarian organization, and co-chair of the International AIDS Conference, in spite of funding from international sources to about $8 billion this year she proposes that the spread of HIV has not met with success mainly because of the shift of focus from prevention to treatment of the disease. She states that much is needed to be done to integrate better prevention and treatment.

Without that failure was certain. In addition she stated the need for better coordination of prevention, testing, treatment and counseling to stop the disease..

When questioned about the results of prevention methods of the past 25 years she said, ‘HIV rates have decreased in countries like Uganda and Thailand and now in some countries in eastern and southern Africa. When people enroll in trials to test microbicides [topical agents that may prevent HIV transmission] or preventive drug therapies, their rate of HIV transmission often drops because they receive intensive preventive counselling, access to condoms and treatment for their other sexually transmitted diseases. This may explain why the first microbicide trial, done several years ago, couldn’t detect a difference between those who used the product and those who didn’t.’

She quoted the example of Thailand to show the role of the government in preventing the spread of HIV. She said, ‘Information and education are critical, but they’re not enough. When Thailand wanted to stop HIV transmission in the brothels, it didn’t just suggest that people use condoms. It took a proactive approach and adopted a 100 percent rule. Brothels that didn’t enforce condom use were shut down like restaurants with code violations, and it worked. The transmission rate fell and the country averted a disaster.’

She stated that the Bush administration’s ABC approach [abstain, be faithful, use condoms] was effective only if it is part of a balanced and comprehensive prevention strategy as was seen in Uganda. When children started delaying their sexual debut, and people embraced condoms and partner reduction, the infection rate came down.

However she warned that there were limits to that approach, especially for women. She said, ‘Social, cultural and political factors make some people more vulnerable to HIV. If you’re a woman lacking food for your kids, sex may be the only asset you can sell. You’re not in a good position to dictate the terms. Women who are themselves monogamous may be in relations with partners who have multiple partners and won’t use a condom. Women in many societies don’t have the social power to negotiate safer sex or control sexual interaction, including within marriage.’

She hailed the efforts of CARE to address these deeper sources of risks. Gayle said, ‘I just visited a community-based savings-and-loan program that CARE supports in Guatemala. CARE has similar programs in Africa and in Asia. This program provides small loans that women can use to start businesses if they send their daughters to school. Woman after woman described how earning money had raised her stature within her family and marriage. The girls said the same thing about going to school. They were headed for lives where they would be able to make their own choices. We can’t do away with poverty overnight, but we can counter some of its worst effects. We also need to change the social norms that condone coercive sex and treat women as property. How do you make it unacceptable for schoolmasters to harass young girls? You prosecute them for it.’

Dr. Helene Gayle asserted that the big remaining challenges for governments, foundations and international health agencies was the need to develop new tools. She said, ‘We need to develop new tools. Diaphragms, circumcision, microbicides, treatment of herpes, oral prevention drugs and, ultimately, a vaccine—these technologies may all have roles to play. We’re making rapid progress toward effective microbicides, and we can hope that antiretroviral drugs will help prevent HIV infection as well as they treat it.'

However she said, 'These technologies are at least five to seven years from the market, and technology alone won’t solve the problem. Condoms are cheap, simple and highly effective, but they’re still underused. Only one in five people at risk for HIV has access to existing prevention approaches like education, condoms, HIV testing and treatment of other sexually transmitted disease. Even the best prevention programs typically reach only 10 to 30 percent of the people who could benefit. We need to get to a tipping point where we’re reaching at least 50 percent of people at risk. Then we will start to see greater impact.’