India to develop its own AIDS vaccine.

PIP: UNAIDS believes that more than 3 million Indians are infected with HIV, approximately 200,000 of which have AIDS. Failing in its attempt to check the spread of HIV/AIDS through disease prevention messages and the promotion of condom use, the government of India has launched a program to develop a vaccine against HIV/AIDS. Some see the development of a vaccine as the only viable course of action against HIV/AIDS in India, for educational campaigns have failed and AIDS drugs are unaffordable even for wealthy Indians. Interest in producing an indigenous vaccine stems from concern that vaccines being developed in the West may not be effective in India due to differences in HIV subtypes. A 5-year extension of an existing Indo-US program started in 1987 to develop vaccines against a range of infectious diseases was signed in December 1997, with AIDS added to the list of original program diseases. This revised agreement includes collaboration with US vaccine research groups and possible US funding, but details of the terms have yet to be disclosed. The following Indian teams are working on the project: the government Department of Biotechnology (DBT), the All India Institute of Medical Sciences, the National Institute of Communicable Diseases (New Delhi), Christian Medical College (Vellore), and the National AIDS Research Institute (Pune). The DBT argues that there will be enough funding even without a US contribution. Indian scientists plan to develop a DNA vaccine mixture containing the desired gene sequences of the HIV subtypes which are prevalent in India.^ieng

Ethical considerations of clinical trials to prevent vertical transmission of HIV in developing countries.

PIP: The Public Citizen's Health Research Group recently called attention to ethical concerns with trials of AZT which are either planned or underway in developing countries. The trials are being conducted to determine the minimum dose of AZT needed to prevent the vertical transmission of HIV from infected mothers to their unborn children. To that end, women who have given their informed consent to enter the trials are randomized into various dosage and placebo arms of the trials. The problem with this standard trial format in this case is that AZT is already proven capable of blocking approximately two thirds of transmissions of HIV to the fetus. The Public Citizen's Health Research Group therefore argues that the trials violate the Helsinki Declaration in that every patient enrolled in a clinical trial should be assured of receiving the best available treatment. Since these study subjects cannot obtain HIV prophylaxis elsewhere, they may enter the trials out of desperation, thereby invalidating their ability to autonomously consent to study participation. The author considers the ideal of informed consent which equates autonomy with competence rather than with freedom, whether freedom equals choice, and freedom, autonomy, and trials in developing countries. AZT vertical transmission trials could be markedly improved by replacing the placebo arm with a contrasting dose cohort.^ieng

World Bank will lend more money to India for AIDS.

PIP: This article discusses the World Bank's plans to lend India money that will be used in part to fund HIV/AIDS prevention and control. The loan amounts to about US$200 million, of which 25% would be directed to research and development for HIV/AIDS. The loan is a 5-year extension of support that ended March 1999. The loan will cover the cost of blood safety programs, hospital and community care plans, and medical drugs for treating opportunistic infections. According to the Department of Biotechnology and the Indian Council of Medical Research, research and development money will be split between indigenous AIDS vaccine programs and assessment of local production of HIV diagnostic kits and development of vaginal microbicides. The government will support clinical trials of more than herbal medicines for treating tuberculosis. Funding will also support evaluation research on cost of patient care and the HIV/AIDS impact on the work force. A major focus will be on the high risk population of women and children. The World Bank requires that 50% of the loans go to nongovernmental organizations (NGOs). However, the National AIDS Control Organization (NACO) of India lost government financial funding and will not be able to fund NGO efforts directly. NACO must channel funding through state governments. There is fear that the AIDS control program will suffer due to the restructuring of operations and shortages of manpower. The AIDS program funding could be halted by the Bank due to India's nuclear testing.^ieng

The development of a national HIV Plan in Belgium: Achieving consensus despite institutional complexity.

BACKGROUND: The development of a national HIV Plan poses serious challenges to countries with a complex distribution of legal powers such as Belgium. This article explores how the Belgian national HIV Plan 2014-2019 was developed. METHODS: Applying the policy streams model of John Kingdon, the analysis of the HIV Plan development process was based on published government statements, parliamentary documents, and websites of stakeholders. RESULTS: The Federal Ministry of Health initiative to achieve the HIV Plan was characterized by a coordinating role with a participatory approach towards the other Belgian governments and stakeholders. The 2013 protocol agreement of the Belgian governments committed them to principles, actions, and cooperation, but not to budgets, priorities, or target figures. DISCUSSION: The Federal government followed a successful strategy to create momentum and commitment to a common national vision on HIV/AIDS. The window of opportunity was not sufficient to create an implementation plan prior to the 2014 elections, and major challenges were left to the subsequent governments, including financing. CONCLUSION: The country of Belgium represents an example of a consensus strategy to achieve a national HIV Plan with its achievements and limits within institutional complexity and limited Federal legal powers.

A research agenda for AIDS prevention in the developing world.

BACKGROUND: In the developing world, HIV is spreading in many epidemiologic patterns, ranging from slow spread in limited segments of the population to exponential growth to mature epidemics. These differences are superimposed on widely varying cultures and patterns of behavior, creating unique challenges for prevention in each setting. Local prevention research is continually necessary to respond appropriately and effectively to local prevention needs and to best use scarce resources. THE RESEARCH AGENDA: We propose a research agenda for AIDS prevention in the developing world, consisting of three main components: epidemiologic and behavioral surveillance; enhancing local understanding of HIV risk behavior; and testing interventions. We review examples of each. This 'bottom-up' research is contrasted with 'top-down' research conducted in the developing world by scientists from developed countries to answer questions of general interest. RESULTS: The articles published in this volume exemplify the scope and importance of AIDS prevention research in the developing world. They also show what can be accomplished through international collaboration directed towards meeting local needs.

PIP: In the developing world, HIV is spreading in many different epidemiologic patterns. The spread may be slow among a few population groups, exponential, or at the level of a mature epidemic. HIV is spreading across a wide range of cultures and behavior patterns. A need therefore exists to tailor prevention measures to conditions and needs at local levels. Research at the local level is needed to guide the development and implementation of appropriate HIV prevention programs. The authors propose a research agenda for AIDS prevention in the developing world which consists of the following central components: epidemiologic and behavioral surveillance, improving the local understanding of HIV risk behavior, and testing interventions. Examples of each component are reviewed. In addition, bottom-up research is contrasted with top-down research conducted in the developing world by scientists from developed countries.

Prevention of HIV transmission by blood transfusion in the developing world: achievements and continuing challenges.

In industrialized countries, the use of sensitive HIV screening tests, donor deferral, and more conservative use of blood have resulted in a dramatic decrease in the transmission of HIV infection by blood transfusion. The risk of HIV transmission in the USA by blood screened negative for HIV antibody was recently estimated at one in 440,000-660,000 donations. Despite this low risk, continued public concern has compelled blood collection agencies and policy makers to continue to search for more sensitive HIV screening tests. Genome amplification techniques are receiving increased attention and are being piloted in Germany. HIV-1 p24 antigen testing was implemented in the USA in March 1996. In the first 18 months of p24 antigen testing, an estimated 18 million blood donations were tested at a cost of US$90 million to detect three antigen-positive, antibody-negative donations. However, in many developing countries where severe anemia is widespread and the prevalence of HIV infection among blood donors is orders of magnitude greater than in industrialized countries, the blood supply is either incompletely screened or not screened at all for HIV antibody. Although the contribution of transfusion-transmitted infection to the HIV epidemic has not been accurately assessed, an estimated 5-10% of HIV infections in developing countries are due to blood transfusion. In a study conducted 1 year after implementation of HIV blood screening in the largest hospital in the capital city of the Democratic Republic of the Congo, an estimated 25% of pediatric HIV infections, and 40% of infections among children over 1 years of age, were due to transfusion. Lack of commitment by national governments and international aid organizations to this fundamental element of HIV prevention has resulted in a shortage of basic equipment, supplies, and trained personnel for blood screening. Moreover, provision of test kits alone cannot prevent HIV transmission by transfusion in resource-poor areas. More comprehensive programs are needed to improve the recruitment and retention of safe donors, essential laboratory services for blood banking and screening, technical training and supervision, appropriate use of transfusions, and the prevention of severe anemia. This article summarizes the steps being taken by developing countries to prevent HIV transmission by blood transfusion, lessons learned, and the work that still lies ahead.

PIP: Screening of the blood supply, a cost-effective strategy for reducing HIV transmission, has not been implemented consistently in developing countries. An estimated 5-10% of HIV transmission in these countries remains attributable to blood transfusion. Lack of commitment by national governments and international aid organizations has resulted in a shortage of basic equipment, supplies, and trained personnel for blood screening. The situation is further complicated by problems recruiting and retaining safe donors, a lack of essential laboratory services for blood banking and screening, the nonavailability of rapid tests, inadequate supervision of personnel, and widespread need for blood transfusions for malaria-related severe anemia. International donor organizations, government agencies, and health care providers are urged to give renewed attention to the issue of blood safety in resource-poor areas of the world so that this effective method of HIV prevention can be universally accessible.

One world, one hope: the cost of providing antiretroviral therapy to all nations.

OBJECTIVE: To estimate the potential direct cost of making triple combination antiretroviral therapy widely available to HIV-positive adults and children living in countries throughout the world. METHODS: For each country, antiretroviral costs were obtained by multiplying the annual cost of triple antiretroviral therapy by the estimated number of HIV-positive persons accessing therapy. Per capita antiretroviral costs were computed by dividing the antiretroviral costs by the country's total population. The potential economic burden was calculated by dividing per capita antiretroviral costs by the gross national product (GNP) per capita. All values are expressed in 1997 US dollars. RESULTS: The potential cost of making triple combination antiretroviral therapy available to HIV-positive individuals throughout the world was estimated to be over US$ 65.8 billion. By far the greatest financial burden was on sub-Saharan Africa. The highest per capita drug cost in this region would be incurred in the subregions of Southern Africa (US$ 149) followed by East Africa (US$ 116), Middle Africa (US$ 44), and West Africa (US$ 42). In the Americas, subregional data indicated the highest per capita drug cost would be in the Latin Caribbean (US$ 22), followed by the Caribbean (US$ 17), Andean Area (US$ 7), the Southern Cone (US$ 6), North America (US$ 6), and Central American Isthmus (US$ 5). In Asia and Europe the percentage of the GNP necessary to finance drug therapy was less than 1% in most countries examined. CONCLUSION: Our results demonstrate that the cost of making combination antiretroviral therapy available worldwide would be exceedingly high, especially in countries with limited financial resources.

PIP: In 1997, an estimated 5.8 million people worldwide were infected with HIV, of whom 90% lived in developing countries, especially in sub-Saharan Africa. While antiretroviral therapy has been shown to prolong survival in people with HIV/AIDS, many of the countries with the highest rates of HIV infection have little or no access to antiretroviral therapy, for a number of reasons, including cost. Findings are presented from a study conducted to estimate the potential direct cost of making triple combination antiretroviral therapy widely available to all of the world's HIV-infected population. The potential cost of making such therapy available to HIV-positive people worldwide was estimated to be over US$65.8 billion, in 1997 US dollars, with the greatest expenditures needed in sub-Saharan Africa. The highest per capita drug cost in sub-Saharan Africa would be incurred in Southern Africa (US$149), followed by East Africa (US$116), Middle Africa (US$44), and West Africa (US$42). In the Americas, per capita drug costs would be US$22 in the Latin Caribbean, US$17 in the Caribbean, US$7 in the Andean Area, US$6 in the Southern Cone and North America, and US$5 in the Central American Isthmus. In Europe and Asia, the percentage of GNP needed to finance drug therapy was less than 1% in most countries examined. For each country, antiviral costs were determined by multiplying the annual cost of triple antiretroviral therapy by the estimated number of HIV-positive people accessing therapy. Per capita therapy costs were calculated by dividing the antiretroviral costs by the country's total population. The potential economic burden was calculated by dividing per capita antiretroviral costs by the gross national product (GNP) per capita.

Evaluation of AIDS prevention and control programs.

PIP: To date, no full-scale community-based trials of acquired immunodeficiency syndrome (AIDS) prevention interventions with appropriate controls have been conducted and the true effect of such programs on the community-wide incidence of human immunodeficiency virus (HIV) infection cannot be measures. A review of the literature indicates, however, that some AIDS prevention programs are building in an evaluation component, including baseline studies and needs assessments, pre- and post-test measures of knowledge, attitude, and behavioral changes, and biomedical indicators of program-related effects such as HIV serostatus. The literature from the period July 1988-June 1989 reveals a trend toward interventions targeted at high-risk populations such as racial and ethnic minorities, prostitutes, prison inmates, substance abusers, and adolescents. Evaluations of programs aimed at specific populations commonly measure the impact of one or more types of interventions on the knowledge and practice of behaviors known to reduce the risk of HIV transmission. Programs that give participants the skills needed for the initiation and maintenance of risk-reduction behaviors appear to be more effective than programs emphasizing cognitive or affective learning alone. The literature confirms the benefits of use of indigenous health communicators in program planning and implementation and of a multi-faceted (e.g., mass media, community, and individual-level interventions) strategy.^ieng

Prevention of sexual transmission of HIV in sub-Saharan Africa: lessons learned.

PIP: More than 80% of cases of HIV infection in Africa are attributed to heterosexual transmission, and most prevention efforts have focused upon checking the sexual spread of HIV. A range of interventions have been implemented over the past 10-15 years in different countries throughout the continent. The nature of the activities depends upon the stage of the epidemic, the target population, the funding level, the level of policy support, donor interests, and the capabilities of implementing agencies in the public and private sectors. Despite reports of some encouraging results, the epidemic remains powerful, dynamic, and spreading. Slowing the HIV/AIDS epidemic in Africa will probably require comprehensive, integrated, and multisectoral programs. Most programs to date, however, intervene almost exclusively at the individual level. The authors describe the evolution of intervention programs to prevent the sexual transmission of HIV in sub-Saharan Africa, discuss lessons learned from programs, and identify gaps in the existing knowledge. Sections review interventions to prevent the sexual transmission of HIV, STD treatment, promoting condoms and making them more available, and behavior change interventions.^ieng

Prevention of mother-to-child transmission of HIV-1 in Africa.

PIP: With the prevalence of HIV among pregnant women higher than 35% in some parts of sub-Saharan Africa, the number of HIV-infected children will continue to grow. It is estimated that almost 70% of the approximately 500,000 children who became infected with HIV in 1995 were born in sub-Saharan Africa. An effective intervention to prevent the vertical transmission of HIV is therefore most urgently needed in Africa. Following the release of the results of the AIDS Clinical Trials Group (ACTG) 076 study, the routine use of zidovudine (AZT) among HIV-infected pregnant women in the US and Europe has resulted in a significant reduction in the rate of mother-to-child vertical HIV transmission. However, most women in Africa will not benefit from these advances in the immediate future due to inadequate prenatal health care, the unavailability of prenatal HIV testing, and the high cost and complexity of the recommended regimen. Researchers need to build upon the findings of developed countries to identify feasible, effective, and implementable interventions to reduce the vertical transmission of HIV as well as to prevent HIV infection among women and to protect the health of HIV-infected women in Africa. Rates and timing of vertical HIV transmission, risk factors associated with vertical HIV transmission, and prevention interventions are discussed.^ieng

Condom issues in AIDS prevention in Africa.

PIP: In vitro studies have demonstrated that an intact latex condom provides an effective barrier against several sexually transmitted pathogens, including herpes simplex virus type 2, hepatitis B virus, cytomegalovirus, HIV, Neisseria gonorrhea, Chlamydia trachomatis, and mycoplasma. This paper discusses some of the major advances and critical issues which should be incorporated in condom program design and implementation. The authors drew extensively from their experience with Family Health International's AIDSTECH Project with 21 targeted HIV prevention programs in 14 African countries. The programs are designed primarily to reach high-risk behavior groups among whom the virus is most prevalent. The authors observe from their work that a number of social, economic, political, and cultural obstacles impede greater condom use in Africa; private sector initiatives which recruit members of target populations to be key personnel in project implementation show promise for reaching high-risk behavior groups; condom logistics systems remain a weak link in condom distribution programs; rising costs and inadequate sources of latex condoms are problematic; and alternatives to the male latex condom could be commercially available by 1992. Sections discuss barriers to condom use, new approaches in condom distribution, condom quality assurance, condom costs and economics, and technological advances in condoms.^ieng

Integration of AIDS program activities into national health systems.

In this paper we have defined integration as being the health unit team acceptance of responsibility for all aspects of care at the health service/community interface level. The health unit functions within a system whose elements (hospitals, laboratory, pharmacy, etc.) function in complementarity with those of the FLHS. Vertical approaches are often adopted because of weaknesses in some elements of the NHS, thereby further undermining such an NHS. The development of innovative community-based approaches in some areas and countries has resulted from this type of situation. However, isolated from the NHS, such approaches cannot be expected to be sustainable or to have long-term impact. Integration is the best choice of approach; it offers a chance to influence the course of the AIDS epidemic and the response of health systems in each country. The basic structure of the NHS and the characteristics of a FLHS are analyzed. The challenge to AIDS programs is to define more exactly objectives and activities at the operational, interface levels. Based on this analysis, planning of operations should be delegated to the district. Weakness of some elements and aspects of the NHS which are relevant to AIDS control program implementation can be overcome, not by organizing the program vertically and independently from the NHS, but rather by sharing resources to strengthen the weak elements. Integration may be more difficult in the early stages of implementation, but in the long term it offers sustainable development of AIDS prevention and control activities.

PIP: This paper reviews the integration of AIDS program activities into national health systems as a possible way to make the activities more effective, efficient, and sustainable. For the purposes of this paper, integration is the health unit team acceptance of responsibility for all aspects of care at the health service/community interface level. Consideration is limited to the integration of AIDS control activities into national health systems, but the concept of integration is also applicable to other sectoral service systems such as education, religion, and rural development. The integration of activities will become a prerequisite for sustainability as the AIDS epidemic spreads. While such integration may be difficult in the early stages of implementation, it offers the sustainable development of AIDS prevention and control activities over the long term. Examples of the successful integration of AIDS activities into other health programs need to be studied in order to identify what is the most effective form of integration. The authors discuss integration and vertical approaches, and the structure of the national health service and characteristics of first-line health services.

Strategies for AIDS prevention and control in sub-Saharan Africa.

PIP: Most countries in sub-Saharan Africa began routine reporting of AIDS to the World Health Organization (WHO) during or after 1987 and, as of May 1, 1991, more than 90,000 cases of AIDS had been reported from the region. The WHO, however, estimates based upon serological data up to early 1991 that more than 5 million adults in the region had been infected with HIV, of whom approximately 50% are women. Using that estimate, 1980 as the year when the extensive spread of HIV infection began, and assuming an adult progression rate from HIV infection to the onset of AIDS of 50% within 10 years, the WHO estimates that about 700,000 adult AIDS cases had probably occurred in sub-Saharan Africa by early 1991. The WHO further estimates that approximately 2 million children had been born to HIV-infected mothers in the region as of early 1991; more than 500,000 children are therefore thought to have been infected with HIV by early 1991. This paper considers preventing the sexual transmission of HIV, preventing HIV transmission through blood, and preventing perinatal HIV transmission. Objectives, strategies, and interventions to reduce the personal and social impact of HIV infection include providing health care to HIV-infected individuals, providing psychosocial support to HIV-infected people with and without AIDS, and promoting multisectoral actions to reduce the social and economic consequences of HIV infection. Challenges for the 1990s are discussed.^ieng

Treatment, prophylaxis and research priorities for developing countries.

PIP: An estimated two million new adult and pediatric HIV infections occurred worldwide during 1992, more than 50% of them in sub-Saharan Africa, 25% in Asia, and one-eighth in Latin America and the Caribbean. The remaining infections occurred in Europe, North America, and the industrialized countries of the Pacific Rim. Transmission by sexual intercourse and from an infected woman to her fetus/child remain major routes of transmission. The World Health Organization estimates that there will be a cumulative total of 30-40 million people infected with HIV by the year 2000. Over time, increasing numbers of people already infected with HIV and soon to be infected will develop AIDS and require higher levels of care. Obstacles to increasing access to cost-effective drugs for HIV/AIDS in developing countries, however, include weak drug distribution systems, the improper prescribing of available drugs by health workers, and the improper use of these drugs by patients who have not been appropriately educated by prescribing health workers. Currency shortages and lack of political will underlie these obstacles. This paper considers cost-effective prophylaxis and treatment of HIV-related infections including tuberculosis, candidiasis, penicilliosis, combined chemoprophylaxis, pruritus and diarrhea with wasting, and HIV infection. The prevention of HIV transmission is discussed under headings on heterosexual and perinatal transmission, followed by a discussion on increasing access to cost-effective drugs.^ieng

Collaborative AIDS prevention research in the developing world: the CAPS experience.

BACKGROUND: Prevention through behavior change is the only way to control the spread of HIV infection in the developing world. Success in prevention requires consistent and persistent intervention over time, a clear understanding of the realities of target populations and involvement of members of these populations in prevention efforts. Applied local research is urgently needed, especially in the developing world, to design interventions that meet these criteria and to test their effectiveness. CENTER FOR AIDS PREVENTION STUDIES (CAPS) MODEL OF INTERNATIONAL COLLABORATIVE RESEARCH: Each year, eight to 10 scientists from developing countries visit CAPS in San Francisco for 10 weeks of intensive learning and collaboration. The main emphasis is on designing a protocol for a research project related to AIDS prevention in the visiting scientist's home country. CAPS provides pilot study funding and technical assistance to implement the project. RESULTS: The quality of the resulting collaborative research is represented by the articles published in this volume and by the many alumni of the program who have undertaken additional research projects and/or assumed leadership positions in AIDS control efforts in their countries.

PIP: Prevention through behavior change is the only way to control the spread of HIV infection in the developing world. Success in prevention requires consistent and persistent intervention over time, a clear understanding of the realities of target populations, and involvement of members of these populations in prevention efforts. Applied local research is urgently needed, especially in the developing world, to design interventions that meet these criteria and to test their effectiveness. The Center for AIDS Prevention Studies (CAPS) model of international collaborative research has been used at the University of California, San Francisco, for the past eight years. The model involves an intensive period for protocol development and another one for data analysis. Each year, 8-10 scientists from developing countries visit CAPS in San Francisco for 10 weeks of intensive learning and collaboration. They are immersed in HIV epidemiology, research design, computer skills, data management, and psychosocial aspect of the AIDS epidemic. The main emphasis is on designing a protocol for a research project related to AIDS prevention in the visiting scientist's home country. The greatest impediment to intervention trials in developing countries is lack of funding. CAPS provides pilot study funding and technical assistance to implement the project in the home country. In the summer of 1995 eight alumni worked intensively with the CAPS faculty on data analysis and manuscript preparation. The quality of the resulting collaborative research is represented by the articles published and by the many alumni of the program who have undertaken additional research projects and/or assumed leadership positions in AIDS control efforts in their countries. These studies cover a wide range of risk groups, including sexually transmitted disease patients in Zambia; adolescents in the Philippines and Russia; wives of HIV-infected men in Uganda; female sex workers in Brazil, India, and Thailand; and HIV-infected women of childbearing age in Rwanda.

Socioeconomic obstacles to HIV prevention and treatment in developing countries: the roles of the International Monetary Fund and the World Bank.

PIP: This paper explores the socioeconomic obstacles to HIV prevention and treatment in developing countries. The opening sections explain the historical origins of structural adjustment programs and their characteristics. Structural adjustment programs undermine the social fabric of many developing countries, and potentially promote behaviors which place people at increased risk of HIV infection. The authors discuss the declining sustainability of the rural subsistence economy, development of a transportation infrastructure, migration and urbanization, and reductions in spending on health and social services. Social and economic interventions are needed to stem the spread of HIV and care for those who are already infected. While a substantial amount of biomedical research has been conducted, socioeconomic aspects of the AIDS epidemic have often been ignored. For HIV transmission in developing countries to be substantially reduced, economic policies which may have promoted the spread of disease must be modified. An alternative development strategy consists of satisfying people's basic human needs, shifting from an export-driven economy to diversified agricultural production in the interest of securing regional self-sufficiency, supporting marginal producers and subsistence farmers, and placing greater emphasis upon human resource development in developing countries. Moreover, the IMF and World Bank need to change their policy to one which is truly about cooperative development, while the charters of the IMF and World Bank need to be altered to permit the cancellation or rescheduling of debt. These institutions should also play a leading role in the restructuring of debt owed to private lenders.^ieng

Safer sex maintenance among gay men: are we making any progress?

PIP: Although early acquired immunodeficiency syndrome (AIDS) prevention programs produced dramatic reductions in unsafe sexual practices on the part of homosexual men, there is evidence that new behaviors have not been maintained consistently. Various cohort studies have related risky sex relapse to low self-efficacy, emotional depression, and relationship issues. Unprotected sex is widely perceived as more pleasurable than condom use and is likely to be practiced by gay men concerned with their partner's presumed preferences. This finding suggests a need to identify ways of increasing the pleasure associated with safe sex by eroticizing condom use. Approaches that include erotic descriptions of safe sex (e.g., pamphlets with explicit photographs, mass media campaigns that use sexually explicit language, and attractively packaged condoms) have been found to increase behavioral risk reduction practices. All interventions aimed at preventing risky sex relapse should be empirically based and delivered in a fashion acceptable to the homosexual community.^ieng

Social marketing sexually transmitted disease and HIV prevention: a consumer-centered approach to achieving behaviour change.

This paper proposes that international sexually transmitted disease (STD)/HIV prevention efforts might be enhanced by the application of social marketing principles. It first outlines the conceptual basis of social marketing approaches to health behaviour change generally and then explores key issues and opportunities for using these principles to improve current STD/HIV prevention efforts.

PIP: Social marketing is a research-driven, consumer-centered process used in the field of public health to change individuals' behavior. Social marketing differs from other health education strategies only in its approach, which is based upon commercial marketing techniques. In social marketing campaigns, social products such as condom use are viewed as commercial products and promoted using the same principles applied in the commercial sector. With consistent and long-term government commitment, social marketing programs have been highly effective. When used properly, social marketing-based public health interventions can help to prevent and control STDs and HIV. Health consumer behavior and focus, targeting and audience segmentation, social market research, the social marketing mix, and implications for social marketing STD/HIV prevention are discussed. Decreasing sexual partner change and making sex safe, improving access to effective STD treatment, and condom social marketing are then discussed as elements of social marketing to reduce sexual risk, followed by an examination of important policy considerations.

Beyond the dichotomy: linking HIV prevention with care.

In the past decade, the global strategy against AIDS has focused primarily upon prevention. Regardless of the effectiveness of prevention efforts being made today and advances in treatments, the numbers of persons infected globally continues to grow at an alarming rate, especially in developing countries. With numbers of infections increasing, and the trend to more people learning their HIV status earlier, demands for care will mount dramatically into the next century. This paper examines the virtually unexplored role care can play in prevention and its potential to have a mitigating effect on the pandemic. Critical issues addressed include (i) the relationship between care, HIV and productivity; (ii) the role of both care and prevention in promoting acceptance of HIV/AIDS as a community problem; (iii) the role of care in decreasing the vulnerability to HIV in specific populations such as women and children; (iv) the role of care in sustaining behavior change over time for infected persons; and (v) the synergy between improved treatments and prevention. Future areas of research are proposed examining these prevention and care issues that move beyond the traditional dichotomy.

PIP: The global strategy against AIDS over the past decade has focused mainly upon preventing the spread of HIV infection to additional populations and individuals. However, despite such prevention efforts and advances made in treatment, the number of people infected globally with HIV continues to grow at an alarming rate, especially in developing countries. The provision of care for HIV-infected people has historically not been viewed as a component of the overall strategy to reduce the incidence of HIV infection. However, HIV-infected people are important partners in preventing the spread of the virus. If they feel abandoned by care services, they may be less likely to understand the need for prevention and therefore less motivated to protect others. Demands for HIV/AIDS care will grow dramatically into the next century. The authors examine the largely unexplored role care can play in prevention and its potential to have a mitigating effect upon the pandemic. Main issues addressed include the relationship between care, HIV, and productivity; the role of care and prevention in promoting acceptance of HIV/AIDS as a community problem; the role of care in decreasing the vulnerability to HIV in populations such as women and children; the role of care in sustaining behavior change over time for infected persons; and the synergy between improved treatments and prevention. Future areas of research into prevention and care are proposed.

Applying social, behavioral and evaluation research to developing country HIV prevention programs.

OBJECTIVE: To examine the role that social, behavioral and evaluation research played in a 6-year global HIV prevention program working in 45 developing countries. METHODS: Computerized review of project database inventories: 320 research abstracts, 591 subproject abstracts, on-line literature search of project peer-reviewed literature, and hand review of 390 final project reports and country evaluations. DESIGN: Research included descriptive, correlational, ethnographic, survey, quasi-experimental and experimental designs. RESULTS: Over 400 social, behavioral and evaluation studies were conducted and consisted of program-related research, controlled intervention research and multi-year competitive research grants to advance the science of HIV prevention. Program research involved extensive use of qualitative methodologies and the development of innovative research tools such as rapid ethnographic assessments, behavioral surveillance surveys, and targeted intervention research. Intervention studies and multilevel evaluations of prevention programs in 19 countries demonstrated that HIV prevention has changed knowledge, attitudes, and behavior in target groups. Triangulating the results of a variety of data sources and methodologies, and increasing reliance on surveillance of behavioral trends among targeted population groups helped to circumvent numerous methodological problems. CONCLUSION: Linking research to program interventions is a critical component of effective HIV prevention but operationalizing the linking process remains a major challenge.

PIP: The campaign against HIV/AIDS has been hindered by a disjunction between behavioral research and the design of preventive interventions. A review was conducted of over 400 social, behavioral, and evaluation studies conducted as part of Family Health International's AIDS Control and Prevention Project in 45 countries in Latin America, Africa, and Asia in 1992-1997. Program-related research showed a shift from repetitive studies of knowledge, attitudes, and practice (KAP) to studies that yielded tangible information on how people change. Extensive use was made of findings from focus group discussions, key informant interviews, and baseline and follow-up KAP surveys to design culturally relevant interventions. Behavioral research evolved over time from a focus on traditional high-risk groups to broader populations such as adolescents and women. Most research continues to be descriptive, conducted in response to urgent program needs (e.g., for baseline data), and focused on individuals rather than social organizations. Valid assessment of the effectiveness of behavior change interventions presents numerous methodological and evaluation problems, including the bias inherent in self-report data, an inability to attribute behavioral changes to specific interventions, and the insensitivity of HIV prevalence as an indicator of short-term behavior change. However, the results of controlled intervention studies attest that prevention had had a substantial impact on HIV knowledge, attitudes toward those infected with HIV, perceptions of individual risk, and sex behavior among target groups. Continued triangulation of the results of a variety of sources and methodologies will reduce systemic bias in the research data.