"All programmes require a strong community empowerment element and specific efforts to address legal and policy barriers, as well as the strengthening of health systems, social protection systems and actions to address gender inequality and stigma and discrimination."
This Joint United Nations Programme on HIV/AIDS (UNAIDS) report describes concerning trends in new HIV infections among adults worldwide, also breaking down data by specific regions in focus. Noting that, since 2010, the annual number of new infections among adults (15+) has remained static at an estimated 1.9 million, it gives the clear message that HIV prevention efforts need to be increased in order to stay on the Fast-Track to ending AIDS by 2030. The present summary focuses on the communication-related elements of the extensive report.
The report explains that getting back on track to reducing new infections to 500,000 by 2020 requires continued progress towards the 90-90-90 target and intensive focus on five prevention pillars delivered through a people-centred approach:
- Combination prevention, including comprehensive sexuality education, economic empowerment, and access to sexual and reproductive health services for young women and adolescent girls and their male partners in high-prevalence locations.
- Evidence-informed and human rights-based prevention programmes for key populations, including dedicated services and community mobilisation and empowerment.
- Strengthened national condom programmes, including procurement, distribution, social marketing, private-sector sales, and demand creation.
- Voluntary medical male circumcision in priority countries, as part of wider sexual and reproductive health service provision for boys and men.
- Pre-exposure prophylaxis (PrEP) for population groups at higher risk of HIV infection.
As noted here, the heterogeneity of the HIV epidemic underscores the importance of a location-population approach to efficient planning and programming of HIV prevention services. Many populations continue to be left behind. Gender inequalities, including gender-based violence, exacerbate women's and girls' physiological vulnerability to HIV and block their access to HIV services. Young people are often denied the information and the freedom to make free and informed decisions about their sexual health, with many lacking the knowledge required to protect themselves from HIV. Key populations - including sex workers, people who inject drugs, transgender people, prisoners and gay men and other men who have sex with men - remain at much higher risk of HIV infection.
However, according to UNAIDS, few countries have consistently applied a combination HIV prevention approach, which provides packages of services - including behavioural, biomedical, and structural components - tailored to priority population groups within their specific local contexts. To help address this weakness, the report offers a chapter focused on structural change, which is a requisite component of combination HIV prevention. Here, the reader learns that harmful cultural and social gender norms, for example, block HIV prevention and increase risky behaviour. Homophobia drives gay men and other men who have sex with men away from HIV testing and HIV prevention activities, and is associated with lower adherence to treatment. The way forward involves steps to, for example: strengthen legislation, law enforcement, and programmes to end intimate partner violence; increase girls' access to secondary education; remove third-party authorisation requirements and other barriers to women and young people's access to HIV and sexual and reproductive health services; decriminalise same-sex relationships, cross-dressing, sex work, and drug possession and use for personal consumption; and bring to scale community empowerment and other programmes that have been proven to reduce stigma, discrimination and marginalisation, including in health-care settings.
Along these lines, UNAIDS notes that specific pillars of the response - for example, condom programmes - need to be predicated on sexual and reproductive health and rights and gender equality. Continuing with the example of condom programming, UNAIDS contends that the challenge ahead is to invest in, and scale up, a new generation of data-driven and people-centred approaches that include demand creation, community mobilisation, supply chain management, planning, programme management, and monitoring and evaluation. Comprehensive condom programmes include the public and private sectors and social marketing. In order to be responsive to individual and context-specific needs, organisers of such programmes must ensure that vulnerable populations - young people, people living with HIV, sex workers, men who have sex with men, and people who inject drugs - are involved in the planning and implementation of condom programming. These populations should also contribute to efforts to improve data and increase innovation through programme science, market research, needs estimates, costing, and monitoring and evaluation.
This theme of community engagement is one explored, for example, in the chapter on eliminating new HIV infections among children. It has been found that a major contributor to the successful increase in treatment coverage for pregnant women living with HIV was the involvement of communities. Networks and support groups of women living with HIV were particularly valuable in boosting outreach activities and service delivery, providing counselling, supporting treatment adherence, educating women about their reproductive rights, encouraging them to seek care and HIV testing, and providing psychosocial support. In many countries, community health workers were trained and enlisted in providing basic services, strengthening referral systems, and supporting mothers and their families. Community organisations tend to be most effective when they receive adequate support from the formal health system and when their capabilities and expertise are recognised.
In a similar vein, UNAIDS stresses that engaging male partners and fathers as parents who also desire healthy children and healthy families is vital to continued success. Successfully engaging men in testing and treatment to prevent HIV transmission reduces the number of new infections in women, and the greater engagement of men would improve results at every step of the cascade for elimination. Men need to be involved in family planning, with reproductive health positioned as the domain of both sexes, and more emphasis should be placed on promoting and facilitating couples testing.
UNAIDS asserts that behaviour change communication and demand generation form a basic component of combination prevention; to that end, an entire chapter of the report focuses on these approaches. They are described as an inclusive way of addressing the cultural contexts within which risk behaviours occur, and of stimulating uptake of HIV prevention services. These programmes entail a range of activities, from individual counselling to community awareness-raising to communication through mass media. They also feature intensive approaches involving a combination of activities to address multiple outcomes, including knowledge, risk perception, norms, skills, sexual behaviours, and HIV service demand. Multi-media, school-based, and broader community mobilisation activities complement the delivery of HIV services such as condom distribution, voluntary medical male circumcision, HIV testing, and PrEP. As new biomedical tools are rolled out, effective social-behavioural and structural programmes help mitigate the potential emergence of risk compensation.
However, as noted here, there are prevention gaps in this area. For instance, data show that most young people lack the knowledge required to protect themselves from HIV. In 23 countries outside of sub-Saharan Africa, just 13.8% of young men and 13.6% of young women had correct and comprehensive knowledge about HIV. Furthermore, there are gaps in personal risk perception. In one survey, a significant proportion of young adults living with HIV who did not yet know their HIV status, said they did not perceive themselves at high risk of HIV. Systematic implementation of behaviour and social change communication and demand generation has not taken place. However, according to UNAIDS, the evidence from recent initiatives like SHARE, SASA!, and Stepping Stones has rekindled interest in these programmes, with critical elements being incorporated into new, large-scale programmes, such as DREAMS, which provides HIV services to young women and girls and addresses structural drivers that increase their HIV risk, including poverty, gender inequality, sexual violence and a lack of education, in 10 countries of eastern and southern Africa.
Comprehensive sexuality education is a specific form of social and behaviour change communication programme involving young people in the school setting. Evidence cited here indicates that comprehensive sexuality education can facilitate the adoption of safer sexual behaviours, such as delayed sexual debut and increased condom use, and thereby contribute to reducing sexually transmitted infections, HIV transmission and unintended pregnancy. By 2015, many countries had embraced the concept of comprehensive sexuality education and were engaged in strengthening its implementation at the national level. Despite this, a major gap remains between global and regional policies and the actual implementation of comprehensive sexuality education on the ground.
With regard to behaviour change communication and demand generation, suggestions for the way forward include:
- Ensure that the design and implementation of behaviour change programmes are based on solid evidence of what works.
- Widely disseminate objective, comprehensive information on sexuality, including through comprehensive sexuality education.
- Leverage information and communication technology (ICT) to improve behaviour change communication and link people at risk of HIV infection to services. While stand-alone media approaches are unlikely to yield the desired results, the leveraging of new information tools, such as the integration of mobile telecommunications within health programmes, has been shown to improve service delivery.
The report concludes that evidence from a diversity of countries shows that a combination approach to prevention - comprehensive packages of behavioural, biomedical, and structural components, tailored to priority population groups within their specific local contexts - produces the strongest results. UNAIDS contends that of critical importance for the future of the prevention response will be the relationship between government and community actors. Country compacts should include strengthened and clearly defined civil society roles in prevention programme planning, implementation, and joint monitoring of progress against targets. Experience from Australia, India, South Africa, and several countries in western and central Europe and North America shows that prevention programme implementation, especially with regards to key populations, should be carried out in collaboration with civil society and peer organisations that have the trust and ear of the populations at greatest need of services. Formal contractual arrangements between government and civil society organisations, including supervision and mentoring, and capacity building, should be put in place across countries. More broadly, global targets need to be translated into national and sub-national implementation plans that focus on the populations and locations in greatest need, and address the legal, social, and economic barriers to prevention service access and uptake at national and local levels.
Editor's note: In addition to the full report, a 36-page summary document [PDF] is available.
UNAIDS website, September 26 2017. Image credit: UNICEF India/Candace Feit