Authors: Julie Pulerwitz and John Bongaarts, crossposted on May 27 2014 - The achievement of an AIDS-free future will surely be a priority discussion topic at the upcoming International AIDS Society conference in Melbourne, Australia. The discovery that antiretroviral therapy (ART) limits HIV transmission1 follows several years of steady progress in controlling the epidemic, with the number of new HIV infections falling from 3·7 million in 1997 to 2·3 million, and AIDS deaths from 2·3 million in 2005 to 1·6 million in 2012.2 Nevertheless, the number of people living with HIV is still rising as the number of new infections exceeds the number of deaths in this group. Moreover, coverage of ART in people meeting even the 2010 WHO [World Health Organization] standard for treatment (ie, CD4 cell count <350 cells/μL) is still far from complete, and plans to expand treatment to cover all people living with HIV for the rest of their lives are viewed with scepticism by some people.3 Crucial international funding for HIV and AIDS has remained static for several years.2 Although funding from national budgets is rising, countries will find it very difficult to cover the growing cost of treatment, especially when the more expansive 2013 WHO standard (ie, CD4 cell count <500 cells/μL) is applied.
Sub-Saharan Africa remains the region most affected by HIV, but the rapid scale-up of ART programmes has had clear results: the number of AIDS deaths - which has risen steadily since the 1970s and peaked in 2004-05 at 1.8 million - fell to 1.2 million by 2012.4 In the African region, an equally important but underappreciated reason for the recent decline in deaths is the peaking of new infections in 1997 at 2.7 million. Most of the subsequent decrease to 1.6 million new infections in 2012 occurred before ART became widely available in the mid-2000s. Instead, behavioural change in response to the threat of AIDS and to prevention efforts underlies this trend. Its effect is well documented in Uganda and Zimbabwe,5, 6 but reductions in risky behaviour have also occurred in other countries.2 One of the most striking trends since the early 1990s7 is the rise in condom use in women not in marital unions (figure). This trend seems to be an important reason why infection rates in young women have fallen sharply. Without the change in behaviour and resulting decline in HIV incidence, the number of AIDS-related deaths in sub-Saharan Africa would now be substantially higher than it actually is.
However, millions of people are still becoming infected with HIV every year, and key populations such as sex workers, injection drug users, and men who have sex with men are disproportionately affected. Compared with the general population, men who have sex with men and sex workers are 13·5 times more likely to be infected with HIV, and injection drug users are 20 times more likely to be infected with the virus.8 Although the overall prevalence of HIV is falling, epidemics in these key groups are expanding in many places worldwide.9 Prevention of HIV in these marginalised groups is difficult to address because of stigma, discrimination, and their sequelae.2, 10, 11 Key populations actually experience a double stigma related to both being associated with HIV and the reinforcement of pre-existing stigmas.12 This situation has led to inadequate access to service provision and treatment, in addition to many other negative outcomes. Increasing evidence indicates that “prevention basics for key populations can be highly effective”.13 Calls are growing to bring behavioural approaches, including harm reduction and condom promotion, “back to the centre of the debate for HIV prevention”.14, 15 To more effectively reach key populations with the prevention basics, explicit reduction in HIV stigma should be made a priority. One notable example is HIV counselling and testing, a health system entry point that can address both prevention or treatment and care objectives, including treatment as prevention. Stigma inhibits the use of HIV counselling and testing, and evidence suggests that addressing of stigma will probably increase access to and use of HIV counselling and testing.16
Stigma and discrimination experienced by sex workers, injection drug users, and men who have sex with men is tough to tackle. Responses need to be tailored to very different circumstances and require interventions on several levels: policy, societal, health system, and individual. There is no magic bullet response, however, many examples exist of stigma-reduction strategies and programmes with proven effectiveness.17-19 The effects of such programmes have often been limited because they are rarely taken to scale, and appropriate targeting to and tailoring for key populations has not been done frequently.
Funding to address stigma confronts two problems: not only do general primary prevention strategies (such as the promotion of behaviour change) suffer from “striking underfunding”3 but also prevention efforts for key populations remain minimum to non-existent throughout much of the world.2 Additionally, 90% of current HIV programme funds for sex workers, injection drug users, and men who have sex with men come from international donors.8 Without more political and economic commitment from local governments, the needs of key populations will be difficult to address.
It is hard to envision that significant progress will continue to be made in HIV prevention efforts with key populations without a prioritisation of stigma reduction and the allocation of adequate funding for behavioural and social change. The importance of tackling stigma has long been recognised, and now is the time to put stigma reduction at the forefront of programmatic responses.
From the authors: We declare no competing interests.
1 Cohen M, Chen Y, McCauley M, et al. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med 2011; 365: 493-505.
2 UNAIDS. Global report: UNAIDS report on the global AIDS epidemic 2013. (accessed Feb 12, 2014)
3 Shelton J. HIV/AIDS. ARVs as prevention: a tough road to wide impact. Science 2011; 334: 1645-1646.
4 UNAIDS. AIDSINFO website. (accessed Jan 22, 2014).
5 Stoneburner RL, Low-Beer D. Population-level HIV declines and behavioral risk avoidance in Uganda. Science 2004; 304: 714-718.
6 Gregson S, Garnett G, Nyamukapa C, et al. HIV decline associated with behavior change in eastern Zimbabwe. Science 2006; 311: 664-666.
7 USAID. STATcompiler. (accessed Jan 22, 2014).
8 UNAIDS. Global report: UNAIDS report on the global AIDS epidemic 2012. (accessed Feb 12, 2014).
9 Beyrer C, Baral S, van Griensven F, et al. Global epidemiology of HIV infection in men who have sex with men. Lancet 2012; 380: 367-377.
10 Altman D, Aggleton P, Williams M, et al. Men who have sex with men: stigma and discrimination. Lancet 2012; 380: 439-445.
11 Beyrer C, Malinowska-Sempruch K, Kamarulzaman A, et al. 12 myths about HIV/AIDS and people who use drugs. Lancet 2010; 376: 208-211.
12 Parker R, Aggleton P. HIV and AIDS-related stigma and discrimination: a conceptual framework and implications for action. Soc Sci Med 2003; 57: 13-24.
13 Laga M. Effect of HIV prevention in key populations: evidence accumulates, time to implement. Lancet Glob Health 2013; 1: e243-e244.
14 Laga M, Piot P. Prevention of sexual transmission of HIV: real results, science progressing, societies remaining behind. AIDS 2012; 26: 1223-1229.
15 Beyrer C, Malinowska-Sempruch K, Kamarulzaman A, Kazatchkine M, Sidibe M, Strathdee S. Time to act: a call for comprehensive responses in HIV in people who use drugs. Lancet 2010; 376: 551-563.
16 Obermeyer CM, Osborn M. The utilization of testing and counseling for HIV: a review of the social and behavioral evidence. Am J Public Health 2007; 97: 1762-1774.
17 Mahajan AP, Sayles JN, Patel VA, et al. Stigma in the HIV/AIDS epidemic: a review of the literature and recommendations for the way forward. AIDS 2008; 22: S67-S79.
18 Pulerwitz J, Michaelis A, Weiss E, Brown L, Mahendra V. Reducing HIV-related stigma: lessons learned from Horizons research and programs. Public Health Rep 2010; 125: 272-281.
19 Sengupta S, Banks B, Jonas D, Miles MS, Smith GC. HIV interventions to reduce HIV/AIDS stigma: a systematic review. AIDS Behav 2011; 15: 1075-1087.
Click here to access this blog on the Lancet website. Image credit: Population Council
Contacts: Julie Pulerwitz
HIV and AIDS Program, Population Council
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