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surprising prevention success: Why did the HIV epidemic decline
T. Halperin, Owen Mugurungi, Timothy B. Hallett, Backson Muchini,
Bruce Campbell, Tapuwa Magure, Clemens Benedikt, Simon Gregson,
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gains in the availability of antiretroviral medications in developing
countries have been achieved, there is growing consensus that, unless
prevention efforts can be made more effective, there will ultimately
be no victory in the fight against HIV/AIDS. Maintaining tens of
millions of people on treatment throughout their lifetimes will
not be sustainable or affordable, particularly as drug resistance
may increasingly result in the need for much more expensive second
and third line medications. Although there have been promising breakthroughs
in a few other areas, notably male circumcision and prevention of
mother-to-child transmission (PMTCT), it is widely recognized that
behavior change must remain the core of prevention efforts.
While the often
cited prevention success stories of Thailand and Uganda are inspiring
and informative, some of the specific socio-cultural, historical,
and other factors in the southern African region-now the global
epicenter of the HIV pandemic-are distinctive. In these ''hyper-endemic''
settings, where adult HIV prevalence ranges from 12% to 26% , HIV
transmission is highly generalized, whereas Thailand's epidemic
was much more concentrated. There, HIV transmission was driven mainly
by brothelbased sex work-enabling the aggressive ''100 percent condom''
programs to be feasible, enforceable, and effective. The unprecedented
HIV decline and associated behavior change in Uganda, mainly involving
large reductions in multiple sexual partnerships, occurred some
20 years ago and under rather different contextual and programmatic
data from national antenatal clinic surveillance and the household-based
2005/6 Demographic and Health Survey (DHS) were used to fit a mathematical
model to estimate trends in HIV incidence and AIDS deaths in Zimbabwe
(Figure 1A). Data from the DHS and other longitudinal surveys were
used to examine the possible contributions of changes in sexual
behavior to reductions in HIV infection. Published data from focus
group discussions with 90 adult men and 110 women in diverse urban
and rural sites and several dozen in-depth key informant interviews
as well as an extensive historical mapping of prevention programs,
were examined in assessing the contributions of different contextual
and programmatic factors to observed changes in behavior. Finally,
DHS data on various potential proximal and contextual determinants
of behavior change for Zimbabwe were compared with similar data
for seven other southern African countries to identify distinctive
patterns that might help to explain the earlier and faster HIV decline
observed in Zimbabwe (Figures 2, S1).
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