From the Director
the continued urgency of HIV prevention in the era of treatment scale-up

By Anke A. Ehrhardt, Ph.D.

When one thinks about the global HIV/AIDS epidemic, the Middle East and North Africa (MENA) region may not be the first part of the world to come to mind. The devastation caused by AIDS in Sub-Saharan Africa, as well as in other regions including Southeast Asia and the Caribbean, has rightly focused much attention on those afflicted areas. But HIV is, of course, a pandemic – found in every region and, indeed, every country in the world, and as we know only too well, the epidemic can spiral out of control unless proactive steps are taken to promote effective HIV prevention. The MENA region, as an area of comparatively low seroprevalence, thus offers an important opportunity to try to get ahead of the virus. The HIV Center and our collaborators at the UCLA Program in Global Health (Director: Thomas J. Coates, Ph.D.) have undertaken a wide range of activities and initiatives in this region, a topic which is the subject of the lead story in this issue of the HIV Center E-Newsletter.

Despite important advances in the roll-out and scale-up of access to HIV treatments in the developed world, we will never be able to “treat ourselves out of the epidemic.” Given present technologies, those who acquire HIV are infected for life and thus able to further transmit the virus. With no viable vaccine on the horizon, prevention will remain key to halting the spread of HIV. In most of the world, the epidemic is predominantly transmitted through sexual contact. While intravenous drug use plays an important role in many regions and may be the critical mode of transmission in the beginning of an epidemic, typically it overlaps with increasing sexual transmission. In other words, HIV positive IDUs may not only infect others through needle sharing but also through sexual contact with non-IDUs and other uninfected IDUs.

Thus, prevention of sexual transmission is crucial, yet often impeded by a host of behavioral factors, such as low condom use and multiple concurrent partnerships, in interplay with social factors including age mixing between older men and younger women or girls, sexual violence, and economic dependence. Our unfolding work in the MENA region seeks to address these factors by maximizing knowledge gained through research into behavioral interventions.

Over the past 25 years, behavioral science research has established the efficacy of such interventions to reduce HIV risk behavior and disease incidence. A large number of well-designed, controlled, randomized trials have demonstrated substantial efficacy, including among women, [continued ...]

adolescents, drug users, men who have sex with men, and other vulnerable populations; these have employed individual, couple, small-group, and community-level interventions. Behavioral interventions are critical components of any strategic plan, but they are labor-intensive and are not sufficient by themselves to change the course of the epidemic. While we know what prevention strategies work, there remain huge barriers to implementation of a comprehensive and sustained effective efforts on prevention. Thus we will increasingly also need to turn to structural interventions, which are defined as programs or policies that change the environments in which risk behaviors occur, without necessarily attempting to directly change knowledge, attitudes, or social interaction patterns of the persons at risk.

The most dramatic success has been achieved in those countries that reacted quickly or mobilized the entire society, when the epidemic reached a critical level. Unfortunately, there are only a few success stories which can be reviewed. However, their strategies are impressive and quite consistent and, thus, can and should teach other nations important lessons. The decline in Uganda was the earliest reported in HIV prevalence for women between 15 to 49 years of age, declining from 30% to 10%. Uganda had initiated a comprehensive HIV program on ABC -- abstinence, be faithful, and condom information and distribution. Sexual changes were observed in delaying first sexual intercourse, having fewer sexual partners, and adopting condom use, particularly with casual partners. More recently, similar results have been reported in parts of Kenya and Zimbabwe. Thailand employed a different policy by focusing on brothels and making condom use mandatory for male customers and sex workers.

Fortunately, the Middle East and North Africa has not experienced an AIDS epidemic on the scale of that found in Uganda, Kenya, or Thailand. But it is for precisely that reason that the unfolding research agenda there is so promising. Of course, researchers with the HIV Center -- or indeed anywhere outside the MENA region itself -- can only have a limited impact. The crucial impetus must, ultimately, come from within those societies, and thus a great deal of our work has been to help build connections and collaborations with researchers from throughout the region. To learn more about the vision for HIV prevention in the Middle East and North Africa from an insider’s perspective, we invite you to read the article in this issue by our Cairo-based colleague Dr. Sherine Shawky entitled “An HIV Center in the Middle East and North Africa?”