Towards Combination Prevention

Good evening. It is an honour to make the first presentation of this important satellite session and I am delighted to see so many of you here. For me this great turnout shows that there is momentum building to make a new commitment to prevention and to put it at the forefront of HIV where it belongs. Having been responsible for this area while in UNAIDS, nothing could make me happier than to see HIV prevention get the attention it merits.

Tonight we will hear a number of interesting and important presentations from around the world on combination prevention. I want to set the stage by talking about what combination prevention means and why it is so important.

We’ve heard this statistic many time times in this Conference - For every two individuals starting on antiretroviral treatment five new people get infected with HIV. We know this statistic too well but we are simply doing too little about it. If we don’t intensify our efforts to prevent new infections we cannot turn the course of the HIV epidemic and we cannot sustain treatment. This is why we are making a new commitment for a prevention revolution.

In HIV prevention, no single strategy will ever be enough. There is no magic bullet. Not even treatment as prevention. Instead we need a combination approach that is carefully tailored to national and local needs, that focuses resources on both immediate risks and underlying vulnerability, and operates consistently on multiple levels, individual, relationship, community and society.

What does this mean in practice? It means it is not enough just to provide access to condoms if people don’t want to use them. It is not enough to change a law if its enforcement is not human rights based and appropriately applied. It will not be enough to make health services available if people are stigmatised when they use them. Access must be coupled with demand creation. Communities must be involved in ensuring an individual’s ability to exercise their rights. And discrimination must be fought at all times for uptake of prevention services.

In this satellite session we are focusing on combination prevention and key populations – sex workers, transgender people, people who use drugs and men who have sex with men. In a very real sense the needs, rights and realities of key populations best illustrate why the holistic approach of combination prevention is the only way forward for an effective response.

The starting point for combination prevention programming is: know your epidemic. We must know the epidemic and the modes of HIV transmission and take into account the populations or groups most at risk and the context that shapes their risk and vulnerability.

We have learnt enough to know that even within a national level epidemic there can be significant variation in what is happening between rural and urban areas, in border areas, in humanitarian settings, and among specific population groups. This knowledge of the epidemic must be translated into carefully tailored approaches that are community owned and respond specifically to the local needs.

Secondly, combination prevention is about addressing the specific factors that make key populations more vulnerable to HIV infection.

Resources need to be focused on both the immediate risks and the underlying vulnerability through a mix of biomedical, behavioral and structural interventions which are tailored to local needs.

Biomedical approaches we know well: condoms – male and female, male circumcision, PEP-kits, blood safety, preventing mother-to-child transmission, and treatment as prevention. While new technologies are on the way – and we have heard of the exciting CAPRISA research in the past few days - right now, we need to make efficient use of the ones that are currently available. In this context, I am happy to report that 2009 was a record year for the distribution of female condoms with 50 million distributed worldwide. Not enough but an encouraging development.

We know that behavioral strategies are as important as the biomedical approaches. Information, education and communication are vital not only in changing individual behavior to reduce the risk of contracting HIV but also in reducing stigma and discrimination and fostering a spirit of tolerance and inclusion.

To really get to the deep-rooted drivers of the epidemic, we need to complement the portfolio of interventions with strategies to address the structural factors that are outside the control of individuals but influence their perceptions, their behaviour and their health and can impede prevention uptake and enhance vulnerability to HIV - poverty, gender inequality, legal inequities, stigma, discrimination and social exclusion, being some of them.

Today, there is wide recognition that structured interventions are a critical component of effective prevention programmes, including redefining gender norms and creating enabling legal and policy environments for HIV prevention, treatment, care and support.

Thirdly, an effective combination prevention strategy has to operate consistently on multiple levels including individual, relationship, community and societal levels.

For instance, while removing punitive national laws is important, it is of equal importance that human rights-based legal reform is enacted at the local level and that implementation is monitored closely by communities. While it is important to strengthen national health systems we also need to ensure that services are, in practice, accessible, affordable, non-judgmental and of quality, available for the most marginalized.

To have the kind of in-depth knowledge and reach needed for an efficient intervention, we must have meaningful partnerships with community organizations and networks. A meaningful partnership means more than just having a tokenistic dialogue. We need partners who are involved in developing, implementing, monitoring and evaluating programmes and also in designing technical guidelines. Easier said than done in practice, causing many prevention programmes to fail, without full engagement, of and total ownership by communities.
We will hear examples from our speakers but here I would like to contribute one:

Brazil stands out as one national example of successfully using combination prevention. With strong political support for a vigorous HIV response, the country has based its national response on human rights principles, social solidarity, and community empowerment strategies, carrying out community-level social marketing campaigns to raise HIV awareness and reduce behaviours that place people at risk of HIV infection, closely integrating prevention and treatment programmes, massively distributing condoms, allocating substantial resources and services towards key populations, and critically engaging organizations of sex workers, men who have sex with men, transgender people and people who use drugs as equal partners in the response.

When we look at HIV prevention, we see that many gaps still remain. Addressing these gaps should guide our efforts for combination prevention. Today, fewer than half of people at high risk of HIV infection receive the prevention support they need. Less than 40% of people living with HIV know they are infected. In planning HIV prevention strategies, many countries are working in the dark, lacking basic information about the dynamics of their national and local epidemics, wasting their limited resources.

And sometimes when the information is there, it is simply ignored. We have the data: men who have sex with men, who are 19 times more likely to become infected with HIV than the general population; fewer than 1 in 5 sex workers receive adequate HIV prevention services and, of the estimated 16 million injecting drug users worldwide, almost 3 million are living with HIV, and only 4% of those are on HIV treatment. Not reaching these populations, when we know this is absolutely unethical.

So we have set a task for ourselves: we are calling for a prevention revolution. We need to make prevention a priority in our HIV work and design and implement effective programmes that reach and involve key populations such as sex workers, men who have sex with men, transgender people, and injecting drug users who are at greatest risk and most affected in this epidemic.

Currently, combination prevention is more of an aspiration than a reality and this is holding us back from achieving an effective response. Most responses focus on one or a few approaches and do not match their response to the nature of their local epidemics. This is why UNAIDS and partners are advocating for the right policy environment to support combination prevention through the Joint Outcome Framework.

What do we need immediately?

First, we need to ensure that HIV responses are urgently scaled up and adapted to different local contexts and individual needs. For instance, sex workers and injecting drug users are men and women who have sexual and reproductive health needs and are entitled to the protection of their human rights. When thinking of preventing mother-to-child transmission, do we think of pregnant sex workers or injecting drug users? And do we think of injecting drug users or sex workers who are HIV positive and aspire to have children? We need to.

Second, we need to work with local communities and ensure that human rights become a reality of people's daily lives. This requires cultural knowledge and sensitivity and community dialogue and listening to people’s hopes, fears and dreams.

We need to support existing and emerging community leaders and advocates to build their efforts. We need to prioritize work in locations where HIV advocacy and HIV interventions are already led by and for men who have sex with men, drug users, sex workers, and transgender people. Where communities are already visible and mobilised, we need to support expanded investment in helping those communities to scale up informed and effective HIV interventions.

Environments that support health promotion are created through concrete and effective community action in setting priorities, making decisions, and planning and implementing strategies to achieve better health. At the heart of this process is the empowerment of communities—their ownership and control of their own endeavors and destinies.

Third, we need to promote and protect human rights for all. As the IAC theme say: Right here, rights now. Today many countries still criminalize sexual minorities, people who use drugs, people who engage in sex work, as well as people living with HIV. The result is that too many people fear or are unable to get tested for HIV, to disclose their HIV status and to access HIV prevention, treatment and care. This puts both these groups and the larger public at risk. We need to ask ourselves, what are the driving forces behind stigma and discrimination? What are the driving forces behind human rights violations that deprive individuals their fundamental right to health? Eliminating those underlying forces is an essential part of effective HIV prevention.

Where the right laws are in place, we need to ensure that resources are allocated to raise awareness and enforce them correctly and that, for example, legal services are available for all citizens but in particular for vulnerable groups to know their rights. When sex workers are unduly arrested for carrying condoms or when men who have sex with men are rejected from a health care facility because of their sexuality, their vulnerability to HIV is increased and their human rights are violated. We need to make sure that they know it and the judicial, health care, and the police know this.

Legal and policy reviews should also consider and address the societal determinants of HIV risk and vulnerability. Promoting efforts towards gender equality and equal access to information and services can help people to negotiate safer sex, safer drug use and increase the use of HIV treatment. We know that providing harm reduction services to drug users actually decreases drug use – a win-win outcome with less drug use and less HIV transmission. The value of harm reduction – the provision of needle and syringes and opioid substitution therapies – is not only reducing individual risk to drug users but provides a mechanism for social inclusion of drug users by addressing the root causes of social marginalization. By viewing harm reduction as an essential component of crime reduction and engaging law enforcement, organizations of people who use drugs, health service providers in constructive partnerships the human rights of people who use drugs are protected and their immediate risk and vulnerability to HIV infection are reduced.

In conclusion, we need to recognize that combination prevention is about embracing and addressing the complexity of the HIV epidemic without making the response so complex that we are frozen into inaction. This common-sense approach allows us to yield stronger results, both in the short and long term, by putting structural interventions at the centre while also mitigating immediate risk.

Bringing existing HIV prevention strategies to scale – focusing the right interventions at the right scale on the right populations – would avert half or more of all HIV infections projected to occur by 2015 and put us on the right course forward.

If we want zero new infections, zero discrimination and zero AIDS-related deaths, right here, right now, a prevention revolution is inevitably needed. Right here, right now, we must make our prevention efforts a priority and we must make them more efficient. And right here, right now, we must make the right to prevention, treatment, care and support a reality for the most vulnerable.

Thank you.