Prevention Issue Brief 0311

March 2011
The Foundation
for AIDS Research ISSUE BRIEF
Accelerating an HIV Prevention Revolution:
A Roadmap
In 2009, 33.3 million people were living with HIV/AIDS
and 2.6 million people were newly infected worldwide.1
Today, in the United States alone, an estimated 1.1
million adults and adolescents are living with HIV/
AIDS.2 Despite significant progress in knowledge about
HIV/AIDS and its treatment over the past 25 years,
much remains to be done to slow the rapid spread of
this disease: as of 2010, for every two people starting
antiretroviral treatment, five more were newly infected
worldwide.3
Experts agree that stemming the tide of the AIDS epi-

demic will require a significant emphasis on prevention.4
A recent report from the Institute of Medicine under-
scores that prevention must be the central tenet of the
long-term response to HIV/AIDS, especially given the
significant challenges that treatment scale-up faces in
the current global economic downturn.5 However, recent
scientific advances related to the effectiveness of pre-
exposure prophylaxis (PrEP), microbicides, and AIDS
vaccine development, as well as the establishment of a
high-level United Nations Commission on HIV Prevention
and the release of the National HIV/AIDS Strategy in the
U.S., have reinvigorated the hope for a prevention revo-
lution in the years ahead.
Adapted from: AIDS Vaccine Advocacy Coalition. Piecing together

Expansion of preventive interventions could the HIV Prevention Puzzle. 2009.
potentially avert more than half of the HIV

infections projected to occur by 2015 and
Prevention is not only the most effective defense against
could save $24 billion in AIDS treatment the virus, but also the most cost-effective. Researchers
costs globally. estimate that for every HIV infection prevented in the U.S.,
approximately $355,000 is saved in medical treatment
HIV prevention consists of a range of educational costs.7
programs, services, and technologies to reduce HIV
transmission. To be successful, interventions must be Despite their promise and effectiveness, HIV prevention
tailored to the needs of diverse groups at the national and programs have received inadequate resources and
community levels.6 Federal, state, and local health systems attention. Prevention programs currently reach less than
must be strengthened in order to carry out the broad half of people at high risk for HIV worldwide (see Figure
and systematic efforts needed to stop the spread of HIV. 1).1 Additionally, only 28.8% of the U.S. President’s
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2 Accelerating an HIV Prevention Revolution: A Roadmap
Emergency Plan for AIDS Relief (PEPFAR) budget While HIV/AIDS prevention efforts have proven effective in
supports prevention programs including counseling and slowing the rate of the epidemic, no single prevention tech-
testing.8 Expansion of preventive interventions could nology or strategy can be 100% effective. Therefore, a com-
potentially avert more than half of the HIV infections bination prevention approach that integrates evidence-based
projected to occur by 2015 and could save $24 billion behavioral, biomedical, and structural interventions is the
in AIDS treatment costs globally.9,10 However, according most promising strategy for preventing HIV/AIDS in the
to a recent UNAIDS report, these efforts could be in U.S. and abroad.
jeopardy due to the current global economic crisis, which
is projected to have a greater impact on reducing support This issue brief reviews the scientific evidence regarding
for prevention initiatives than for treatment programs the effectiveness of behavioral strategies and prevention
worldwide.11 technologies that have the potential to avert millions of new
HIV infections worldwide. It emphasizes the importance of
In the U.S., only 3% of the FY 2011 HIV/AIDS budget was combining behavioral approaches and prevention technolo-
allocated to domestic prevention programs (see Figure gies and provides research and policy recommendations
2).12 Furthermore, the continuing spread of the epidemic that serve as a roadmap for future domestic and international
has outpaced prevention funding. While the number of HIV prevention efforts.
people living with HIV/AIDS in the U.S. rose between 2002
and 2007, in the same period HIV prevention spending
at the Centers for Disease Control and Prevention (CDC) Education and Behavior Change Strategies
decreased by 19%, when adjusted for inflation.13
Education and behavior change strategies that target the
Prevention also has economic benefits. The CDC has needs of diverse populations are critical to HIV prevention
estimated that 40,000 new infections in a single year efforts. Clinical trials have shown that behavioral interventions
would ultimately cost approximately $8.4 billion in lifetime are essential to reversing the HIV epidemic.14 For example,
HIV-related medical expenses.14 This means that only reducing high-risk sexual and drug-use behaviors decreases
3,430, or 8.6%, of the 56,000 new HIV cases reported the HIV transmission rate.15 Furthermore, prevention
annually must be prevented to achieve cost savings.14 In technologies such as PrEP, microbicides, and condoms are
addition to the financial benefits, preventive measures only effective when used consistently and as prescribed.
are the best strategy for reducing the human toll of HIV/ Behavioral research is critical to better understanding how to
AIDS.14 The bottom line is that prevention saves lives and motivate people to adopt and consistently use a broad range
is cost-effective. of prevention approaches and technologies.
Figure 1: HIV prevention programs for selected populations

Median coverage of HIV prevention programs for selected
population groups, 2008 and 2010.
Source: UNAIDS Report on the Global AIDS Epidemic, 2010.
% 10 20 30 40 50 60
Sex workers
(60 countries in 2008, 54 countries in 2010)
MSM
IDU
2008 2010
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Accelerating an HIV Prevention Revolution: A Roadmap 3
her partners.18 Education should

Figure 2: U.S. Federal Funding for HIV/AIDS by Category, FY 2011 Budget encourage both HIV testing
prior to initiating relationships
and safe sex practices even in
monogamous relationships.19
Research supports the efficacy
of these strategies in reducing
rates of HIV infection. However,
in the U.S. and worldwide, there
are significant social, religious,
cultural, financial, and political
barriers that continue to impede
the widespread implementation
of evidenced-based HIV/AIDS
education programs.
Innovative new strategies

should be employed in tandem
with conventional prevention
Educational strategies such as comprehensive, evidence- approaches to create an additional line of defense. Two
based, age-appropriate sex education, rather than recent studies supported by the World Bank in Malawi and
abstinence-only programs, are needed in schools and Tanzania suggest that “conditional cash transfer” programs,
communities. A recent CDC study found that 84.2% in which financial incentives are used to encourage positive
of public secondary schools in the U.S. included HIV behaviors, could be used to reduce the incidence of HIV
prevention in their curriculum, but only 21.1% addressed and other sexually transmitted infections. In the Malawi
all eleven CDC-recommended HIV prevention topics, study, for example, small monthly cash payments to poor
which include 1) abstinence as an effective method to schoolgirls, aged 13 to 22, and their families as an incentive
avoid pregnancy, HIV, and STDs; 2) correct condom to continue their education resulted in these young
usage; 3) condom efficacy; 4) the risks associated with women delaying the onset of sexual activity and having
having multiple sexual partners; 5) social and cultural sex less often and with fewer partners.20 The study also
influences on sexual behavior; 6) prevention of HIV demonstrated a 60% lower prevalence of HIV and herpes
infection; 7) HIV transmission methods; 8) the effects of infections compared to the girls who did not receive any
HIV on the human body; 9) the influence of alcohol and payments in the 18 months following implementation of
other drugs on HIV-related risk behaviors; 10) where to the program.21 These small financial incentives made it less
find information and services related to HIV and testing; likely that young women living in poverty participated in
and 11) compassion for persons living with HIV or AIDS.16 sexual activity with men in exchange for gifts or money.
Educational efforts and interventions are needed to reduce Another important social factor fueling the AIDS epidemic
the number of individuals’ concurrent sexual partners, is the widespread stigma that still surrounds HIV/AIDS
which is greatest in areas of the world with the highest despite decades of progress in the fight against this dis-
HIV prevalence rates.17 In countries such as Zimbabwe, ease. This stigma is promoted by myths, lack of knowledge
Botswana, and Swaziland, it is common practice to have regarding disease transmission, homophobia, and value-
multiple long-term sexual partners, which is a high-risk judgments associated with its acquisition.22 Educational and
practice with regard to the spread of HIV. Long-term behavioral strategies, when coupled with effective use of
partners are more inclined to engage in sexual activity the media, can reduce the stigma and discrimination asso-
without the use of protection, increasing the risk of HIV ciated with HIV/AIDS. These interventions may encourage
transmission. This behavior also creates a sexual network individuals at risk for HIV infection to seek testing and treat-
that can extend across large regions of countries when ment,23 while those already infected and receiving medica-
one person infected with the virus transmits it to his or tion will be more likely to adhere to their treatment.24
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Further research is needed to determine the most Education and early detection help to facilitate early
effective delivery models for behavioral and educational treatment and changes in high-risk behaviors.28 Data
interventions and whether a combination of strategies suggest that HIV-infected individuals who are aware of
would be more beneficial. Priority must be given to their serostatus are more likely to adopt risk-reduction
evaluating preventive interventions for vulnerable behaviors than those who do not have this knowledge.29
populations, as well as investigating the scale-up of these
programs in a broad range of community settings in the BCT is important both for individuals with HIV and those
U.S. and globally. A better understanding is needed of at risk of contracting HIV. Counseling should occur before
the factors that motivate individuals to initiate behavior and after HIV testing with the purpose of encouraging
changes and use prevention technologies. Additionally, behavioral changes, and should include a risk reduction
the social “drivers” that make people more vulnerable plan for alcohol and drug use as well as risky sexual
to HIV infection, such as poverty, homelessness, social behaviors to avoid infection and/or transmission of the
stigma, discrimination, and unequal power dynamics in virus. Though it often follows HIV-positive diagnoses,
relationships, must be effectively addressed. counseling should also be offered to those with an HIV-
negative diagnosis. Counseling assesses an individual’s
HIV risk while identifying and implementing strategies for
HIV Behavioral Counseling and Testing risk reduction.
The availability and effectiveness of new prevention BCT providers should tailor programs to their clients’
technologies and treatment options for HIV/AIDS have needs, provide an explanation of HIV and STD infection,
increased the importance and benefits of routine HIV the testing process, confidentiality, and the meaning of
testing and counseling.25 HIV behavioral counseling and a positive or negative test result, as well as refer patients
testing (BCT) involves access to an array of medical, to medical care or substance abuse treatment if needed.
preventive, psychosocial, and referral services.26 Almost Community-level interventions with local input on the
11% of HIV infections in the U.S. are transmitted by design and implementation of programs are necessary.
undiagnosed HIV-positive individuals,27 and up to 25% Studies have shown that BCT has beneficially changed
of HIV-positive people do not know their serostatus. the behavior of HIV-positive individuals, but has been less
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successful in reducing the risky behavior of HIV-negative aimed at promoting their use, condoms as a means of
individuals.15 While sustained reductions in high-risk preventing HIV have risen in popularity in many parts of
behavior have proven difficult over the long term, behavior the world. Male condom sales have increased dramatically
change interventions have been associated with a across the globe as a result of successful social marketing
decrease in HIV incidence.30 The effectiveness of most HIV campaigns.33 Free condom distribution programs have
prevention technologies depends on patient behavior and also increased their availability and use. Condoms have
adherence; thus, research is needed to learn how to better played an important role in decreasing prevalence of HIV/
tailor BCT to the needs of specific populations in order to AIDS in high-risk populations, such as sex workers and
alter high-risk behaviors. their clients.35
New approaches and technologies for HIV testing are However, male condoms are not well accepted by some
also needed. For example, health professionals use the populations. In the U.S., condom use has been difficult
number of CD4 cells present in the blood to evaluate to sustain among men who have sex with men (MSM),
when an HIV-infected individual should begin treatment with a less than 75% usage rate, depending on whether
with ARVs.31 Conducting this test requires sophisticated a partner has HIV.36 Obstacles that impede the use of
lab equipment that many communities lack. A portable, condoms include social and cultural stigma, religious
inexpensive device to confirm an HIV diagnosis is currently beliefs, unequal power dynamics between sexual partners,
in development. Such a device would allow health care lack of awareness of condoms’ effectiveness, personal
providers to conduct these tests in underserved areas and reluctance, quality, and availability.33 Strategies to combat
could be used to yield accurate test results within minutes, these barriers include persuading people to reframe their
aiding all those who now must wait a critical number of attitudes and behaviors regarding condoms; ensuring
days, if not weeks, before learning whether they should widespread condom distribution and use; promoting
be receiving ARV treatment. Rapid testing of pregnant condom use as responsible, acceptable, and health
women and provision of ARV therapy would also further promoting; and providing easier access to condoms
reduce mother-to-child transmission of HIV worldwide. through price reductions or free distribution.33
Female Condoms
Prevention Technologies HIV continues to spread at an alarming rate among wom-
en, who account for 50% of HIV cases worldwide.37,38 In
Barrier Methods the developing world, lack of economic, social, or cultural
empowerment for women can impede access to currently
Male Condoms available HIV prevention strategies. The female condom is
Male condoms are currently the most effective available one method that can be initiated by women and can lead
means of preventing HIV transmission. Research has to an increased sense of empowerment;29 it can also serve
demonstrated that most latex and polyurethane condoms as an alternative barrier method for intercourse among
cannot be penetrated by particles the size of HIV; in MSM, though further studies are needed to evaluate ef-
contrast, lambskin condoms have pores large enough ficacy.39 It provides protection against most STIs including
for HIV to pass through. Studies have shown that HIV, and is sold without a prescription. The female con-
latex condoms, when used consistently and correctly, dom is made of a material that is stronger than latex, is
can reduce the risk of sexually transmitted infections odorless, causes no allergic reactions, and can be safely
(STIs), including HIV, by 90–96%.32,33,34 For HIV-positive used with both oil-based and water-based lubricants. In-
individuals, condom use during sexual intercourse is still serted prior to intercourse, it usually neither hinders male
an important preventive measure, both to avoid onward erection nor requires immediate withdrawal after ejacula-
transmission and prevent further infection with other tion.40 A new formulation of the female condom has made
strains of HIV, which could increase the severity of their it easier to use and less expensive.
condition.33
Although the female condom is widely accepted41 and
Condoms are relatively inexpensive, are sold without represents a significant advance in female-initiated
a prescription, and have no side effects. Due to their protection, significant impediments exist to its widespread
effectiveness and the number of educational campaigns utilization, including conspicuous appearance, insertion
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difficulties, the possibility of reduced sensation, reluctance women.56 Furthermore, in the U.S., heterosexual males
of male partners, imbalances in relationships in many with a genital ulcer, who were more likely to report not
countries, and cost.42,43 Campaigns addressing enhanced being circumcised, were found to have a 3.5-fold higher
access to and education about female condoms, as well risk of HIV infection compared to men without a genital
as recent reductions in cost, will help to increase its use. ulcer.57 Circumcision may also help protect women from
contracting HPV (and thus help prevent cervical cancer):
Cervical Barriers a study conducted in Uganda in 2005-6 found that
Diaphragms and cervical caps are soft latex or silicone circumcision reduced HPV incidence among the female
cups that fit at the anterior end of the female genital tract long-term partners of study participants by 77%.58
to cover the cervix. These barriers can be inserted before
intercourse and remain in the body for several hours.
Recent studies suggest that male
Cervical interventions aim to fortify the cervix, which, due circumcision is a cost-effective,
to its thinness, is the preferential infection site for many
enduring, and proven strategy to
STIs, including HIV.44 Compared to the vaginal mucosa
composed of stratified squamous epithelium, which is prevent HIV in high-prevalence areas.
more than thirty cell layers thick, the endocervical mucosa
of the cervix is covered by only a single layer of columnar Concerns have been raised about the possible increased
epithelial cells.45 risks of transmitting HIV immediately following the
circumcision procedure. A study conducted among
Although cervical barriers have been approved for contra- African men found that most avoided sex until healing
ceptive use around the world, their distribution has been had occurred; of those who did engage in sexual activity,
limited and usage rates have been low compared to those it was not associated with an increased risk of acquiring
of other contraceptive methods. 46 Clinical trials have dem- HIV.59 However, another study conducted in Uganda
onstrated that cervical barriers alone do not prevent HIV revealed that sexual activity among HIV-positive men after
infection, but these devices have significant potential for circumcision (prior to complete healing) may have led to
improving topical delivery of microbicides and may prove an increased risk of HIV transmission to their wives.60 It is
in the future to play an important role in increasing the recommended that HIV-positive men abstain from sex for
overall efficacy of microbicides.47 6 to 8 weeks following circumcision until proper healing
occurs.
Male Circumcision
A recent study suggests that male circumcision is
Research provides compelling evidence that male a cost-effective, enduring, and proven strategy to
circumcision prevents the transmission of HIV/AIDS in prevent HIV in high-prevalence areas.17 Additionally, 13
heterosexual populations,48 reducing HIV infection by studies conducted across nine sub-Saharan countries
50-60%.49 The WHO and UNAIDS have concluded that demonstrated that attitudes toward the procedure were
male circumcision should be actively promoted as part of consistently positive among both men and women.61
comprehensive global HIV prevention efforts.50
As with other prevention technologies, considerations of
Several studies have demonstrated a correlation between access and cost, as well as cultural, ethical, and religious
male circumcision and decreased rates of HIV infection factors, can hinder the widespread implementation
among heterosexual males,51 with results from recent of male circumcision as an intervention. Educational
randomized controlled trials in Africa confirming this campaigns are needed to increase awareness about the
relationship.52 Studies conducted in Kenya and Uganda benefits of male circumcision, conducting the procedure
demonstrated a 53% and 48% reduction, respectively, in infants, adequately training local health care workers
in heterosexually acquired HIV infection in circumcised in its administration, and diminishing cultural barriers to
men.53,54 While statistics have been inconclusive thus the procedure. Research on strategies to promote the
far on the efficacy of circumcising MSM to prevent continued use of other prevention approaches, including
infection,55 the procedure may be worthwhile for MSM, condoms, among circumcised men are also needed.
especially those who concurrently engage in sex with
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Treatment of Sexually Transmitted Infections heterosexual women.71 Studies suggest that the risk of
becoming infected from unprotected anal sex is greater
The U.S. has one of the highest rates of STIs among than from unprotected vaginal sex, in part because the
all developed countries.62 Studies have shown that rectal lining is more fragile than vaginal mucosa, making it
STIs, including those that are asymptomatic, increase easier for the HIV virus to permeate tissue. 72
susceptibility to HIV infection two- to five-fold.63,64,65
Herpes, for example, causes genital ulcers that function Research suggests that an effective microbicidal agent
as entry points for HIV, while inflammation caused by could have a significant impact on curbing the global
other STIs increases the number of cells that HIV targets HIV/AIDS epidemic. A study using epidemiological and
in genital secretions.66 STIs also lead to higher HIV loads in economic models reported that if a microbicide with a
the genital secretions of HIV-positive individuals, thereby 60% efficacy rate reached 20% of the at-risk population
increasing the chance of infecting their sexual partners.44 in 73 low-income countries, approximately 2.5 million HIV
infections could be averted over a three-year period.73,74
When STIs are treated, these risk factors can be
eliminated. However, there are certain limitations.
Studies have shown that the success of STI treatment
Mathematical modeling studies have shown
as an HIV prevention strategy depends on the stage of that a tenofovir-based microbicide gel
infection when treatment is administered, with treatment could possibly prevent up to 1.3 million HIV
effectiveness decreasing over time as HIV becomes
more established.67 Uncircumcised and HIV-positive men
infections and 800,000 deaths over the next
typically require a longer course of treatment and do not 20 years in South Africa alone.
respond as well to antibiotic therapy for STIs.68
For the first time in the fight to control the global pan-
Since STI treatment does not require a sexual partner’s demic, and after two decades of research to develop a
consent, it is a particularly valuable tool for women in safe and effective microbicide, a significant breakthrough
unequal sexual partnerships. Furthermore, the recent was achieved with the July 2010 announcement of the
development of a vaccine to prevent HPV infection in CAPRISA 004 trial results, which evaluated the effective-
women, recently found to be effective for men as well,69 ness of a 1% tenofovir antiretroviral-based vaginal gel to
represents an important STI prevention tool and a step prevent HIV infection.75 In this study, the gel was used
forward in reducing vulnerability to HIV. Increased access by 889 HIV-negative women living in two South African
to STI diagnosis, therapy, and prevention services can communities, one urban and the other rural, who were fol-
help decrease the spread of HIV and promote sexual lowed for two and a half years and directed to use the gel
health more generally. before and after sexual activity. The microbicide reduced
HIV acquisition by approximately 39% overall, and among
Microbicides women who most regularly used the compound, by 54%.75
The gel also reduced herpes (HSV-2) transmission by
Microbicides are virus- and bacteria-killing compounds 51%.76 The effectiveness of this microbicide, however,
formulated as gels, creams, films, or suppositories and diminished over time, possibly due to a decline in the
applied inside the vagina or rectum to protect against diligent use of the product by women in the study. This
STIs, including HIV.70 These compounds are currently hypothesis is supported by the finding that participants
in various stages of development and must be safe, who achieved higher concentrations of tenofovir in cervi-
effective, easy to use, and affordable to be considered for covaginal fluid had lower rates of infection, pointing to the
widespread use. powerful influence of adherence on efficacy.77 Mathemati-
cal modeling studies have shown that a tenofovir-based
Microbicides are a prevention priority because they can be microbicide gel could possibly prevent up to 1.3 million
used without the cooperation, consent, or knowledge of HIV infections and 800,000 deaths over the next 20 years
a partner. A safe and effective vaginal microbicide would in South Africa alone.50
be an important defense for women. Rectal microbicides
could also help prevent HIV transmission via receptive Improved microbicide products will become a “game
anal intercourse for both men who have sex with men and changer” for women who wish to self-initiate HIV preven-
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tion measures, especially in cases where there are production and evaluation of and innovative marketing
significant barriers to successfully negotiating mutual strategies for a new generation of microbicides are
monogamy or condom use with partners. 20,75 The teno- needed to fill an important HIV prevention gap.
fovir-based gel used in the CAPRISA study will require
further evaluation to determine the safety, efficacy, and Chemoprophylaxis, Including PrEP and PMTCT
impact of broader utilization of this and other potential
microbicide candidates. A larger clinical trial, VOICE, Chemoprophylaxis is the administration of antiretroviral
is currently under way to test daily use.77 Higher ARV therapies and other medications to prevent HIV infection.
concentrations within the gel, as well as the addition of ARVs prevent HIV infection by disrupting various stages
other ARVs to microbicide formulations, may also boost of viral replication, thereby interfering with the life cycle of
effectiveness. In 2011, the International Partnership HIV. Chemoprophylaxis may be used as an HIV prevention
for Microbicides will initiate trials testing vaginal rings strategy for: 1) post-exposure prophylaxis (PEP) for indi-
containing dapivirine, while USAID will fund a project to viduals following a high-risk situation that could potentially
develop rings containing tenofovir combined with a con- result in HIV infection; 2) prevention of mother-to-child
traceptive.50 transmission (MTCT) during pregnancy, labor, and deliv-
ery; and 3) pre-exposure prophylaxis (PrEP) for individuals
A recent study found that for the first time, a microbicidal at high risk of contracting HIV.
gel containing tenofovir protected rectal tissue against
HIV. However, significant gastrointestinal side effects PEP is a strategy that uses ARVs to reduce the risk of
were experienced by some of the study participants.72 HIV after high-risk events, such as unprotected sex, rape,
Additional research is needed on the development of needle sticks, or the sharing of needles. When initiated
safe and effective vaginal and rectal microbicide agents. promptly (within 72 hours of exposure) and administered
Studies are also needed on the acceptability of and for 28 days, PEP has been shown to reduce the risk of HIV
adherence to these products. Investments in the infection by 80%.78
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ARVs given to HIV-positive pregnant women for purposes

of prevention of mother-to-child transmission (PMTCT)
have proven extremely effective in preventing transmission
of the virus to newborns. When women are treated with
ARVs during pregnancy, labor, and delivery, the newborn
is treated with ARVs, and delivery is performed via
caesarian section, MTCT can be reduced to less than
2%, as has occurred in the United States.64 Even when
mothers begin ARVs during labor and delivery, the rate of
MTCT can be reduced to 10% or less.79 In 2010, UNITAID
and UNICEF began implementing a “Mother-Baby Pack”
program, which provides pregnant women with an “all-in-
one” take-home package of drugs for before, during, and
after delivery, as well as ARV medication for the infant to
prevent HIV transmission for six weeks after delivery. The
packages are designed for easy use and are in unmarked
bags to avoid stigma within communities.80 It is estimated
that with sufficient funding, this drug delivery method
could help reduce MTCT to 5% or less globally.80 A recent
study has shown that mothers who were continued on
ARV treatment until breastfeeding was completed were
43% less likely to transmit HIV to their babies than women countries. Efficacy climbed to 92% among men in the
who stopped receiving therapy one week after delivery.81 study who had diligently adhered to the PrEP regimen, as
Intensified efforts to prevent MTCT could lead to an HIV- determined by medication levels detected in their blood.83
free generation in the years ahead.
In 2011, four other major clinical trials of PrEP are under
Injection drug use accounts for about 10% of HIV way, including the Bangkok Tenofovir Study, Partners PrEP,
infections worldwide, rising to 80% in some regions of FEM-PrEP, and VOICE (MTN 003). These studies are test-
the world such as Eastern Europe and Central Asia.82 ing the safety and efficacy of tenofovir and a combination
A 2010 study supported by the National Institute on of tenofovir and emtricitabine in several countries. Results
Drug Abuse demonstrated that ARVs can decrease the are expected in 2012 or 2013.84 Preliminary analysis of a
spread of HIV among those with a history of injection phase II clinical safety trial using tenofovir among MSM
drug use, as well as in the general population. The study populations in the U.S. suggests that daily administration of
found that increased levels of ARV use in the community the medication has no significant side effect safety issues
corresponded with decreased viral load and fewer new to date.85
HIV diagnoses on a population level.99
While PrEP, if proven to be safe and effective, has the
These important results about the effectiveness of potential to revolutionize HIV prevention with its use as a
chemoprophylaxsis led scientists to study whether “prevention pill,” widespread implementation will require
ARV administration on a daily (PrEP) or intermittent further research and the establishment of evidence-based
basis (iPrEP) to high-risk populations would reduce the policies. Issues that must be addressed include: 1) evalu-
likelihood of acquiring HIV. PrEP had been found to ation of candidate drugs; 2) use in various populations,
reduce the transmission of a virus analogous to HIV in including women of childbearing age, adolescents, and
primate studies. In November 2010, the first definitive MSM; 3) schedule of administration and dosage (continu-
results of PrEP use in humans were released from the ous vs. intermittent); 4) cost; 5) health insurance reimburse-
iPrEx study.83 The study demonstrated an overall 43.8% ment policies; 6) impact on sexual behavio; and 7) potential
efficacy rate for tenofovir and emtricitabine-based PrEP risk of developing drug resistance and other side effects of
among gay men, transgender women who have sex long-term use.50
with men, and other men who have sex with men in six
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Vaccines than previously known antibodies to the virus, marking

a significant advance in HIV vaccine design research.90
Since the discovery of HIV in 1983, the development of a Additionally, computer modeling work in a separate
safe and effective vaccine has been a prevention priority. May 2010 study has shed light on how white blood cells
While significant advances in scientific knowledge about develop in some individuals who, when exposed to HIV,
HIV have been made, the development of a suitable either progress slowly to AIDS or never develop the
vaccine candidate has been particularly difficult due to disease at all.91 This study has significant implications
challenges stemming from the virus’ rapid mutation rate as for developing vaccines that might stimulate a similar
it replicates, the differing strains found around the world, response to HIV that individuals with “natural immunity”
and the virus’ ability to remain latent in cells. appear to have. The researchers found that an HIV-
protective gene in these individuals results in more potent
A vaccine is a product that produces immunity, thereby CD8 killer T cells that bind to HIV more effectively.91 These
protecting the body from disease. Vaccines can be promising results highlight the urgent need for intensified
administered orally, through needle injections, or by efforts, increased investments, and new approaches to
nasal sprays.86 A successful HIV vaccine may need to vaccine development.
induce both antibodies to broadly neutralize the virus and
cytotoxic T lymphocytes to destroy HIV-infected cells.
Vaccine candidates that primarily induce the latter are a Public Health Strategies for HIV Prevention
particular focus of current research efforts. Such vaccines
would not be expected to prevent infection; rather, they Harm Reduction
would control virus levels, reduce early destruction of
CD4 helper T cells, delay disease progression, and reduce Injection drug use accounts for 15.6% of HIV infections in
secondary transmission. Recent T-cell vaccines used in the U.S. and an estimated 10% globally.93 Notably, people
both the STEP and Phambili clinical trials unfortunately who inject drugs are believed to constitute up to one-third
proved unsatisfactory in these large-scale efficacy of new HIV infections outside of sub-Saharan Africa.92
studies.87 The HIV Vaccine Trials Network (HVTN) 505 In some regions of Eastern Europe and Central Asia, as
study is currently testing a new T-cell-based vaccine.88 many as 80% of HIV infections are linked to injection drug
use.93 The term “harm reduction” refers to public health
While more than 80 clinical vaccine trials have been programs that work to minimize the consequences of
conducted to date without success, in December 2009, high-risk behaviors such as drug use and unsafe sex.94 It
more than 25 years after the virus was identified, a uses a hybrid approach combining education, behavior
study in Thailand revealed the first evidence of a vaccine change strategies, counseling, and syringe and needle
providing any level of protection against HIV infection.89 exchange programs (SEPs/NEPs), which provide injection
Researchers reported that a combination of two vaccines drug users (IDUs) with sterile syringes in exchange for
tested over a six-year period had a modest but statistically used syringes at no cost.
significant impact on protecting people from HIV infection.
Though the study involved only a small sample size, the SEPs provide a range of services. A survey found that
vaccine was the first to make any headway against HIV in 77% of these programs provided referrals to substance
humans and is providing valuable clues for future vaccine abuse treatment, 72% provided on-site voluntary
development (it should be noted that some experts have counseling and HIV testing, and more than two-thirds
challenged the validity of the study’s findings). Scientists provided supplies such as bleach to disinfect needles,
are now exploring the mechanism by which this vaccine alcohol pads, and male and female condoms. Many also
decreased infection risk, since it did not affect the level of provided screening for hepatitis and tuberculosis and
virus in the blood of volunteers. offered on-site medical care to address wounds caused
by frequent injections. Notably, many IDUs who use
Another major discovery reported in July 2010 has SEPs often informally provide information about health
rekindled hope for an effective vaccine. Scientists at maintenance and risk reduction to other drug users
the National Institute of Allergy and Infectious Diseases outside the exchange program.95 Since the mid 1980s,
(NIAID) identified two antibodies that naturally occur in SEPs in conjunction with other harm reduction strategies
the blood of HIV-positive individuals. These antibodies have been associated with reductions of up to 80% in
neutralize more HIV strains with greater overall strength
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risk behaviors and 30% in HIV incidence among IDUs in two steps: 1) promoting and providing annual, universal,
the U.S. and have been shown to be cost-effective.96,97,98 and voluntary testing of all people aged 15 or older; and
Furthermore, studies have demonstrated that SEPs do 2) immediately providing ART to those who test positive
not increase drug use99 and help to keep communities for HIV. In 2010, a mathematical model developed by the
and law enforcement personnel safe from contaminated World Health Organization (WHO) demonstrated that global
syringes.100 universal treatment with antiretroviral drugs could reduce HIV
incidence and mortality to less than one case per thousand
Despite the success of SEPs, more than 8,000 new by 2016 while reducing the worldwide HIV prevalence rate to
HIV infections still occur among IDUs in the U.S. every 1% in 50 years.109 This model suggests that the test-and-treat
year, representing 16% of new infections and 24% of strategy could move the AIDS epidemic from an endemic
Americans living with HIV/AIDS.101 Around the world, up phase into an “elimination phase,” in which most adults
to 20% of IDUs are HIV positive.102 While the number of living with HIV are on ART, within five years of the program’s
IDUs infected with HIV could be significantly reduced implementation.110 Furthermore, recent studies suggest that
with increased usage of SEPs in conjunction with other expanded ART utilization combined with increased access
prevention strategies, only 8% of IDUs worldwide receive to HIV screening and counseling could reduce HIV incidence
HIV prevention services.103 in the United States by 24% over the next 20 years.111
Extending these efforts to include harm reduction strategies
Until recently, there was a ban on the use of federal could add considerable additional benefit, with an estimated
funds for SEPs/NEPs in the U.S. even though states and 65% reduction in the size of the epidemic in the U.S. within
localities have supported some of these programs in the approximately 20 years of implementation.111
past. On December 16, 2009, a significant legislative
victory was achieved when the ban was removed. By Some experts, however, suggest that this approach is un-
July 7, 2010, the US Department of Health and Human realistic considering the low rates of testing worldwide, the
Services released the interim guidance for state health high costs involved, and the wide range of epidemic settings.
departments interested in implementing SEPs with FY An additional concern is treatment adherence. In theory, an
2010 appropriated dollars as part of a comprehensive increase in the number of patients on ARVs worldwide, some
HIV prevention program.104 While not guaranteeing an of whom do not adhere to their regimen, could result in an
increase in funding for SEPs, the lifting of the ban ensures elevated risk of drug resistance.
that federal money can now be provided to states and
localities to support SEPs.105 Federal funding for SEPs Furthermore, a British research team developed a model
helps to increase the prevalence and acceptability of suggesting that the success of the “test and treat” program
these programs, which would reduce the rate of new would be dependent upon the characteristics of local
HIV infections among IDUs and their sexual partners and epidemics. In areas where concurrent sexual partners were
children. frequent, new infections would be reduced by 85%, but not
completely eliminated.112 In this case, HIV could be reduced
As of January 2011, there are 211 SEPs in 32 states, the by 95% in most areas if 80% of the population were to be
District of Columbia, the Commonwealth of Puerto Rico, tested every three to four years; in “hyperendemic” regions,
and the Indian Nations.106 One study found that 90% testing would be needed in 80% of the population every
of IDUs who lived within a 10-block radius of an SEP two to three years to achieve the WHO estimates for HIV
participated in the program.107 SEP attendance was also reduction.112
positively correlated with both safer injection and sexual
practices.107 IDUs who did not acquire syringes exclusively Currently, the NIH is collaborating with the Washington,
from SEPs or pharmacies were more than twice as likely D.C., and New York City Health Departments on studies
to report high-risk behavior compared to those who did.108 to determine the efficacy of an aggressive “test and treat”
strategy on HIV infection rates in the U.S.113 If the results
“Test and Treat” from this research support WHO’s predictions, the findings
could have important implications for national policies,
A new prevention concept termed “test and treat” focuses resulting in a bold new strategy to stop the spread of AIDS
on diagnosing and treating people early in the course by routinely testing everyone in the community and promptly
of a confirmed HIV infection. This strategy involves starting those who test positive on treatment.113 The recent
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in HIV transmission rates when an HIV-

positive person takes ARVs, lowering
their viral load and thereby decreasing the
likelihood of transmitting HIV to others.
The effectiveness of ART in reducing HIV
transmission is estimated to be as high as
92%.84 Among serodiscordant couples, a
2009 meta-analysis of cohort studies found
that HIV transmission was 92% lower if the
affected partner was taking ARVs.84 A phase
III clinical trial (HPTN 052), ongoing as of
2011, is directly examining the effect of ARV
administration on HIV transmission rates in
serodiscordant couples at sites in Africa,
India, Brazil, and Thailand.84 However,
numerous challenges in implementing
“treatment as prevention” programs exist.
A recent review found that only 60% of
individuals who were aware of their HIV
status were linked to care.84 Furthermore,
the study found that among those who were
offered ART, some did not accept treatment
because of denial of their condition, worries
about potential medication side effects, or
concerns regarding stigma.84
Mapping Community Viral Load

New inexpensive, accurate HIV testing
To facilitate evaluation of the effectiveness of new
technologies are needed that could be used
approaches such as “treatment as prevention” and
in underserved communities worldwide to “test and treat,” new methods are needed to determine
immediately and accurately determine HIV whether these prevention strategies work and to highlight
areas for improvement. While it has been proven that on
serostatus in order to speed the time from
an individual level, ART mediated virologic suppression
diagnosis to treatment. reduces perinatal transmission and may reduce sexual
transmission as well,114 it remains uncertain whether
passage of health reform legislation in the U.S. should increased HIV testing and widespread use of ARVs can
help to ensure greater access to HIV testing and therapy. actually decrease HIV incidence on a population level. In
the 1990’s, the introduction and expanded use of ARVs
New inexpensive, accurate HIV testing technologies are in some regions of the world was accompanied by a
needed that could be used in underserved communities reduction in new HIV infections. For example, in Taiwan,
worldwide to immediately and accurately determine HIV the increased utilization of ARVs was matched by a 50%
serostatus in order to speed the time from diagnosis to reduction in newly reported HIV cases.115 However, in
treatment. other areas, such as San Francisco, the success of ART
may have led to complacency about the need for vigilant
Treatment as Prevention prevention interventions resulting in a rise in risky sexual
behavior and an alarming increase in HIV incidence among
The “treatment as prevention” concept is gaining MSM. Consequently, the San Francisco Public Health
ground as an innovative public health approach, in light Department intensified its efforts to combat HIV infection
of recent findings that suggest a significant reduction by simplifying HIV testing procedures, increasing partner
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notification, and providing linkages to care. A recent Structural Interventions

study found that these actions resulted in a decline in
new HIV cases in the city from 2004 to 2008.116 Most-at-risk-populations (MARPs), including men who
have sex with men, sex workers, and injecting drug
Researchers in San Francisco have used surveillance users, bear a disproportionately heavy burden of the HIV
and mapping techniques to chart community viral load epidemic. Many governments codify prevailing hostility
(CVL) and assess HIV rates across the city. Total CVL is toward MARPs into law, effectively institutionalizing
a measure of the potential infectiousness of a particular stigma and negative attitudes towards these vulnerable
geographic population (neighborhood community), while groups, isolating them, and impeding the delivery of HIV
mean CVL is an indicator of treatment effectiveness prevention and care services to the individuals who most
and transmission risk.116 Mapping and comparing these need them.117
numbers across specific populations can illuminate
“hotspots” with particularly high HIV incidence, facilitating In Eastern Europe and Central Asia, where the HIV
the targeting of interventions to populations at greatest epidemic is primarily driven by drug use, nearly 60%
risk. Such a mapping strategy also helps identify of countries report having laws that limit drug users’
barriers to accessing care that may be based on gender, access to HIV services.117 Although sex work is a primary
ethnicity, insurance coverage, and other factors. In this driver of the AIDS epidemic in Asia, more than 80% of
way, mapping CVL provides a window through which countries in this region of the world have adopted legal
we can see the geographic and demographic face of frameworks that hinder sex workers’ access to services.117
the epidemic in communities, and provides important Furthermore, although infections among MSM in Asia
knowledge that can help eliminate structural barriers, and the Caribbean are on the rise, approximately 60%
improve services, and address other factors that may of countries in these regions have discriminatory laws in
keep interventions from reaching individuals most at place regarding MSM.117 In fact, some 76 countries around
risk.116 the world—most of them developing nations—criminalize
same-sex sexual behavior.118 In many countries, criminal
Reductions in the mean and total CVL in San Francisco penalties for homosexual behavior are extremely severe,
following comprehensive public health measures to including five nations that permit the death penalty to be
increase HIV testing and ART use were consistent imposed.119
with apparent declines in HIV incidence and strongly
associated with reductions in newly diagnosed HIV These structural barriers, attitudes, and social condi-
infections. This positive health outcome occurred tions undermine the overall response to HIV/AIDS. For
despite a rise in rectal gonorrhea in the city suggesting maximum impact, HIV programs must include structural
that risky sexual behaviors had not diminished; rather, interventions aimed at changing the environment so that
public health interventions to increase HIV testing and all populations can access HIV prevention and treatment
treatment had been the major factor in decreasing HIV services.120 Laws should be revised to prohibit discrimina-
infection rates in the city.116 In this way, CVL can serve tion on the basis of membership in a marginalized group.
as a useful biomarker for the overall success of ART Specifically, countries should repeal all laws that criminal-
use in communities and for HIV prevention efforts. More ize same-sex sexual behavior and impede HIV prevention
research on such mapping and surveillance strategies is interventions. Laws restricting access to essential health
needed. services should be removed, and policies affirming the hu-
man rights of vulnerable populations are urgently needed.
For maximum impact, HIV programs must HIV Prevention 2.0
include structural interventions aimed

New media technologies and social marketing campaigns
at changing the environment so that all are being harnessed to empower people to make informed
populations can access HIV prevention health decisions, to promote adherence to treatment, and
to spread the word about HIV prevention strategies. With
and treatment services.
more than 5 billion mobile phones in use globally121 and 2
billion Internet users worldwide,122 new media with its wide
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Accelerating an HIV Prevention Revolution:

Policy Recommendations
With more than two million new HIV infections occurring

globally each year and 56,000 in the U.S. alone, prevention
is essential to stemming the tide of the AIDS epidemic.
However, no single prevention strategy by itself is sufficient;
rather, a combination of interventions is needed including
expanded access to lifesaving AIDS treatments. Now is
the time for vision, innovation, commitment, and strategic
direction to scale up proven interventions and to develop
innovative new approaches to HIV prevention.
The following recommendations provide a roadmap

for putting prevention into practice in the fight against
HIV/AIDS:
Invest in Basic, Clinical, and Public Health Research
• Increase investments by government, foundations, and

availability and instantaneous reach, can play a powerful other donors in research on prevention technologies and
role in mobilizing a prevention revolution. Increasingly, behavioral approaches including PrEP, microbicides,
the mobile phone is the primary route for accessing the vaccines, behavioral/educational interventions, and
Internet. Recent studies conducted in South Africa and strategies that utilize a combination of approaches.
Mexico demonstrated that the use of new media increased
• Address the needs and circumstances of diverse
patient participation in health services and adherence
populations (e.g., youth, MSM, IDUs, women, and
to medication.123 These positive behavior changes can
communities of color) to maximize their participation in
be attributed in part to increased connectivity between
clinical trials of prevention technologies and behavior
providers and their patients, as well as patient texting
change strategies.
‘support groups’ in some cases.
• Ensure that clinical trials of prevention technologies
A 2010 review conducted in nine countries that evaluated appropriately analyze data for any biological and
12 randomized clinical trials using text messaging in psychosocial differences with respect to age, sex, and
disease prevention efforts yielded promising results. The race/ethnicity.
research found that text messaging was a cost-effective
tool for achieving positive behavioral or clinical outcomes • Ensure community engagement in and broad stakeholder
related to disease prevention and management.124 The support for the development and implementation of
widespread integration of new media into prevention clinical trials.
programs could benefit consumers, patients, researchers,
• Support studies that evaluate the “test and treat” and
and healthcare providers alike, and the progress seen thus
“treatment as prevention” models for HIV prevention in
far shows there is great promise in this emerging field.
the United States and globally; implement widely if found
Additionally, the use of video and voice messages would
to be safe and effective.
expand the reach of HIV prevention efforts in areas of the
world with low literacy rates. More research is needed • Establish systems for data-sharing and collaboration
to assess current and potential applications for reaching across institutions and countries.
diverse population groups and to evaluate the impact of
new media approaches on HIV education, prevention, and • Conduct public health research, including
treatment outcomes. Mobile technology should also be implementation science, to promote innovation and
further explored as a platform for conducting research in strengthen current and future HIV prevention efforts.
the U.S. and in the developing world.
www.amfar.org
• Develop new, highly accurate, rapid, and portable HIV • Make elimination of disparities in access to HIV
testing methods. prevention based on ethnicity, race, gender, sexual
identity, and socioeconomic status a priority in policy
• Evaluate multidisciplinary, combined prevention and program development.
approaches for their effectiveness.
• Reduce stigma experienced by vulnerable populations
in health care settings.
Implement Prevention Strategies
• Optimize state policies for implementation and
• Fully implement prevention recommendations in the utilization of syringe exchange programs.
National HIV/AIDS Strategy. Coordinate initiatives
across Federal government agencies in partnership • Work to ensure that Congress does not backtrack by
with the private sector, and develop new cross-cutting reinstating the ban on use of Federal funds to support
approaches. SEPs.
• Implement prevention initiatives contained in the recent • Ensure that local and national prevention portfolios are
health care reform legislation, the Patient Protection closely informed by the HIV epidemic’s profile so that
and Affordable Care Act, including those that will programming reaches those populations that are most
ensure increased access to HIV testing, treatment, and affected.
prevention services.
• Use innovative monitoring and evaluation strategies
• Support the implementation of evidence-based such as mapping of community viral load to better
prevention technologies that include barrier methods understand where structural barriers are greatest and
(male and female condoms), male circumcision, harm what opportunities exist to ensure that HIV testing and
reduction programs including SEPs, and STI treatment. care reach the most vulnerable populations.
• Expand HIV/AIDS education and counseling programs

to increase testing frequency and reduce high-risk Raise Awareness About the Power of Prevention
behaviors.
• Conduct national and global education campaigns
• Make the lowering of HIV incidence in communities a on HIV/AIDS prevention to raise awareness, change
prevention priority. attitudes and behaviors surrounding HIV, and decrease
stigma.
• Train health care personnel to implement HIV/AIDS
prevention and testing strategies. • Increase policymaker and public awareness about
the impact of ARV therapy on lowering HIV viral load
• Target preventive strategies to meet the needs of in communities, which may reduce the likelihood of
vulnerable populations including communities of color, transmitting the virus.
MSM, women, IDUs, the economically disadvantaged,
and incarcerated populations. • Use new media including text messaging and social
marketing techniques to enhance prevention efforts.
• Develop a toolbox of innovative and effective
approaches to prevention to reduce new infections and
change the course of the epidemic. Target Funding and Advance Evidence-Based Policies
• Provide national leadership to make prevention a

Eliminate Barriers to Accessing Prevention Services priority in domestic and global programs.
• Ensure that prevention services are delivered at the • Increase Federal and private sector funding for
scale necessary to reach all those who need them. prevention research and services in national and global
HIV/AIDS programs through the NIH, CDC, PEPFAR,
• Reduce legal barriers and policy restrictions to utilizing the Global Health Initiative, and contributions to the
effective prevention services and new technologies. Global Fund to Fight AIDS, Tuberculosis and Malaria.
www.amfar.org
Direct resources to programs that can have the Summary

greatest impact at the international, federal, state and
local levels. Since the first case of HIV was reported in 1981, scientists
have made significant strides in the prevention and treat-
• Establish a National Task Force on HIV Prevention to
ment of HIV/AIDS. Yet much more remains to be done.
engage leaders from the government, NGOs, health
Advances in the treatment of HIV/AIDS have made a
care, business, and civil society to accelerate an HIV
lifesaving difference, but prevention of the disease is the
prevention revolution in the United States. Link its
ultimate goal. This issue brief has reviewed the scientific
work to the newly established UNAIDS Commission on
evidence about currently available prevention technolo-
Global HIV Prevention.
gies and behavioral interventions and has examined the
• Support demonstration projects in the U.S. and potential of several new approaches that are under devel-
globally to follow up on the promising efficacy results opment. It underscores the fact that we are on a path to
of PrEP. Such projects should investigate questions making AIDS history.
important to effective use of PrEP including adherence,
behavior change, cost-effectiveness, and approaches Benjamin Franklin once said, “An ounce of prevention
to delivering PrEP as part of a package of preventive is worth a pound of cure.” While Mr. Franklin was refer-
interventions. ring to fighting fires, his words remind us of the urgency
with which we must fight the HIV/AIDS epidemic using
• Support structural level interventions to foster HIV a combination of evidenced-based prevention technolo-
prevention efforts by ensuring that policies are evi- gies, behavioral approaches, and public health strate-
denced-based and designed to engage organizations, gies while expanding provision of comprehensive AIDS
systems, government, the media, and social networks. treatment programs in communities worldwide. These
strategies must target the needs of diverse populations
• Reform or repeal laws that criminalize same-sex sexual with attention to gender, age, and community and cultural
behavior, and protect human rights, which is essential issues. Recent research advances demonstrating the ef-
to ensuring access to testing, care, and treatment. fectiveness of new HIV prevention technologies suggest
that we are in the midst of a prevention revolution to ac-
• Direct Federal funding towards domestic and interna-
celerate progress in eradicating the HIV/AIDS epidemic.
tional programs that scale up the implementation of
If the spread of HIV/AIDS in America and globally is to be
prevention technologies and interventions targeting
halted, critical actions are needed including increasing
high-risk groups.
investments in HIV prevention programs and research, a
• Engage a broad spectrum of stakeholders worldwide multidisciplinary, innovative approach, broad stakeholder
in the development and implementation of prevention and community involvement, removing barriers to care,
clinical trials and service delivery programs. committing adequate resources, and scaling up effective,
evidence-based programs. The bottom line: prevention
• Create a collaborative system of advocacy for preven- saves lives, averts suffering, is cost-effective, and, in the
tion, research, treatment, and health systems strength- future, may lead to a world without AIDS.
ening to ensure that the response to AIDS remains an
urgent priority.
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March 2011

Experts agree that stemming the tide of the AIDS epi-

Adapted from: AIDS Vaccine Advocacy Coalition. Piecing together

potentially avert more than half of the HIV

Figure 1: HIV prevention programs for selected populations

Source: UNAIDS Report on the Global AIDS Epidemic, 2010.

her partners.18 Education should

Innovative new strategies

ARVs given to HIV-positive pregnant women for purposes

Vaccines than previously known antibodies to the virus, marking

in HIV transmission rates when an HIV-

Mapping Community Viral Load

notification, and providing linkages to care. A recent Structural Interventions

For maximum impact, HIV programs must HIV Prevention 2.0

include structural interventions aimed

Accelerating an HIV Prevention Revolution:

With more than two million new HIV infections occurring

The following recommendations provide a roadmap

Invest in Basic, Clinical, and Public Health Research

• Increase investments by government, foundations, and

• Expand HIV/AIDS education and counseling programs

• Provide national leadership to make prevention a

Direct resources to programs that can have the Summary

Public Policy Office

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