HIV infection rates decreasing in several countries but global number of people living with HIV continues to rise. Increased HIV prevention and treatment efforts needed to slow and reverse AIDS epidemic, according to new UNAIDS/WHO report.

There is new evidence that adult HIV infection rates have decreased in certain countries and that changes in behaviour to prevent infection-such as increased use of condoms, delay of first sexual experience and fewer sexual partners-have played a key part in these declines. The new UN report also indicates, however, that overall trends in HIV transmission are still increasing, and that far greater HIV prevention efforts are needed to slow the epidemic

Kenya, Zimbabwe and some countries in the Caribbean region all show declines in HIV prevalence over the past few years with overall adult infection rates decreasing in Kenya from a peak of 10% in the late 1990s to 7% in 2003 and evidence of drops in HIV rates among pregnant women in Zimbabwe from 26% in 2003 to 21% in 2004. In urban areas of Burkina Faso prevalence among young pregnant women declined from around 4% in 2001 to just under 2% in 2003.

These latest findings were published in AIDS Epidemic Update 2005, the annual report by the Joint United Nations Programme on HIV/AIDS (UNAIDS) and the World Health Organization (WHO). The joint report, which this year focuses on HIV prevention, was released today in advance of World AIDS Day, marked worldwide on the first of December.

Several recent developments in the Caribbean region (in Bahamas, Barbados, Bermuda, Dominican Republic and Haiti) give cause for guarded optimism-with some HIV prevalence declines evident among pregnant women, signs of increased condom use among sex workers and expansion of voluntary HIV testing and counselling.

Despite decreases in the rate of infection in certain countries, the overall number of people living with HIV has continued to increase in all regions of the world except the Caribbean. There were an additional five million new infections in 2005. The number of people living with HIV globally has reached its highest level with an estimated 40.3 million people, up from an estimated 37.5 million in 2003. More than three million people died of AIDS-related illnesses in 2005; of these, more than 500000 were children.

According to the report, the steepest increases in HIV infections have occurred in Eastern Europe and Central Asia (25% increase to 1.6 million) and East Asia. But sub-Saharan Africa continues to be the most affected globally- with 64% of new infections occurring here (over three million people).

"We are encouraged by the gains that have been made in some countries and by the fact that sustained HIV prevention programmes have played a key part in bringing down infections. But the reality is that the AIDS epidemic continues to outstrip global and national efforts to contain it," said UNAIDS Executive Director Dr Peter Piot. "It is clear that a rapid increase in the scale and scope of HIV prevention programmes is urgently needed. We must move from small projects with short-term horizons to long-term, comprehensive strategies," he added.

Impact of treatment

The report recognizes that access to HIV treatment has improved markedly over the past two years. More than one million people in low-and middle-income countries are now living longer and better lives because they are on antiretroviral treatment and an estimated 250 000 to 350 000 deaths were averted this year because of expanded access to HIV treatment.

Commenting on the potential enhanced impact of integrating prevention and treatment, the 2005 report emphasizes that a comprehensive response to HIV and AIDS requires the simultaneous acceleration of treatment and prevention efforts with the ultimate goal of universal access to prevention, treatment and care.

"We can now see the clear benefit of scaling up HIV treatment and prevention together and not as isolated interventions," said WHO Director-General Dr LEE Jong-wook. "Treatment availability provides a powerful incentive for governments to support, and individuals to seek out, HIV prevention information and voluntary counselling and testing. Effective prevention can also help reduce the number of individuals who will ultimately require care, making broad access to treatment more achievable and sustainable."

Future challenges for strengthening HIV prevention

New data show that in Latin America, Eastern Europe and particularly Asia, the combination of injecting drug use and sex work is fuelling epidemics, and prevention programmes are falling short of addressing this overlap. The report shows how sustained, intensive programmes in diverse settings have helped bring about decreases in HIV incidence-among young people in Uganda and Tanzania, among sex workers and their clients in Thailand and India, and among injecting drug users in Spain and Brazil.

The report notes that, without HIV prevention measures, about 35% of children born to HIV-positive women will contract the virus. While mother-to-child transmission has been virtually eliminated from industrialized countries and service coverage is improving in many other places, it still falls far short in most of sub-Saharan Africa. An accelerated scale-up of services is urgently needed to reduce this unacceptable toll.

Levels of knowledge of safe sex and HIV remain low in many countries - even in countries with high and growing prevalence. In 24 sub-Saharan countries (including Cameroon, Côte d'Ivoire, Kenya, Nigeria, Senegal and Uganda), two-thirds or more of young women (aged 15-24 years) lacked comprehensive knowledge of HIV transmission. According to a major survey carried out in the Philippines in 2003, more than 90% of respondents still believed that HIV could be transmitted by sharing a meal with an HIV-positive person.

Finally, weak HIV surveillance in several regions including in some countries in Latin America, the Caribbean, the Middle East, and North Africa is hampering prevention efforts and often means that people at highest risk - men who have sex with men, sex workers, and injecting dug users - are not adequately covered or reached through HIV prevention and treatment strategies.

The UNAIDS Policy Position Paper for Intensifying HIV Prevention details essential policy and programmatic actions for HIV prevention.

Essential policy actions for HIV prevention

  1. Ensure that human rights are promoted, protected and respected and that measures are taken to eliminate discrimination and combat stigma.
  2. Build and maintain leadership from all sections of society, including governments, affected communities, nongovernmental organizations, faith-based organizations, the education sector, media, the private sector and trade unions.
  3. Involve people living with HIV, in the design, implementation and evaluation of prevention strategies, addressing the distinct prevention needs.
  4. Address cultural norms and beliefs, recognizing both the key role they may play in supporting prevention efforts and the potential they have to fuel HIV transmission.
  5. Promote gender equality and address gender norms and relations to reduce the vulnerability of women and girls, involving men and boys in this effort.
  6. Promote widespread knowledge and awareness of how HIV is transmitted and how infection can be averted.
  7. Promote the links between HIV prevention and sexual and reproductive health.
  8. Support the mobilization of community-based responses throughout the continuum of prevention, care and treatment.
  9. Promote programmes targeted at HIV prevention needs of key affected groups and populations.
  10. Mobilizing and strengthening .nancial, and human and institutional capacity across all sectors, particularly in health and education.
  11. Review and reform legal frameworks to remove barriers to effective, evidence based HIV prevention, combat stigma and discrimination and protect the rights of people living with HIV or vulnerable or at risk to HIV.
  12. Ensure that suf.cient investments are made in the research and development of, and advocacy for, new prevention technologies.

Essential programmatic actions for HIV prevention

  1. Prevent the sexual transmission of HIV.
  2. Prevent mother-to child transmission of HIV.
  3. Prevent the transmission of HIV through injecting drug use, including harm-reduction measures.
  4. Ensure the safety of the blood supply.
  5. Prevent HIV transmission in healthcare settings.
  6. Promote greater access to voluntary HIV counselling and testing while promoting principles of confidentiality and consent.
  7. Integrate HIV prevention into AIDS treatment services.
  8. Focus on HIV prevention among young people.
  9. Provide HIV-related information and education to enable individuals to protect themselves from infection.
  10. Confront and mitigate HIV-related stigma and discrimination.
  11. Prepare for access and use of vaccines and microbicides.

New prevention methods: innovation for Universal Access

Female condoms

Although shown to be effective in prevention of pregnancy and acceptable to users, the female condom has not achieved its full potential in national programmes because of its relatively high cost. A new version of the Reality® female condom is made of synthetic nitrile, which makes it considerably less expensive. The new device has the potential for wider acceptability and utilization.

It is hoped that, if high utilization rates of the new device can be achieved, it will make a substantial contribution to prevention of unwanted pregnancy and sexually transmitted infections, including HIV. In addition to the new female condom, trials are also under way to test the effectiveness of diaphragms and other methods of protecting the cervix for HIV/STI prevention. Results are expected in 2006.

Male circumcision

A recent study in South Africa found that circumcised men were at least 60% less likely to become infected than uncircumcised men. These promising results must be confirmed in ongoing studies in Kenya and Uganda before male circumcision can be promoted as a specific HIV prevention tool. If proven effective, male circumcision may help increase available proven options for HIV prevention, but should not cause the abandonment of existing effective strategies such as correct and consistent condom use, behavioural change and voluntary testing and counselling. Male circumcision does not eliminate the risk of HIV for men and the effects of male circumcision on women's risk of HIV are not known. It also remains to be demonstrated whether and to what degree circumcision could reduce HIV transmission in cultures where it is not currently practised.


Microbicides offer the best promise of a prevention tool women can control. They could have a substantial impact on the epidemic. Currently, the HIV microbicide field has four candidate microbicides entering or in phase III trials, five in phase II, and six in phase I. They include soaps, acid buffering agents, seaweed derivatives and anti-HIV compounds. Modelling indicates that even a 60%-ef.cacious microbicide could have considerable impact on HIV spread. If used regularly by just 20% of women in countries with substantial epidemics, hundreds of thousands of new infections could be averted over three years (Rockefeller, 2001).

Pre-exposure prophylaxis

Pre-exposure prophylaxis (PrEP) to prevent sexual-and possibly parenteral-transmission of HIV holds promise for serodiscordant couples, sex workers, men who have sex with men and injecting drug users who may be exposed to HIV despite using precautions. Small-to-medium sized phase II trials are under way in Atlanta and San Francisco, with larger phase II/III studies under way or planned in Botswana, Ghana, and possibly Thailand. Some of these studies have been dogged by controversy. The main issues were the adequacy of pre-trial community consultation and informed consent, linkages to HIV treatment programmes for those found to be infected at baseline or in the course of the study, and-in the case of Thailand-the lack of access to sterile needles in a study designed to examine HIV transmission among injecting drug users. Two PrEP studies were cancelled (Cambodia, Nigeria) and another (Cameroon) postponed. A consultation in Seattle and a series of consultations led by UNAIDS in two African regions, Asia and Geneva involving community activists, researchers, sponsors and others helped identify the problems in trial design in this promising research area. Trials have moved forward in six other sites.


A vaccine to overcome HIV is our most compelling hope. But developing a vaccine remains an enormous challenge for reasons related to inadequate resources, clinical trial and regulatory capacity concerns, intellectual property issues and scientific challenges. There are now 17 vaccine candidates in phase I trials and four vaccines in phase I/II (including the promising Merck adenovirus vector vaccine now in phase IIb, which may stimulate anti-HIV cell-mediated immunity). There is only one in phase III (the NIH/Department of Defense's ALVAC vCP 1521 canary pox vector/AIDSVAX prime-boost vaccine trial now under way in Thailand). The Global HIV Vaccine Enterprise has rallied scientists, activists, funders and others worldwide around a Strategic Scienti.c Plan to rapidly advance progress towards effective HIV vaccines, the world's best long-term hope for bringing the global HIV epidemic under control. n

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