4

PEPFAR’s Prevention Category

Summary of Key Findings

  • PEPFAR’s ambitious prevention target—to support the prevention of a total of 7 million infections in the 15 focus countries—differs from the treatment and care targets in several respects: the target represents long-term impact, it is to be estimated at the national level by modeling, and it is to be measured for the year 2010. To achieve this target, PEPFAR is implementing a wide variety of HIV prevention activities, including those related to preventing mother-to-child transmission, preventing sexual transmission and transmission through injecting drug use, and reducing the risk of transmission through blood transfusion and medical injection. While many of these activities have been shown to lead to a decrease in the transmission of HIV, it is difficult to report on short-term progress for most prevention activities because of the long-term nature of their impact and a lack of indicators that can easily be linked to national declines in incidence.

  • PEPFAR is making progress in prevention of mother-to-child transmission, one of the few areas of preventive activity for which specific indicators exist that allow relatively direct estimation of infections averted. Thus far, PEPFAR has supported the provision of services aimed at preventing mother-to-child transmission to women during more than 6 million pregnancies. These efforts have included providing prophylactic antiretroviral therapy to more than 530,000 women, estimated to have resulted in more than 100,000 infant infections averted.

  • PEPFAR’s approach to achieving the prevention target involves planning and implementing prevention programs and activities that are evidence-based, harmonized with country plans and priorities, and appropriate to each country’s unique epidemiologic and cultural context. However, the abstinence-until-marriage budget allocation in the Leadership Act hampers these efforts and thus PEPFAR’s ability to meet the target. Despite the efforts of the Office of the U.S. Global AIDS Coordinator to administer the allocation judiciously, it has greatly limited the ability of Country Teams to develop and implement comprehensive prevention programs that are well integrated with each other and with counseling and testing, care, and treatment programs and that target those populations at greatest risk.

  • PEPFAR has contributed substantially to improvements in HIV surveillance that enables an overview of the epidemiologic context in the focus countries and can be used to measure progress. However, the focus countries are not conducting adequate behavioral surveillance surveys, which are critical for obtaining information on patterns of exposure and at-risk populations. PEPFAR could provide more support for such surveys.

  • PEPFAR is supporting targeted evaluation of some prevention programs, but could be doing more program evaluation and operations research, particularly for unproven interventions, to ensure that prevention funds are being used most efficiently to have the greatest impact on the focus countries’ HIV/AIDS epidemics.



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PEPFAR Implementation: Progress and Promise 4 PEPFAR’s Prevention Category Summary of Key Findings PEPFAR’s ambitious prevention target—to support the prevention of a total of 7 million infections in the 15 focus countries—differs from the treatment and care targets in several respects: the target represents long-term impact, it is to be estimated at the national level by modeling, and it is to be measured for the year 2010. To achieve this target, PEPFAR is implementing a wide variety of HIV prevention activities, including those related to preventing mother-to-child transmission, preventing sexual transmission and transmission through injecting drug use, and reducing the risk of transmission through blood transfusion and medical injection. While many of these activities have been shown to lead to a decrease in the transmission of HIV, it is difficult to report on short-term progress for most prevention activities because of the long-term nature of their impact and a lack of indicators that can easily be linked to national declines in incidence. PEPFAR is making progress in prevention of mother-to-child transmission, one of the few areas of preventive activity for which specific indicators exist that allow relatively direct estimation of infections averted. Thus far, PEPFAR has supported the provision of services aimed at preventing mother-to-child transmission to women during more than 6 million pregnancies. These efforts have included providing prophylactic antiretroviral therapy to more than 530,000 women, estimated to have resulted in more than 100,000 infant infections averted. PEPFAR’s approach to achieving the prevention target involves planning and implementing prevention programs and activities that are evidence-based, harmonized with country plans and priorities, and appropriate to each country’s unique epidemiologic and cultural context. However, the abstinence-until-marriage budget allocation in the Leadership Act hampers these efforts and thus PEPFAR’s ability to meet the target. Despite the efforts of the Office of the U.S. Global AIDS Coordinator to administer the allocation judiciously, it has greatly limited the ability of Country Teams to develop and implement comprehensive prevention programs that are well integrated with each other and with counseling and testing, care, and treatment programs and that target those populations at greatest risk. PEPFAR has contributed substantially to improvements in HIV surveillance that enables an overview of the epidemiologic context in the focus countries and can be used to measure progress. However, the focus countries are not conducting adequate behavioral surveillance surveys, which are critical for obtaining information on patterns of exposure and at-risk populations. PEPFAR could provide more support for such surveys. PEPFAR is supporting targeted evaluation of some prevention programs, but could be doing more program evaluation and operations research, particularly for unproven interventions, to ensure that prevention funds are being used most efficiently to have the greatest impact on the focus countries’ HIV/AIDS epidemics.

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PEPFAR Implementation: Progress and Promise Recommendation Discussed in This Chapter Recommendation 4-1: The U.S. Global AIDS Initiative should enhance and intensify HIV prevention through a planning process that links timely national information on the epidemic to the selection of the most appropriate intervention packages and to the optimal targeting of interventions to populations in whom infections are most likely to occur. The U.S. Global AIDS Coordinator should enhance current data on HIV prevalence by supporting quality behavioral surveys to identify patterns of risk. The Coordinator should support country plans to identify where infections are to be averted to achieve prevention targets and should track progress toward achieving prevention goals by measuring risk behaviors, the prevalence and incidence of other sexually transmitted infections, and ultimately the prevalence and incidence of HIV.

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PEPFAR Implementation: Progress and Promise 4 PEPFAR’s Prevention Category CATEGORY, TARGET, AND RESULTS The Prevention Category The prevention category encompasses five funding and reporting subcategories: (1) abstinence/be faithful, (2) condoms and other prevention, (3) prevention of mother-to-child transmission, (4) blood safety, and (5) injection safety. Funding for these subcategories for fiscal years 2004–2006 is shown in Table 4-1. Corresponding to these subcategories are four types of prevention activities funded by the President’s Emergency Plan for AIDS Relief (PEPFAR): promotion of behavior change aimed at risk avoidance and risk reduction, provision of comprehensive programs for people who engage in high-risk behavior, prevention of mother-to-child transmission of HIV, and reduction of medical transmission of HIV by ensuring safe blood supplies and safe medical injections and providing training in universal medical precautions (see Table 4-2). Strategies guiding these activities include scaling up existing prevention programs, advancing policy initiatives that support prevention of HIV infection, and collecting strategic information needed to monitor and evaluate progress and ensure compliance with PEPFAR policies and strategies (OGAC, 2006d). PEPFAR’s authorizing legislation requires that 33 percent of total prevention funding be spent on abstinence-until-marriage activities; PEPFAR allocates these funds under the abstinence/be faithful subcategory. Voluntary counseling and testing, typically a key component of HIV

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PEPFAR Implementation: Progress and Promise TABLE 4-1 PEPFAR Prevention Funding (in millions of U.S. dollars) and Percent by Subcategory for Fiscal Years 2004–2006 Subcategory Fiscal Year 2004 Fiscal Year 2005 Fiscal Year 2006 Total Fiscal Years 2004–2006 Funding Percent Funding Percent Funding Percent Funding Percent Abstinence/Be Faithful 63 31 76 26 104 33 243 30 Condoms and Other Prevention 45 22 66 22 72 23 183 22 Prevention of Mother-to-Child Transmission 44 21 66 23 71 23 181 22 Blood Safety 27 13 53 18 31 10 111 14 Injection Safety 27 13 33 11 34 11 94 12 Total* $207 100 $294 100 $311 100 $812 100 *Numbers may not add to the totals shown because of rounding. SOURCE: OGAC, 2005d, 2006c. prevention programs, is listed as a prevention activity in PEPFAR’s authorizing legislation. However, PEPFAR budgets and reports on voluntary counseling and testing under the care category, and those activities are therefore discussed in Chapter 6. Also included under the care category is secondary preventive care for HIV-positive people and their family members/caregivers. Likewise, prevention activities specifically targeting orphans TABLE 4-2 PEPFAR Activities Corresponding to Funding and Reporting Subcategories Prevention Activities Prevention Funding and Reporting Categories Promotion of behavior change aimed at risk avoidance and risk reduction Abstinence/be faithful; condoms and other prevention Provision of comprehensive programs for people who engage in high-risk behavior Condoms and other prevention Prevention of mother-to-child transmission of HIV Prevention of mother-to-child transmission of HIV Reduction of medical transmission of HIV by ensuring safe blood supplies and safe medical injections and providing training in universal medical precautions Blood safety; injection safety SOURCE: OGAC, 2004, 2005a, 2006a.

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PEPFAR Implementation: Progress and Promise and other vulnerable children are included in that category and thus are discussed in Chapter 7. Target The overall target for PEPAR prevention programs, as described in the legislation, is to prevent approximately 7 million HIV infections in the 15 focus countries by 2010. Each country has a target that represents roughly 50 percent of the expected incidence of HIV. These country targets are to be achieved through both PEPFAR-supported activities and the prevention activities of the host government and other donors. The Office of the U.S. Global AIDS Coordinator (OGAC) plans to measure achievement of the prevention target by using U.S. Census Bureau statistical models of country-level prevalence trends at intervals until 2010. Mathematical models of 10 transmission dynamics of the virus will play a central role in calculating HIV infections averted. A range of models representing the spread of HIV through populations have been developed and used over the course of the HIV/AIDS pandemic (Anderson and Garnett, 2000). Models for the expected trends in HIV can be compared with observed trends to determine whether reductions in incidence have occurred. To calculate the expected infections averted by interventions, the predicted HIV epidemic without changes in patterns of exposure is compared with that predicted when interventions are in place. Such a modeling exercise requires epidemiologic and behavioral data to capture patterns of risk and measures of the efficacy of interventions in changing behaviors among individuals and populations. PEPFAR’s initial targets for HIV prevention were based on mathematical models of this type, which used the best available epidemiologic evidence (Stover et al., 2002). To evaluate achievements in HIV prevention, models are used to predict the prevalence of HIV in the near future, which is compared with the estimated prevalence. The latter estimates are based on HIV prevalence in antenatal clinics and in general populations-based surveys, such as the Demographic and Health Surveys, as well as in generalized HIV epidemics. In concentrated epidemics, the size of high-risk groups and the prevalence of HIV in these groups is estimated. The models, developed in part by the Joint United Nations Programme on HIV/AIDS (UNAIDS), use a highly simple representation of an epidemic, which is fit to prevalence data. Such a model extrapolates the previous epidemic trend and determines whether the current trend has diverged from this. Such an approach is reasonable for evaluation, but cannot distinguish between the natural dynamics of an HIV epidemic and the impact of interventions (UNAIDS, 1999, 2002; Garnett et al., 2006). A conservative approach would be to use models to predict the lowest prevalence expected from natural dynamics and see whether

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PEPFAR Implementation: Progress and Promise observed trends fall below this prediction. Such an approach has been used to identify the impact of changes in risk behavior on epidemics in Uganda, Zimbabwe, and urban Kenya (Kilian et al., 1999; Hallett et al., 2006). PEPFAR has established intermediate targets for the focus countries by setting yearly, country-level targets that are used to estimate numbers of infections prevented in infants. These numbers represent part of the total 7 million infections the program aims to prevent. Results As noted above, achievement of the prevention target will be measured in 2010. In the interim, the only result framed in terms of infections prevented is the infections averted through prevention of mother-to-child transmission. The other results are similar to those for treatment and care in that they provide a count of people who have received prevention services, but do not allow determination of the quality of those services or whether they will translate into infections prevented. PEPFAR’s prevention results are summarized in Table 4-3. PEPFAR’s indicators for activities related to prevention of sexual transmission, though generally consistent with globally agreed-upon indicators, have changed over time. The program’s first annual report included measures in addition to those shown in Table 4-3, such as number of mass media HIV/AIDS prevention programs, but these indicators were subsequently dropped in the evaluation guidance published by OGAC and not reported in subsequent annual reports. In 2005, the Center for Strategic and International Studies studied the indicators being used by PEPFAR, comparing them with those included in the United Nations General Assembly Special Session on HIV/AIDS, Global Fund guidance, and Millennium Challenge Goals. The study found that, with regard to indicators for activities related to prevention of sexual transmission, PEPFAR was the only initiative to collect program data based on the components of the ABC model.1 While many of the initiatives did collect information on condom distribution and outlets separately, none of the other initiative separated A, B, and C in the tracking of prevention activities (Morrison et al., 2005). The Committee was unable to evaluate data related to specific at-risk populations because the data collected by PEPFAR are not broken down by these populations. See Chapter 3 for further discussion. 1 The ABC model was developed by the Government of Uganda in 1986 for a national prevention program encouraging Ugandans to abstain from sex until marriage (A), be faithful to one partner (B), and use condoms (C). Uganda’s program is referenced in the Leadership Act.

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PEPFAR Implementation: Progress and Promise TABLE 4-3 PEPFAR Prevention Results by Fiscal Year, 2004–2006 Subcategory Fiscal Year 2004 Fiscal Year 2005 Fiscal Year 2006 Abstinence/Be Faithful       Number of people reached by PEPFAR-supported abstinence-only community outreach programs for HIV/AIDS prevention 11,530,400 Not available Not available Number of people reached by PEPFAR-supported abstinence/be faithful community outreach programs for HIV/AIDS prevention 24,041,800 24,861,700 40,247,500 Number of people receiving PEPFAR-supported training or retraining to promote HIV/AIDS prevention through abstinence and/or being faithful 116,600 174,400 299,300 Condoms and Other Prevention       Number of people reached with community outreach programs that promote HIV/AIDS prevention through condom promotion, related, and other services 11,899,900 17,941,100 21,203,300 Number of people receiving PEPFAR-supported training or retraining to provide condoms and related services 51,200 93,200 129,300 Prevention of Mother-to-Child Transmission       Number of women receiving prevention of mother-to-child transmission services 1,271,300 1,957,900 2,814,700 Number of women receiving a complete course of antiretroviral prophylaxis for prevention of mother-to-child transmission 125,100 122,600 285,600 Number of infant infections averted 23,800 23,400 54,400 Number of people receiving PEPFAR-supported training or retraining in prevention of mother-to-child transmission 24,600 28,600 32,600 Number of service outlets supported by PEPFAR providing the minimum package of prevention of mother-to-child transmission services according to national or international standards 2,200 2,500 4,863 Blood Safety       Number of service outlets related to blood safety supported by PEPFAR 249 585 3,848 Number of people receiving PEPFAR-supported training or retraining in blood safety 2,200 8,000 6,600 Injection Safety       Number of people receiving PEPFAR-supported training or retraining in injection safety 4,300 12,300 52,100 SOURCE: OGAC, 2005b, 2006b, 2007a, 2007b.

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PEPFAR Implementation: Progress and Promise REVIEW OF PROGRESS TO DATE This section reviews the progress of PEPFAR’s activities to prevent HIV infection according to the primary routes of transmission of HIV: sexual, through injecting drug use, from mother-to-child, and medical. Also discussed is PEPFAR’s progress in the crucial area of removing gender barriers to prevention. Prevention of Sexual Transmission of HIV Promotion of Behavior Change Sexual transmission accounts for more than 80 percent of all HIV infections worldwide (Piot et al., 1988). Behavioral interventions designed to reduce the risk of sexual transmission of HIV are tailored to specific groups and to be effective require a current understanding of HIV epidemiology, in particular those people at highest risk of infection. These interventions include providing counseling and testing; encouraging risk reduction in people who are both HIV-positive and HIV-negative; and reducing HIV risk cofactors, such as the presence of another sexually transmitted infection (JHU AIDS Service, 2006). The Leadership Act describes activities to be supported by the U.S. Global AIDS Initiative to prevent HIV transmission. These activities focus on “delay of sexual debut, abstinence, fidelity and monogamy, reduction of casual sexual partnering, reducing sexual violence and coercion, including child marriage, widow inheritance, and polygamy, and where appropriate, use of condoms” (P.L. 108-25, p. 729). As described in the strategy for the program, PEPFAR’s primary approach to preventing sexual transmission of HIV is aimed at changing ABC behaviors. Largely in response to the Leadership Act’s requirement that 33 percent of funding for prevention of sexual transmission go to support abstinence-until-marriage (A) programs, PEPFAR divides activities related to preventing sexual transmission into two funding and reporting subcategories: abstinence/be faithful and condoms and other prevention (GAO, 2006). Abstinence/Be Faithful Operational plans for the 15 focus countries incorporate a variety of activities funded under the abstinence/be faithful subcategory, including school-based, community, and media interventions aimed at delaying sexual activity among youths; promoting fidelity and reduction of the number of partners among sexually active adults; addressing gender norms and HIV-

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PEPFAR Implementation: Progress and Promise related issues, such as intergenerational and coercive sex; increasing family and community involvement in HIV prevention; and promoting counseling and testing, especially for family members of people living with HIV/AIDS (OGAC, 2006c). Funding under abstinence/be faithful also supports technical assistance and capacity building activities, such as the formulation of culturally appropriate school curriculum focused on developing students’ life skills, training of adults (teachers and community counselors) to promote abstinence/be faithful messages in their communities, and strengthening of the capacity of local organizations to enable them to receive U.S. government funding under the abstinence/be faithful subcategory (OGAC, 2006c). Examples of abstinence/be faithful activities in selected focus countries are presented in Box 4-1. BOX 4-1 Selected Examples of PEPFAR-Supported Abstinence/Be Faithful Activities In Ethiopia, PEPFAR is funding programs that address negative social norms that lead to increased risk of HIV infection for young girls. Behavior change activities are directed at older men who seek sexual relationships with younger girls and the communities that explicitly or implicitly condone such relationships. In South Africa, a number of PEPFAR partners are bringing tailored AB messages into communities with door-to-door counseling on risk assessment and behavior change, as well as the use of traditional healers to deliver prevention messages that reinforce traditional values. In Uganda, PEPFAR has supported the development and tailoring of school-based prevention curriculum. Support for the Presidential Initiative on AIDS Strategy for Communication to Youth, a school-based HIV/AIDS communication initiative for youths, has provided training for a large number of primary school teachers on abstinence and life skills messages, as well as related teaching and reading materials. In Namibia, a PEPFAR partner is focusing on prevention by strengthening AB messages at counseling and testing sites in the community setting, providing counseling and testing for partners and family members of people who are HIV-positive, offering risk reduction counseling, and stressing the importance of being faithful to a partner of known HIV status. SOURCE: OGAC, 2006c.

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PEPFAR Implementation: Progress and Promise Condoms and Other Prevention Activities aimed at preventing sexual transmission of HIV under the condoms and other prevention subcategory include interventions for a number of priority groups, such as sero-discordant couples, people living with HIV, the military, police, commercial sex workers and their clients, truck drivers, and refugees. These interventions include mass media campaigns, peer-to peer counseling, condom promotion, and communication interventions targeting behavior change in high-risk venues and along transportation corridors. There are a number of examples of comprehensive and appropriate PEPFAR-funded programs addressing the needs of these populations. However, because of a lack of systematic data on these programs and on the needs of populations most at risk in the focus countries, it is not possible to determine the extent to which these programs are addressing the needs. According to OGAC, the total number of U.S. government–funded male and female condoms shipped to the focus countries increased from 115 million in 2001 to 198 million in 2005 (OGAC, 2006b) with a total of nearly 407 million condoms purchased for the focus countries in the first 3 years of PEPFAR (OGAC, 2007). The number of U.S. government–funded condoms shipped to individual focus countries in 2005 ranged from 0 to nearly 70 million (OGAC, 2006b). It is unclear how much of the increase in condoms provided to the focus countries is due to PEPFAR. The relevant data for 2002 through 2004 were not available to the Committee, and in many of the countries, U.S. government agencies are funding other development programs, such as family planning programs, that include the distribution of condoms. As of June 2006, PEPFAR had supported nearly 86,000 condom outlets (OGAC, 2006a). OGAC reports that the lack of data with which to determine the number of condoms provided specifically under PEPFAR is linked to rules that apply to the focus countries’ access to a commodities fund that is generally used to purchase condoms for U.S. Agency for International Development (USAID) programs. According to discussions with OGAC and Country Teams, USAID programs in countries other than the PEPFAR focus countries typically pool worldwide condom orders and procure the condoms centrally for both family planning and HIV prevention programs. Because the focus countries are reportedly not eligible to receive condoms from the commodities fund because of the interpretation of legislative intent, a number of PEPFAR-supported programs use their PEPFAR funds to purchase condoms. OGAC officials also reported that family planning and HIV prevention programs promote the use of condoms for health generally, including prevention of both disease and pregnancy. Thus all of the condoms shipped to the focus countries are used for both purposes.

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PEPFAR Implementation: Progress and Promise In addition to the interventions described above, PEPFAR is supporting the development of a number of new prevention technologies, such as microbicides (female-controlled chemical barriers to prevent transmission of HIV). The U.S. Global AIDS Initiative, through the National Institutes of Health, supports scaling up for clinical trials of three microbicide candidates as well as the HIV Prevention Trials Network, a worldwide collaborative that develops and tests the safety and efficacy of nonvaccine interventions designed to prevent HIV transmission (OGAC, 2005b). A variety of other prevention activities are funded under the condoms and other prevention subcategory. For example, PEPFAR is supporting studies of risk reduction associated with male circumcision and of alcohol consumption as a risk factor for HIV transmission in a few of the focus countries. PEPFAR is also supporting the training of clinicians and peer counselors in how to communicate comprehensive ABC-based prevention messages. Workplace prevention programs funded by PEPFAR are focused on the development of workplace strategies and training for how to deal with the personal and potential commercial impacts of HIV/AIDS in the workplace. Comprehensive and integrated approaches drawing on all components of ABC and targeting specific populations have been shown to be effective in increasing healthy behaviors and decreasing transmission of HIV, especially when integrated with other HIV services, such as counseling and testing, treatment of other sexually transmitted infections, and antiretroviral therapy (ART) (Stanton et al., 1998; Furguson et al., 2004; Bunnell et al., 2006; Riedner et al., 2006). There is, however, little evidence to show that ABC when separated out into its components is as effective as the comprehensive approach (Bollinger et al., 2004). Examples of condoms and other prevention activities in selected focus countries are presented in Box 4-2. Information Campaigns and Training Overall, OGAC has reported reaching more than 140 million people in the 15 focus countries with messages intended to prevent the sexual transmission of HIV, a number that represents over one-fourth of the combined population of more than half a billion people in the focus countries. Of this total, roughly two-thirds of people received abstinence-until-marriage/be faithful messages and roughly one-third received condoms and other prevention messages. PEPFAR has supported the training or retraining of more than 864,000 people for prevention programs related to preventing sexual transmission of HIV. Roughly two-thirds of those trained were trained for abstinence-until-marriage/be faithful programs (OGAC, 2005b, 2006a,b, 2007).

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PEPFAR Implementation: Progress and Promise safety procedures and services (OGAC, 2005b, 2006b, 2007). Other accomplishments, such as supporting the establishment of government entities responsible for adopting national guidelines, monitoring injection safety practices, and overseeing the development of nursing school curriculum on medical injection, are described in the Country Operational Plans (OGAC, 2005d, 2006a,c). Examples of PEPFAR-supported injection safety activities are presented in Box 4-5. Increased Focus on Gender Issues in Prevention OGAC has provided Country Teams with guidance on ways to address gender issues in prevention programming appropriate to the context of each country. The Gender Technical Working Group identified review criteria for PEPFAR-supported prevention activities for the fiscal year 2007 Country Operational Plans. These include the following (OGAC GTWG, 2006): Ensure equitable access to gender-appropriate prevention messages and services by girls and boys, women and men. Support comprehensive, integrated efforts to reduce the practices of cross-generational and transactional sex, multiple sexual partners, BOX 4-5 Selected Examples of PEPFAR-Supported Medical Injection Safety Activities In Mozambique, PEPFAR has supported the Ministry of Health Biosafety Program and provided technical assistance and training to Ministry of Health staff to introduce a standards-based approach to biosafety in central and provincial referral hospitals, as well as technical assistance and training on injection safety at all levels of health facilities. In Uganda, PEPFAR supported the development of a comprehensive medical safety program that included strengthening national leadership and medical safety bodies; implementing related policy and guidelines; constructing 10 incinerators in 10 districts in partnership with WHO; and procuring adequate supplies, such as auto-disabling syringes and needles. In Vietnam, PEPFAR supports collaboration with the National Institute of Occupational and Environmental Health in Hanoi on medical safety that has been ongoing since 1999. Currently, PEPFAR supports staff exchanges aimed at training institute staff in occupational safety and health research techniques. SOURCE: OGAC, 2006c.

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PEPFAR Implementation: Progress and Promise and gender-based violence, including activities to change male norms and behaviors. Support interventions aimed at eradicating gender-based violence and the exploitation of women and girls by prostitution, sex trafficking, rape, and sexual abuse; provide postrape prophylaxis. Ensure that vulnerable girls and women are reached by services that empower them to prevent HIV infection, including strategies to increase women’s access to employment and income generation. Provide behavior change education on male norms, violence, and alcohol abuse to military, uniformed services, and mobile populations. Address the unique needs of male and female users of injection drugs. OGAC has identified the need to design prevention programs targeting women and girls, such as programs to prevent mother-to-child transmission of HIV and to provide voluntary counseling and testing. OGAC is also suggesting that PEPFAR programs create opportunities to establish connections with nonpregnant women and adolescent girls by using reproductive health and family planning programs as entry points. Many gender issues are being addressed in some PEPFAR-supported activities. The fiscal year 2006 Country Operational Plans contain many examples of PEPFAR prevention programs that include gender components. Without specific gender indicators or good data on which gender-focused interventions work best, however, OGAC will be unable to report what impact these programs are having on women’s risk of contracting HIV (OGAC GTWG, 2006; OGAC, 2006e). Moreover, programmatic barriers remain to reaching women who are at risk of contracting HIV, such as young girls engaging in transactional sex, commercial sex workers, and sero-discordant couples. Examples of gender-related activities supported by PEPFAR in selected focus countries are presented in Box 4-6. ISSUES AND OPPORTUNITIES FOR IMPROVEMENT Although it is difficult to report on the short-term progress of national prevention activities supported by PEPFAR, the Committee identified a number of issues and associated adjustments to the program that could enhance the quality, accountability, and flexibility of PEPFAR’s prevention efforts. These include collection of surveillance data, integration of prevention with treatment and care, greater flexibility to select country-appropriate prevention activities through removal of the abstinence-until-marriage budget allocation, and targeting of populations at greatest risk. Evaluation of prevention interventions, discussed in Chapter 8, represents another opportunity for improvement.

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PEPFAR Implementation: Progress and Promise BOX 4-6 Selected Examples of PEPFAR-Supported Prevention Activities That Include Gender Components In Botswana, a PEPFAR-supported call center used to link people with HIV/AIDS services is being expanded to offer anonymous counseling for mental health problems and gender-based violence. In Zambia, PEPFAR is supporting a weekly interactive national radio show, Club New Teen Generation, which is designed to promote a dialogue among and between youth, parents, teachers, and some high-profile public figures. Key themes of the show include gender issues such as cross-generational sex and means of improving sexual negotiation skills. In Ethiopia, PEPFAR is supporting a program focused on addressing sexual violence against women, the delivery of postexposure prophylaxis, cross-generational and coercive sexual relationship behaviors, and substance abuse and sexual risk-taking behaviors. SOURCE: OGAC, 2006c. Collection of Surveillance Data Data from sentinel and behavioral surveillance surveys are essential if national policy makers are to design responses to HIV/AIDS that appropriately address the risk behaviors fueling their country’s epidemic. For PEPFAR, such data are necessary to identify and target programs to those most at risk of contracting HIV. PEPFAR highlights the need to incorporate these data in the planning of prevention programs in each focus country in its guidance to the Country Teams. According to this guidance, the following steps are to be followed in the planning stage (OGAC, 2005e): Estimate the proportion of new infections that are associated with specific behaviors, such as prostitution, early onset of sexual activity among youths, and transmission through sexual networks. Review prevalence data available from national serosurveys, antenatal clinic surveillance, and/or voluntary counseling and testing clinics to assess infection burdens by age and gender. Understand who is engaging in risk-related activities, how to reach these people, and what individual and structural factors can be leveraged to promote change.

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PEPFAR Implementation: Progress and Promise PEPFAR and other U.S. government–funded programs before it have supported the collection of surveillance data in many of the focus countries. However, the collection, analysis, and appropriate application of both sentinel and behavioral surveillance data pose a number of challenges. For example, methodological issues arise, such as low utilization of antenatal clinics, which compromises the representativeness of surveillance data, and the difficulty of accurate sampling of at-risk and/or marginalized groups for behavioral surveys of at-risk populations. Host countries’ capacity to analyze the data collected and apply the findings may be limited, and there may be political opposition to collecting accurate information on the epidemic. Since 2000, a majority of the 15 focus country governments have been leading the collection of sentinel surveillance data, primarily in antenatal clinics. In addition, the Demographic and Health Surveys have been conducted in the majority of focus countries in the last 6 years. However, only a few of the countries have conducted behavioral surveys focused specifically on high-risk populations. Without behavioral data on these populations, it is difficult for countries and donors to know what specific factors are driving each epidemic and what particular interventions would be most successful for each country in preventing the further spread of HIV. PEPFAR funds have directly supported the collection of surveillance data in all of the focus countries through technical assistance; updating of infrastructure to manage the data collected; and procurement of supplies, such as test kits, to be used in conducting the surveys. In addition, grantees are working to strengthen the capacity of ministries of health and the national AIDS agencies to develop and conduct surveys both on a national scale and for targeted populations. In a number of countries, PEPFAR has supported the placement of experts in the ministry of health or other relevant agencies to assist with specific projects, as well as to train staff in how to improve their data collection activities. PEPFAR has also supported the focus countries in appropriate use of the data being collected and to develop strategies for dissemination (OGAC, 2005c). In addition, slots have been created for PEPFAR Country Team staff with expertise in surveillance to coordinate all PEPFAR-funded surveillance activities and help direct the gathering of data at the country level (OGAC, 2005c). In accordance with its own guidance, PEPFAR will need to use all available information on key risk behaviors and vulnerable populations in planning and implementing tailored prevention programs that address the needs of each focus country. PEPFAR’s continued support for the collection of sentinel surveillance and Demographic and Health Survey data in the focus countries, as well as for Country Operational Plans to conduct more frequent behavioral surveillance surveys, is required to ensure the availability of this information.

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PEPFAR Implementation: Progress and Promise Recommendation 4-1: The U.S. Global AIDS Initiative should enhance and intensify HIV prevention through a planning process that links timely national information on the epidemic to the selection of the most appropriate intervention packages and to the optimal targeting of interventions to populations in whom infections are most likely to occur. The U.S. Global AIDS Coordinator should enhance current data on HIV prevalence by supporting quality behavioral surveys to identify patterns of risk. The Coordinator should support country plans to identify where infections are to be averted to achieve prevention targets and should track progress toward achieving prevention goals by measuring risk behaviors, the prevalence and incidence of other sexually transmitted infections, and ultimately the prevalence and incidence of HIV. Integration of Prevention with Treatment and Care PEPFAR has increasingly emphasized the importance of integrating its prevention, treatment, and care interventions. However, the separation of counseling and testing from prevention in both budgeting and reporting creates a challenge to implementing the optimal package of integrated prevention activities. Even so, PEPFAR programs are working to improve the integration of services. It is, however, difficult to assess the success of these efforts as information on the extent of such programmatic linkages is not being collected. Integration of HIV/AIDS prevention, treatment, and care programs has become more important with the scale-up of treatment and care programs, which has created opportunities to capitalize on prevention interventions (GHPWG, 2004). If countries do not succeed in stemming the tide of new infections, the need for treatment will continue to increase and outpace their ability to develop the capacity to meet it (Mathers and Loncar, 2006). Key integration points include ART, counseling and testing, prevention of mother-to-child transmission, and diagnosis and treatment of sexually transmitted infections. The Global HIV Prevention Working Group (2004) made the following recommendations for integrating HIV prevention and treatment programs: Integrate HIV prevention and treatment. Health care settings, including HIV treatment sites, should deliver HIV prevention services that will train health care workers in the delivery of HIV prevention interventions. There should be significant expansion and aggressive promotion of voluntary HIV testing and counseling, which should be universally offered in all health care settings. Conversely, prevention programs should promote HIV testing, educate communities about HIV treatments, and facilitate linkages to ART and other care.

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PEPFAR Implementation: Progress and Promise Develop prevention strategies for people who are HIV-positive. Programs tailored to the needs of people living with HIV/AIDS should be developed and implemented. These programs should involve people living with HIV/AIDS and combat stigma with enforceable laws. Adapt prevention for people who are HIV-negative. New strategies must emphasize the continued importance of risk reduction and stress that ART is not a cure. Monitor impact. Surveillance systems should closely monitor the behavioral impact of ART. Integrated HIV/AIDS programs have been shown to improve the effectiveness of national programs in decreasing rates of HIV infection and death from AIDS. A UNAIDS (2005a) study projects numbers of new HIV infections and AIDS deaths through 2019 based on models for treatment-centered, prevention-centered, and joint prevention/treatment global responses. The latter model results in the largest number of infections averted and the lowest number of AIDS deaths over a 15-year projection. Similarly, an optimistic model developed by Mathers and Loncar (2006), which assumes increased prevention activity, projects a decline in HIV/AIDS deaths as of 2030 from an estimated baseline of 6.5 million to 3.7 million. Likewise, a conference of Christian Aid HIV partners underscored the need to shift the focus of HIV interventions from a prevention-specific ABC approach to a comprehensive approach developed by the African Network of Religious Leaders Living with or Personally Affected by HIV/AIDS called SAVE (Safer practices, Available medications, Voluntary counseling and testing, and Empowerment). In most of the focus countries, HIV infection is hyperendemic, with transmission occurring from those unaware of their infection status to others unaware of the risk (often spouses of either gender). Counseling and testing are therefore essential to achieving a long-term, sustainable impact on reducing HIV transmission, as well as meeting treatment and care goals. Given its placement in the care category, it appears that PEPFAR views counseling and testing primarily as a means of identifying HIV/AIDS cases eligible for treatment and care. In addition to case finding, however, counseling and testing represents an opportunity to provide HIV education, including prevention messages to people testing both positive and negative for HIV. PEPFAR continues to struggle with how to integrate prevention, treatment, and care activities and how to measure the level of integration both among PEPFAR-funded services and between those services and the broader health care system in each focus country. For example, OGAC has endeavored to afford Country Teams greater flexibility in planning and budgeting their fiscal year 2007 ABC programs. Country Teams will

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PEPFAR Implementation: Progress and Promise be able to use combined abstinence/be faithful and condoms and other prevention funds from the same partner to implement integrated interventions. PEPFAR’s continued attention to the barriers involved is required to improve the integration of prevention with treatment and care services, especially with regard to counseling and testing. Greater Flexibility to Select Country-Appropriate Prevention Activities In addition to epidemiologic data and evidence on specific interventions typically used in the development of prevention programs, PEPFAR’s prevention planning is controlled in part by budgetary allocations outlined in its authorizing legislation. The variability of the epidemics in the focus countries underscores the need for specific and timely information in designing prevention programs that address the most important needs and can result in the most infections averted. Even when sufficient data are available, however, Country Teams are not completely free to target funding and interventions to those at greatest risk of acquiring HIV and to prevent transmission from people living with HIV and within sero-discordant couples through improved integration with counseling and testing, care, and treatment. Since the beginning of the program, concern has been raised about the ability to implement appropriate, integrated, and comprehensive prevention programs given the restriction created by the 33 percent abstinence-until-marriage budgetary allocation. In 2005, OGAC provided guidance to Country Teams for implementing this allocation. This guidance included the implementation definitions of abstaining from sex until marriage (A), being faithful to one partner (B), and using condoms (C), as well as details on how to fund tailored, country-specific prevention activities through the appropriate mix of those components. Nonetheless, confusion and frustration in the field caused by the abstinence-until-marriage allocation have persisted, as reflected in the Committee’s discussions with PEPFAR Country Teams during its country visits in which staff indicated that the allocation did not allow them sufficient flexibility to create the appropriate prevention portfolio based on the available data. The Government Accountability Office (GAO, 2006) reached a similar conclusion. OGAC has attempted to provide the Country Teams with greater flexibility through a variety of management policies, but the problem remains. See Chapter 3 for further discussion of and the Committee’s recommendation related to the budget allocations. Targeting Prevention Interventions The proportions of total PEPFAR prevention funding allocated to each subcategory—abstinence/be faithful (30 percent), condoms and other

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PEPFAR Implementation: Progress and Promise prevention (22 percent), prevention of mother-to-child transmission (22 percent), blood safety (14 percent), and medical injection safety (12 percent)—are not well-aligned with the estimated proportions of new infections from the major routes of transmission. For example, it is estimated that in sub-Saharan Africa, transmission through sexual contact, from mother-to-child, and via health care procedures (including blood transfusions and medical injections) account for 80–90 percent, 5–35 percent, and 5–10 percent of new infections, respectively, with regional variation (NAS, 1994; Quinn et al., 1994; Quinn, 1996, 2001; WHO, 2002b; Askew and Berer, 2003; Bertozzi et al., 2006). Together, the two subcategories related to sexual transmission—abstinence/be faithful and condoms and other prevention (which also includes funds for activities related to people who use injecting drugs), account for approximately 52 percent of PEPFAR’s prevention funding, well below the estimated contribution of sexual transmission to new infections. In contrast, the blood safety and safe injection subcategories make up 25 percent of PEPFAR prevention funding but are responsible for a much smaller proportion of new infections. CONCLUSION In its effort to achieve the target of preventing 7 million infections in the 15 focus countries by 2010, PEPFAR supports the implementation of various prevention interventions, including voluntary counseling and testing, prevention of mother-to-child transmission, and many ABC-related programs, that have been shown to lead to a decrease in the transmission of HIV when targeted to the appropriate populations. It is difficult to know whether these activities will lead to the necessary national declines in incidence, however, because of a lack of information on both the short-term progress of the interventions and the extent to which PEPFAR has been able to target these interventions to those populations most at risk. To support the implementation of comprehensive and evidence-based prevention interventions appropriate to each country’s unique epidemiologic and cultural context in order to achieve the prevention target, PEPFAR will need to make a number of adjustments to enhance its surveillance efforts, integrate prevention with treatment and care, and allow greater flexibility in its prevention programs. REFERENCES Anderson, R. M., and G. P. Garnett. 2000. Mathematical models of the transmission and control of sexually transmitted diseases. Sexually Transmitted Diseases 27:636–643.

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