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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