Strategies for HIV Prevention in Low Prevalence Settings

Family Health International (Thailand)

The session was about how to convince policy makers and politicians that HIV is a serious threat in countries that have low prevalence in their general populations. Globally there are 119 countries currently classified as having prevalence of HIV of less than one percent. This classification is proving problematic. The "low prevalence" status tends to encourage complacency and makes it difficult for these countries to attract international funding which they urgently need to prevent spread of HIV in the future. Tim Brown of the UNAIDS Collaborating Centre at the East-West Centre discussed the need to understand the dynamics of the epidemic to make predictions on what will happen in low prevalence countries. He described a number of explanations for "low prevalence" - risks may be below the "threshold" for supporting an epidemic; the epidemic may not have taken off yet; HIV may be present - but those at risk not yet "found"; HIV may simply not have entered the population yet or surveillance may have been inadequate and simply not detected "reservoirs" of HIV. He suggested that some places in Asia may still be relatively "disconnected", in terms of sexual and injecting networks, despite globalisation, so that there may be low prevalence of HIV in the presence of high prevalence of risky behaviours. In this situation there is obviously the potential for epidemics to grow - and often different small epidemics develop within a country at varied paces. HIV may take time - many years - to become an established epidemic, for example in Thailand it took five years before the epidemic took off, despite plenty of high risk behaviour. He warned how quickly the dynamics of the epidemic can change giving important examples of Japan - where in recent years HIV incidence has begun to increase rapidly among "men who have sex with men", and Indonesia, where the rates of infection among sex workers and injecting drug users has risen rapidly in the past two years. Stephen Mills identified a number of challenges including the difficulty in achieving behaviour change because of low perception of risk among the population, and the reluctance of donors to give to "low prevalence" countries. The strategies recommended included identifying vulnerable sub-populations such as sex workers and their clients, injecting drug users and men who have sex with men, and focusing interventions on these sub-populations, although what will be appropriate will vary from one country to another. There is a need to mobilise and effectively manage resources; limited human resources capacity was identified as a major constraint to successful responses to the threat of the epidemic in low prevalence countries. Dr Chancey, from Lao PDR, described the inter-sectoral approach of the Lao government, with the establishment of a coordinating body in 1998. She stated that "We have no high risk groups in our country", and that "We don't know who is at risk". There are obvious difficulties for officials in identifying that their country has sub-populations with high-risk behaviours - this is another reason why targeted strategies may be ineffective. Neither members of the sub-populations, nor officials, want to recognise that people belong to sub-populations with high-risk behaviours. She was asked a question about this at the end and responded that "officially" there are no "men who have sex with men" in Laos, although of course sex between men may happen.