Tailoring AIDS Prevention

Abstract

I agree with M. Potts et al. (“Reassessing HIV prevention,” Policy Forum, 9 May, p. [749][1]) that HIV prevention efforts should be continually reappraised. Potts et al. call attention to the well-recognized limitations of prevention strategies based solely on condom promotion, HIV testing, and sexually transmitted infection (STI) treatment; however, in their eagerness to promote different strategies, namely, addressing concurrent partnerships and male circumcision, they risk replacing one overly narrow prescription with another equally narrow one. HIV prevention responses need to be tailored to their contexts, and it is unfortunate that Potts et al . have chosen to illustrate their argument about generalized HIV epidemics by using a graphic of UNAIDS estimates for global resource needs, which aggregate all low- and middle-income countries, most of which (75%) are experiencing low and concentrated epidemics. It is not surprising that a good proportion of the HIV expenditure is focused on activities addressing the high-risk populations that are the predominant feature of these epidemics. ![Figure][2] HIV prevention. This UNAIDS pie chart illustrates the financial resources required to achieve universal access to HIV prevention, treatment, care, and support by 2010, including countries with hyper-endemic and generalized epidemics. Together, resources total U.S. $3.2 billion. Figures shown are millions of U.S. dollars and percentage of total prevention. For the subset of countries experiencing generalized or hyper-endemic scenarios, UNAIDS estimates of resource needs are very different (see [figure][3]) ([1][4]). There is a strong emphasis on youth (calling for $362 million, or 11% of resources); community mobilization and communication ($339 million, 11% of resources); and workplace interventions ($437 million, 13% of resources), which primarily focus on delaying sexual debut, decreasing multiple partnerships (both concurrent and serial), and promoting condom use in casual sex. In addition, resources are needed to bring about the most rapid feasible increase of male circumcision in young adults (estimated to be 2.5 million circumcisions by the year 2010 in the 12 most highly affected countries). Finally, the importance of HIV testing in generalized epidemics cannot be discounted now that around half of all HIV infections occur between discordant couples. 1. 1.[↵][5] The figure and additional information are available as Supporting Online Material ([www.sciencemag.org/cgi/content/full/321/5896/1631a/DC1][6]). [1]: /lookup/doi/10.1126/science.1153843 [2]: pending:yes [3]: #F1 [4]: #ref-1 [5]: #xref-ref-1-1 View reference 1. in text [6]: http://www.sciencemag.org/cgi/content/full/321/5896/1631a/DC1