Enhancing HIV prevention requires addressing the complex relationship between prevention and treatment.

Globally each year, HIV continues to infect millions of people, and the number of people living with HIV and AIDS grows. While there has been an increase in funding for HIV and AIDS, there is a growing gap between the funds available and the funds needed for both prevention and treatment. Yet, one of the means of closing that gap - preventing new infections - has slipped down the agenda. In arguing for a significant intensification of the HIV prevention response, and the relevance of a strong social stance within this response, this paper addresses the need to manage finding a balance between prevention and treatment and care. Not only is there not enough being spent on HIV prevention, but also in some instances, the prevention agenda has been hijacked by those who favour morally conservative, but ineffective, HIV prevention strategies. We argue that effective prevention needs to be firmly located within the everyday realities affecting communities and societies, and needs to focus on what is known to work. In particular, we need to move beyond a public health underpinned by neo-liberal notions of agency and individual responsibility to a public health that recognises the collective nature of epidemics, and works with communities and networks to transform social relations. This latter, more 'social' public health, is concerned with the social, political and economic factors that produce HIV risk and responses to it. Contrary to what some might suggest, HIV prevention has not failed, rather, governments and donors have failed HIV prevention.

Involving HIV-positive people in policy and service development: recent experiences in England.

Although the 'Greater Involvement of People Living with or Affected by HIV/AIDS' (GIPA) principle was first articulated over a decade ago (UNAIDS, 1999), relatively few studies have examined the extent to which it is being implemented. A study was undertaken in three areas of England to establish the types of user involvement mechanisms in place for HIV-positive people to influence service and policy development. Drawing on group discussions with 38 people living with HIV and six HIV professionals across the three geographical research sites, as well as interviews with eight professionals with expertise in this area, this paper illustrates variability in opportunities for involvement. Also identified are a range of (innovative) methods for facilitating HIV-positive people's greater participation in service planning and delivery, as well as some of the challenges encountered by people living with HIV and service providers when implementing GIPA. The paper concludes by identifying some specific strategies for improving user involvement in HIV service provision.

Putting sexuality (back) into HIV/AIDS: issues, theory and practice.

After more than twenty years of programming and activism aimed at stemming the sexual transmission of HIV (and addressing the needs of those most vulnerable to infection) the HIV/AIDS epidemic continues to grow worldwide. Taking up this concern, this paper argues that one of the reasons why HIV prevention has had limited success is because of inadequate conceptualization of human sexuality in such work. Giving sexuality a more prominent position in responses to the epidemic raises a range of issues, including theorization of gender, understanding of sexual subjectivity, the significance of pleasure (or lack of pleasure) in sexual decision-making, and conceptualization of sexual behaviour and culture. Taking these themes forward entails asking significant questions about the underlying paradigmatic and methodological commitments of mainstream HIV/AIDS research, especially the tendency to reproduce accounts of human sexuality as if it were a measurable form of conduct only. Advocating new approaches that take the meaning and symbolic value of sexualities into account complicates established orthodoxies in the field whilst offering potential for more effective HIV prevention strategies.

Reflection and dialogue for HIV prevention among young gay men.

Considerable interest has been expressed in young gay men's enhanced vulnerability to HIV-related risk. Relatively little research has, however, been conducted into the circumstances in which risk may be greatest and the strategies young gay men can use to reduce their vulnerability. This paper reports on findings from a recent exploratory in-depth study conducted in Norway. Twenty young gay men participated in repeated dialogic and reflective interviews in which situations of real and potential risk were discussed. Central among the factors enhancing vulnerability were found also to be general social codes such as configurations of 'reciprocity', as well as context-specific factors and individual biographic variables. A mode of intervention is described that seeks to empower young men more fully in sexual communication and negotiation. Such an approach has been operationalized in 'man-to-man dialogues' facilitated by members of the Norwegian Gay Health Committee.

Playing it safe: addressing the emotional and physical health of lesbian and gay pupils in the U.K.

Compared to young people in general, young lesbians and gay men can face specific challenges to their physical and emotional well-being. These include discrimination, victimization, homophobic bullying and an elevated suicide risk. Relative to initiatives which attempt to address bullying in general, little has been done in schools in the U.K. to address physical and verbal homophobic bullying. This paper reports on an exploratory study to examine teachers' perceptions of homophobic bullying, the responses made to this form of bullying, and the factors which impact on the provision of education and support to lesbian and gay pupils. Findings suggested that teachers were aware of homophobic bullying but were confused, unable or unwilling to address the needs of lesbian and gay pupils. Implications for policy, practice and research are discussed. While current U.K. Government policy promoting Healthy Schools and Citizenship education offers hope for the future, much remains to be done to ensure that such initiatives are inclusive of all pupils.

What constitutes evidence in HIV/AIDS education?

It is clear that many sources of evidence have contributed to our grasp of what does and does not work in HIV/AIDS education. Despite this, there has recently been a distinct move to narrow the evidence of success in this field to experimental and comparative work, with randomized controlled trials positioned as the 'gold standard'. Here we take up the question of what constitutes evidence in HIV/AIDS education. We explore the social and historical factors which 'privilege' certain kinds of evidence above others and question whether there exists but one way of understanding what works best in HIV/AIDS education. We draw expressly upon earlier insights and experience in educational evaluation per se and put a case that evidence gleaned through a range of research methods is more useful than exclusive reliance on experimental and comparative work.

Young people and HIV in Cambodia: meanings, contexts and sexual cultures.

Like many other countries in South East Asia, Cambodia is experiencing a rapidly developing AIDS epidemic. Groups reported as being particularly seriously affected include sex workers and their clients. Young people too may be at heightened risk: some young women find sex work a lucrative option in the context of low wages and poor employment opportunities, and some young men pay for sex either as individuals or as part of group socializing. These same young men may subsequently have sex with other partners, thus extending networks of transmission. While there is limited knowledge about the form of such sexual networks, little is known about the meanings that underpin young people's sexual relations and partnerships, the sexual identities associated with such meanings, and prevailing socio-sexual cultures. This paper reports on findings from an in-depth qualitative study conducted among two groups of young people: one urban, the other rural. Following an initial Rapid Assessment Process, data was collected via individual interviews, focus group interviews and participant observation. The research team included young people themselves. Data is presented on dominant discourses about sex and sexuality in Cambodia; contemporary patterns of sexual behaviour; sexual meanings and sexual practices; sexual relations among young people involving payment; and sexual relations not involving payment. The implications for more effective HIV prevention efforts are discussed.

PIP: Like many other countries in southeast Asia, Cambodia is experiencing a rapidly growing AIDS epidemic. Particularly seriously affected are prostitutes and their clients. Young people may also be at increased risk, with some young men frequenting prostitutes either individually or in groups, and some young women lured into prostitution by the opportunity to earn relatively high wages. Men who have sex with prostitutes often have sex with other mainstream sex partners, thereby extending networks of HIV transmission. Findings are reported from an examination of dominant discourses about sex and sexuality in Cambodia, contemporary patterns of sexual behavior among young people, sexual meanings and practices, sexual relations among young people involving payment, and sexual relations not involving payment. Fieldwork for the study took place between February 1995 and April 1996, and included the collection of data through individual interviews, focus group interviews, and participant observation. 218 people aged 13-26 years participated in individual interviews. Of those, 71 men and 52 women were interviewed in Phnom Penh, and 75 men and 83 women were interviewed in selected villages.

Facing the challenge: household responses to HIV/AIDS in Mumbai, India.

How households and families respond to AIDS is of fundamental importance when it comes to designing programmes and interventions to provide support and care to people living with HIV disease. Where household and family responses are negative, different kinds of interventions may be needed from those where responses are more supportive. This paper reports on findings from an in-depth study of household and family responses to HIV and AIDS in India. Using individual and couple interviews, data were collected on the ways in which care and support were offered (or denied) to people living with HIV and AIDS. Findings show that responses are greatly influenced by prevailing gender relations, with men being responded to more positively than women, as well as other variables such as social status. The quality of responses is also influenced by pre-existing patterns of support and discord within the family. Where trust is high and spousal conflict slight, for example, HIV and AIDS are reacted to more positively than when there is mistrust and inter-spousal conflict. Suggestions are made concerning programme and intervention development so as to strengthen existing responses, and to maximize the success of home-based care.

Family responses to HIV/AIDS in Mexico.

This paper presents findings from a qualitative study of household and community responses to HIV/AIDS in Mexico. Fieldwork took place in two contrasting settings: (a) Ciudad Netzahualcóyotl, a socially marginalized urban community and (b) the homosexual community of Mexico City, a sexually marginalized social network. 113 in-depth interviews were conducted with people with HIV/AIDS, their relatives and members of their social networks. This paper describes findings from interviews conducted with family members of persons with AIDS. Four stages of response are identified and characterized within each community: (i) life before AIDS, (ii) life during the discovery of AIDS, (iii) living with a person with AIDS and (iv) surviving those who have died from AIDS. The social marginalization of both communities is central in explaining how families respond to the disease. In Ciudad Netzahualcoyotl, social support derives from a local culture of kinship. In the gay community, on the other hand, solidarity arises out of friendship. Between social support and discrimination, many more "ambivalent" behaviours (neither fully supportive nor discriminating) are displayed by family members and friends. Fear, pre-existing family conflicts and prejudice nurture these negative responses. Family responses and the processes to which they give rise, also differ depending on whether or not a male or female household member is affected. Policy recommendations are made concerning how best to promote positive family and household responses to persons with HIV/AIDS and how to inhibit negative ones.

AIDS-related illness trajectories in Mexico: findings from a qualitative study in two marginalized communities.

This paper describes findings from a recent study examining how people affected directly and indirectly by the HIV/AIDS epidemic cope with HIV-related illness in Mexico. One-hundred-and-thirteen in-depth interviews were conducted with key informants in two contrasting communities: Ciudad Netzahualcóyotl (an economically marginalized community) and the gay community in Mexico City (a sexually marginalized community). This paper describes the AIDS-related wellness/illness careers or trajectories followed by individuals in both communities, and identifies critical points for material and emotional intervention. This career comprises four stages: (1) life before infection; (2) life surrounding the discovery of seropositivity; (3) living as an HIV-positive person; and (4) facing death. Comparisons are drawn between the processes of adjustment and coping found in both communities. In Ciudad Netzahualcóyotl, wellness/illness careers are closely linked to prevailing poverty and oppression, as well as the sense of urgency in which local people live their lives. In the case of the gay community, wellness/illness careers are associated with the intolerance and social repression faced by homosexual men. The paper concludes by suggesting possible interventions to improve the lives of people with HIV/AIDS in Mexico today.

PIP: Characterization of AIDS-related illness trajectories is essential to the design of programs intended to provide support and assistance to HIV-infected persons. These trajectories were investigated through in-depth interviews conducted with 113 HIV-positive persons or their family members from two contrasting communities in Mexico: Ciudad Netza (economically marginalized) and the gay community in Mexico City (sexually stigmatized). This trajectory consisted of 4 basic stages in both settings: 1) life before HIV infection, 2) the discovery of one's HIV seropositivity, 3) living as an HIV-positive person, and 4) facing death. In Ciudad Netza, the daily experience of poverty is so pressing that an HIV diagnosis tends to be viewed as yet another problem to be faced. For many Mexico City gays, HIV infection initiates the need to "come out" both as a homosexual and as an HIV-positive person. In each community, the HIV diagnosis was accompanied by much self-blame and self-recrimination. After diagnosis, many HIV-infected persons who had been living independently stopped working and returned home to live with their families--a step associated with both financial and psychosocial adjustment difficulties. As death approached, financial and health care needs intensified and social stigmatization added to the pain experienced by AIDS patients and their families. Among the needs identified through these interviews are legislation to combat discriminatory employment policies, more sensitive counseling and psychological support at the time of HIV diagnosis, referrals for those who lack family support, and courses for health workers to combat the rejection of patients with AIDS.

The global epidemic.

PIP: The global HIV/AIDS epidemic is comprised of a series of overlapping micro-epidemics, each with its own structure and dynamics. However, at the global level, the HIV/AIDS epidemic continued to grow throughout 1996, with an estimated 3.1 million new infections occurring, or 8500/day. About half of those new infections were among women. The majority of newly infected adults in 1996 were under age 25 years. Worldwide, more than 23 million people are living with HIV/AIDS, while an estimated 1.5 million people died in 1996 due to AIDS. While HIV/AIDS mortality is declining in many wealthy countries largely due to better care, there has been a growing impact overall globally. Many people are unaware that they are infected with HIV. Some encouraging signs suggest that the epidemic can be brought under control even in the relatively poor countries. Sections discuss UNAIDS and the expanded global response, successes and failures in checking the spread of HIV, global inequalities and AIDS, the normalization and mainstreaming of HIV/AIDS-related issues, and an agenda for research and intervention.^ieng

What works best?

PIP: The best HIV prevention programs use a combination of persuasion and enablement. Persuasion involves giving people accurate information and motivating them to protect their health, while enablement involves making it easier for people to implement knowledge about protecting their health into practice. It includes making condoms readily available and making health services accessible and supportive. It also involves changing laws and policies so that people at risk, such as youth, sex workers, and IV drug users, will be easier to reach. The most successful HIV prevention programs involve communities, build partnerships and trust between people, involve people with HIV in all stages, develop communities' skills and knowledge, create an open and accepting environment, involve sectors other than health, gain support from major decision-makers, are carefully planned and evaluated, and recognize that even well planned approaches sometimes fail. Successful programs also include the following components: information on HIV transmission, activities, training, and access to reproductive health resources. People's concerns, risk groups, evaluation, and new opportunities emerging through the development of new technologies are discussed.^ieng

Behavior change communication strategies.

Appropriate and effective communication is central to the success of interventions to reduce the risk of HIV infection. This paper reviews what has been learned about the nature of communication in the behavior change process. It examines the contexts in which communication occurs, as well as the contribution of communication theory, social marketing theory, and structural intervention theory to intervention development. Guidance is offered on the most appropriate ways in which to communicate with different groups and audiences, and future priorities for research and intervention are identified.

PIP: Enhanced knowledge about the behavior change process has facilitated the design of communications programs to reduce the risk of HIV transmission and AIDS. A wide variety of health promotion strategies use communication as either an educational or norm-forming strategy. Health communication, social marketing, and structural intervention theories suggest several principles for HIV/AIDS communication campaigns, including realistic goals, behavior substitution rather than elimination, environmental support for behavioral change, cost-effectiveness, program accessibility to the target audience, and attention to legal and sociocultural obstacles to change. The most successful interventions combine all three approaches in the pursuit of complementary goals. In addition, specific strategies must be designed for high-risk groups such as women, young people, injecting drug abusers, and homosexuals. Major challenges in the years ahead include maintaining government commitment to AIDS prevention; ensuring the continued involvement of nongovernmental and community-based organizations in program development, implementation, and evaluation; and forging closer links between interventions in the fields of prevention and care. The research agenda should include communication strategies for those who are socially marginalized and disenfranchised, the discussion of issues related to drugs and sexuality in cultural climates that discourage open discussion of these topics, the promotion of less stigmatizing attitudes toward people with AIDS, involvement of people with AIDS in the design and implementation of communication programs, and ways to link HIV prevention to other health care activities.

Report from the 3rd AIDS Impact Conference: culture, community, empowerment.

AIDS: Presentations made at the 3rd AIDS Impact Conferences in June 1997 in Melbourne, Australia are summarized. The presentations focused on the importance of local beliefs, practices, and sexual cultures as factors that impact HIV risk. The three dominant themes of this conference were a concern for community, an emphasis on culture, and empowerment for the most vulnerable groups. Speakers illustrated the importance of culture as a factor in the form, context, and meaning of sex among young men and women in Thailand, Australia, Italy, Cambodia, and the United States. Studies conducted in correctional facilities illustrate how the culture of sex and substance use can intensify the HIV risk. Papers examined the sexual revolution in China and the experiences of indigenous people in Brazil, Australia, and New Zealand. The presentations also highlighted drug use cultures among gay men in Australian and German cities and introduced new research methodologies for the analysis of these processes and issues. The closing presentation considered the politics of HIV and their relationship to national and international processes of negative societal responses to HIV diseases.^ieng