With 40 million people currently infected with HIV, 6 million in need of immediate treatment, and funding and resources to meet only a fraction of this need, it will be important for extensive prevention activities to be conducted while ART scale-up proceeds. Indeed, prevention and treatment need not be regarded as mutually exclusive efforts (Blower and Farmer, 2003); they can and should work in parallel and even synergistically. Though details regarding prevention are largely beyond the scope of this report, prevention activities should include general HIV health communication and education; counseling and testing; efforts to delay sexual activity for youth; encouragement of correct and consistent condom use with casual partners and in other circumstances associated with risk; and targeted prevention initiatives for high-risk transmitters, such as female sex workers, long-distance truckers, and military populations. Prevention messages must be sensitive to local cultural interpretations. For example, in some settings, “faithfulness” or “fidelity” may not be understood as monogamy. Some believe one can be “faithful” to a small number of regular partners. The existence of regular sexual networks can challenge the interpretation of the word “casual.” Conceptualizations such as “zero grazing” may be better understood.

The introduction of ART on the scale proposed by WHO, UNAIDS, and the President’s Emergency Plan for AIDS Relief (PEPFAR) could have a direct secondary beneficial effect on HIV prevention, but the major impact could be indirect through the increased public attention paid to HIV, widespread testing and counseling, and stigma reduction that could accompany such programs. HIV/AIDS treatment will have the primary impact of decreasing morbidity and mortality; if accompanied by prevention counseling, it should also reduce transmission from persons under treatment by altering behavior and theoretically by reducing viral load and infectivity (Blower and Farmer, 2003; Blower et al., 2000, 2003a). Additionally, as noted earlier, the availability of ART may increase the use of VTC, which serves as a cornerstone of prevention activities by providing hope to those currently discouraged from being tested and treated.

Recommendation 4-8. National and international program planners should coordinate and integrate stronger and more effective HIV/AIDS prevention initiatives concurrently with the scale-up of antiretroviral therapy programs. Prevention initiatives should focus on those at risk for acquiring or transmitting HIV infection, in addition to those receiving treatment. To be optimally successful, voluntary counseling and testing programs and programs to prevent mother-to-child transmission should encompass both preventive and therapeutic dimensions.

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