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No Time to Lose: Getting More from HIV Prevention
ordination and leadership problems at the federal level, the nation still lacks the federal leadership and integration of prevention activities necessary to effectively address the epidemic (CDC Advisory Committee, 1999; PACHA, 2000).
Although there are difficulties in developing coordinated public and private-sector leadership for prevention, such leadership is not impossible. Studies in select developing and industrialized countries reveal the critical roles of consistent, visible political leadership and commitment, along with community mobilization, in slowing the epidemic. For example, in Uganda, a country ravaged by HIV/AIDS, government leaders openly acknowledged the epidemic and took active steps to prevent its spread by creating, in 1986, a National AIDS Control Programme. The program, which involves collaborations among community, government, and donor agencies, includes extensive prevention education campaigns to promote safer sexual behavior, STD prevention and treatment, condom distribution, HIV counseling and testing, and community mobilization to promote behavior change (UNAIDS, 1998; Abdool Karim et al., 1998). These efforts have contributed to high levels of awareness about HIV/ AIDS and declines in HIV incidence among some populations in Uganda (UNAIDS, 2000; UNAIDS, 1998). Political commitment and strong public health programs have also helped Thailand reduce HIV incidence among some of its populations (UNAIDS, 1998; Nelson et al., 1996), and they have helped Senegal maintain one of the lowest HIV incidence rates in Africa (UNAIDS, 1999). Among industrialized countries, government leaders in Australia and the Netherlands have worked with communities to develop policies that minimize the harm incurred by drug abuse and reduce stigmatization of drug users. These countries offer drug abuse treatment on demand; they also have rapidly expanded the availability of methadone maintenance, and they have successfully developed innovative methods for targeting drug users and slowing the HIV/AIDS epidemic among IDUs (Drucker et al., 1998). Perhaps the most impressive aspect of these successes is that, in some cases, such leadership has occurred in countries that have fewer educational, financial, biomedical, and social resources than does the United States.
While there have been prevention successes in the United States as a result of community mobilization, these have generally occurred on a more localized scale and often in the absence of high-level political leadership. For example, community mobilization in the gay community in the early and mid-1980s led to significant changes in sexual behavior and declines in HIV incidence among MSMs in major urban epicenters such as New York and San Francisco (Katz, 1997). These efforts preceded the development of any official public education programs (NRC and IOM, 1993).