Preventing HIV infections remains an essential, first line of defence against the AIDS epidemic. Two decades of experience-in countries as different as Brazil, Thailand and Uganda-have proved that determined prevention efforts do work and that they are most effective when they involve communities and are combined with strong care and support programmes.

There is abundant evidence that prevention works, as shown in urban gay communities in North America and Western Europe, among injecting drug users in Australia and in heterosexual populations in countries like Brazil, Senegal, Thailand and Uganda.

In the Ugandan capital Kampala, for example, determined prevention efforts (as part of a countrywide mobilisation against AIDS) sent HIV prevalence rates among teenage women plummeting from 28 percent in 1991 to 6 percent in 1998. Thailand's 100 percent condom programme helped that country hold an epidemic in check in the 1990s, while vigorous condom promotion appears to be paying off in Cambodia, too.

Regardless of a country's HIV prevalence rates, early investment in prevention offsets later and much larger social and developmental costs. Investment in prevention among young people is vital at any stage in an epidemic.

Essential for success are public policies that boost and support prevention programmes. The basic elements of successful prevention are communication (including sexual health education) and behaviour change, the creation of an environment that enables people to protect themselves against the virus, condom promotion, HIV counselling and testing, and the treatment of sexually transmitted infections.

Prevention programmes must concentrate on the main routes along which HIV spreads - by addressing blood safety, mother-to-child transmission, injecting drug use and sexual transmission.

At a minimum, prevention must form part of a comprehensive package of activities that link prevention and care, and that slots into countries' wider developmental and public health strategies. Countries that successfully link prevention, care and support programmes reap large social and economic benefits, as Brazil, for example, has shown. Prevention of HIV also reduces prevalence of other diseases, including sexually transmitted infections (STIs).

Special emphasis and sufficient resources must go towards protecting vulnerable populations (such as sex workers, men who have sex with men and injecting drug users) against HIV infection.

Irrespective of their risk, all people must be provided with basic information and the means to protect themselves.

HIV/AIDS affects both rich and poor citizens in both developed and developing countries. It is not a disease of poverty. But the epidemic does push people deeper into poverty, making it more difficult for them to sustain or recover their earlier livelihoods. That, in turn, can make people and their families more vulnerable to HIV infection and to AIDS-related illnesses. Poverty reduction can help limit people's vulnerability to the epidemic.

Economic insecurity, displacement caused by conflicts and disasters, illiteracy, violence and abuse, and social exclusion deprive millions of the ability to protect themselves and others. In order to succeed, prevention programmes must also enable people to choose safer life strategies. That calls for the review of social and economic policies that entrench inequalities, discrimination and social exclusion.

The economic, cultural and social conditions in which people live shape their options and behaviour. Changing those conditions - and the attitudes of others - for the better, can enable people to build their lives around safer choices.

Prevention campaigns are reaching millions, but they still miss too many people, especially the young. Recent surveys in 17 countries on three continents showed that more than half the adolescents questioned could not name a single method of protecting themselves against HIV/AIDS.

Condoms, which are essential to prevention, are being distributed in greater numbers than ever before, but they are still not universally available. It is estimated that six billion condoms are distributed each year, but that many more (some estimates are as high as 24 billion) are needed to protect populations from HIV and other sexually transmitted infections.

The scope of prevention programmes is often inadequate, creating situations where activities do not reach population groups that are most vulnerable to HIV infection. Marginalised groups (such as men who have sex with men, sex workers, injecting drug users or prisoners) are more likely to be ignored in prevention efforts.

Effective prevention is rooted in communities and often has its origins in small but successful grass-roots activities and activism. Community-based outreach work, peer education and service provision are essential. Approaches that involve opinion leaders and role models are just as important. The more successful projects draw their inspiration and leadership from people living with HIV/AIDS.

Sturdy human rights protection bolsters prevention programmes. The success of prevention campaigns depends also on tackling stigma and discrimination. When the epidemic is cloaked in shame and silence, people are less likely to seek out and use preventive information, services and facilities.

Information and the means for protection must reach everyone, especially marginalised sections of societies. Women and men (including young men and women) must be able to apply the lessons and tools of prevention campaigns in their lives. Prevention programmes therefore should link with efforts to tackle the underlying factors that cause people to live in circumstances or choose survival strategies that involve higher risks of infection.

Improving access to education, employment and livelihoods - especially for women - is a valuable feature of effective prevention campaigns. Studies have also shown that people with more education tend to be more likely to protect themselves by using condoms during casual sex. The surveys showed that, especially for girls, even a few years of added schooling translated into more frequent condom use.

In many societies, HIV is transmitted also through practices and behaviour that may be illegal or taboo. In those instances, legal sanction and hostile public attitudes impede programmes aimed at reducing the danger of infection for stigmatised people. That need not be the case. Thailand's campaign to ensure condom use in brothels, for instance, played a huge part in that country's ability to stabilise its HIV/AIDS epidemic.

Decriminalizing sex work, homosexuality, drug use or the possession of condoms and injecting needles could boost prevention efforts and limit the spread of HIV. Likewise, sterner anti-rape laws and stronger enforcement can help reduce HIV transmission through coerced sex.

The kinds of prevention programmes needed may vary according to the situation in each affected community, or may vary in intensity. In some cases, harm reduction programmes for drug users might be a priority, in others condom promotion and sexual health education might be most necessary. Changes to inheritance laws in some countries could help ensure that widows are not left destitute and forced to resort to sex work in order to support themselves and their families.

In this section:

• Basics of successful prevention
• Poverty and HIV
• Getting it right
• A wider view of prevention

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