AIDS Expert: Resource Allocation Should Be Based on HIV Prevalence

WASHINGTON, D.C., April 12, 2002 — In countries where HIV prevalence is below 5%, HIV prevention resources should be devoted primarily to priority (at-risk) group interventions. Where HIV prevalence is more than 5%, resources should be devoted equally to interventions targeted at priority groups and the general population.

That is the rule of thumb proposed by Dr. David Wilson, long-time PSI consultant on HIV/AIDS prevention and a professor at the University of Zimbabwe, in a presentation at PSI recently.

Approximately 53% of PSI programs are in countries with HIV prevalence more than 5% and the other 47% in countries lower than 5%. Most of the higher prevalence PSI countries are in eastern, southern and central Africa. Higher prevalence PSI countries in other regions include Burkina Faso, Cote d'Ivoire, Haiti and Togo. Haiti is the only higher prevalence PSI country not in Africa.

In his presentation, Dr. Wilson described six "key principles" which he calls "vital to reaching groups at risk":

1. It is vital to reach priority groups. Highly sexually active individuals contribute more to HIV transmission than less sexually active individuals. By extension, programs for individuals who contribute significantly to HIV infection make more sense than programs for individuals who contribute little to HIV transmission. The World Bank estimates that priority group HIV prevention programs are at least 40 times more effective than comparable programs in the general population. The key epidemiological principle is to intervene as early and high up the infection chain as possible.

2. It is vital to reach priority groups even in a mature epidemic. World Bank models show that priority group programs remain far more cost-effective than general population interventions, even in a mature epidemic.

3. The right mix is vital. As described above, the mix of priority group and general population programs will depend on the maturity of the epidemic. Countries under 5% prevalence should target only priority groups; over 5% should target priority groups and the general population. Dr. Wilson gave the following example: "In Accra, Ghana, antenatal rates range from 2.2% in low-income Korle-Bu to 3.4% in middle-income Adabraka. Yet 75.8% of sex workers in Accra have HIV. Where should we focus? I think it is obvious," he says. "In Accra and much of West Africa, I'd argue almost all HIV prevention resources should be used to protect priority groups."

"Now take Carletonville, South Africa's largest gold-mining town," Dr. Wilson says. "Prevalence rates in Khotsong residence are 30%, so clearly HIV prevention programs cannot be limited to priority groups. Yet 100,000 minerworkers visit 1,000 sex workers in two informal settlements. An estimated 80% of them are HIV positive, have 20 clients weekly and use condoms with 10% of clients. How can we ever prevent a wider epidemic without making sex work safe in this context? Throughout southern and eastern Africa, HIV prevention must focus equally on priority groups and the wider society."

4. It is vital to pinpoint priority groups. The key priority groups are low-income women forced to exchange sex for survival and mobile men often away from home with some disposable income - truckers, soldiers, fishermen, migrant mineworkers and seasonal plantation workers. The major priority geographic contexts are where male labor magnets are juxtaposed with poor, primarily female, rural communities.

5. It is vital to identify priority strategies. The major HIV prevention strategies — behavior change, condom promotion, sexually-transmitted infection care, voluntary counseling and testing and enabling approaches — have different emphases among priority groups. "Nowhere has condom promotion succeeded better than among priority communities with rapid rates of commercial and casual partner change," he said. But he questioned the wisdom of doing voluntary HIV/AIDS counseling and testing (VCT) programs among priority groups "who may be demoralized and divided by uniformly positive diagnoses" and said that HIV positive sex workers may have no economic alternative to continued sex work. "VCT is best-suited to young couples in high prevalence countries," he said.

6. We need large-scale, high quality programs. Priority groups programs are needed and this requires a framework with three key elements: structured, replicable approaches; an explicit results chain; and an intensive training cycle.

—David J. Olson, Senior Manager for Public Affairs, PSI/Washington

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