Uganda provides the clearest example that human immunodeficiency virus (HIV) is preventable if populations are mobilized to avoid risk. Despite limited resources, Uganda has shown a 70% decline in HIV prevalence since the early 1990s, linked to a 60% reduction in casual sex. The response in Uganda appears to be distinctively associated with communication about acquired immunodeficiency syndrome (AIDS) through social networks. Despite substantial condom use and promotion of biomedical approaches, other African countries have shown neither similar behavioral responses nor HIV prevalence declines of the same scale. The Ugandan success is equivalent to a vaccine of 80% effectiveness. Its replication will require changes in global HIV/AIDS intervention policies and their evaluation.

Of 2157 patients with the acquired immunodeficiency syndrome (AIDS) whose cases were reported to the Centers for Disease Control by August 22, 1983, 64 (3 per cent) with AIDS and Pneumocystis carinii pneumonia had no recognized risk factors for AIDS. Eighteen of these (28 per cent) had received blood components within five years before the onset of illness. These patients with transfusion-associated AIDS were more likely to be white (P = 0.00008) and older (P = 0.0013) than other patients with no known risk factors. They had received blood 15 to 57 months (median, 27.5) before the diagnosis of AIDS, from 2 to 48 donors (median, 14). At least one high-risk donor was identified by interview or T-cell-subset analysis in each of the seven cases in which investigation of the donors was complete; five of the six high-risk donors identified during interview also had low T-cell helper/suppressor ratios, and four had generalized lymphadenopathy according to history or examination. These findings strengthen the evidence that AIDS may be transmitted in blood.

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The risk of human immunodeficiency virus (HIV) transmission was studied by interviewing and testing the serum of heterosexual contacts and casual family contacts of adults with transfusion-associated HIV infections. Two (8%) of 25 husbands and ten (18%) of 55 wives who had had sexual contact with infected spouses were seropositive for HIV. Compared with seronegative wives, the seropositive wives were older (median ages, 54 and 62 years; P = .08) and actually reported somewhat fewer sexual contacts with their infected husbands (means, 156 and 82; P greater than .1). There was no difference in the types of sexual contact or methods of contraception of the seropositive and seronegative spouses. There was no evidence of HIV transmission to the 63 other family members. Although most husbands and wives remained uninfected despite repeated sexual contact without protection, some acquired infection after only a few contacts. This is consistent with an as yet unexplained biologic variation in transmissibility or susceptibility.

In a cohort of 5833 subjects in whom the acquired immunodeficiency syndrome (AIDS) was diagnosed in New York City before 1986, the cumulative probability of survival (mean +/- SE) was 48.8 +/- 0.7 percent at one year and 15.2 +/- 1.8 percent at five years. The group with the most favorable survival rate--white homosexual men 30 to 34 years old who presented with Kaposi's sarcoma only--had a one-year cumulative probability of survival of 80.5 percent; that group was used as the reference group in assessing the effect of five variables: sex, race or ethnic background, age, probable route of acquiring AIDS (risk group), and manifestations of AIDS at diagnosis. The range in the mortality rate was greater than threefold, depending on these variables. Black women who acquired the disease through intravenous drug abuse, for example, had a particularly poor prognosis. The manifestations of disease at diagnosis had the most influence on survival, accounting on average for 56.3 percent of the excess risk. This variable was followed in importance by age (12.2 percent), race or ethnicity (10.6 percent), risk group (8.4 percent), and sex (8.0 percent), with 4.5 percent of the risk attributable to interactions between variables. When we compared subcohorts based on the year of diagnosis (1981 through 1985), we found a significant improvement in the one-year cumulative probability of survival among subjects with Pneumocystis carinii pneumonia, but not among subjects without P. carinii pneumonia.

Increasing mortality in intravenous (IV) drug users not reported to surveillance as acquired immunodeficiency syndrome (AIDS) has occurred in New York City coincident with the AIDS epidemic. From 1981 to 1986, narcotics-related deaths increased on average 32% per year from 492 in 1981 to 1996 in 1986. This increase included deaths from AIDS increasing from 0 to 905 and deaths from other causes, many of which were infectious diseases, increasing from 492 to 1091. Investigations of these deaths suggest a causal association with human immunodeficiency virus (HIV) infection. These deaths may represent a spectrum of HIV-related disease that has not been identified through AIDS surveillance and has resulted in a large underestimation of the impact of AIDS on IV drug users and blacks and Hispanics.

The clearest example of declines in HIV prevalence and changes in sexual behaviour comes from Uganda. Are there lessons to learn for other countries or is Uganda unique? In this paper, we assess the epidemiological and behavioural data on Uganda comparatively to other African countries and then analyse data from other populations where HIV has declined. In Uganda, HIV prevalence declined from 21% to 9.8% from 1991-1998, there was a reduction in non-regular sexual partners by 65% and greater levels of communication about AIDS and people with AIDS through social networks, unlike the comparison countries. There is evidence of a basic population level response initiated at community level, to avoid risk, reduce risk behaviours and care for people with AIDS. The basic elements-a continuum of communication, behaviour change and care-were integrated at community level. They were also strongly supported by distinctive Ugandan policies from the 1980s. We identify a similar, early behaviour and communication response in other situations where HIV has declined: Thailand, Zambia and the US Gay community. In Thailand, visits to sex workers decreased by 55% and non-regular partners declined from 28% to 15% (1990-1993): as important as the '100% condom use policy'. Similarly, in Zambia and Ethiopia risk behaviour has decreased and analysis of Sexually Transmitted Disease (STD) rates among Gay populations in the USA shows a decline from as early as 1985 in White Gay populations, with later declines in Hispanic and Black Gay populations. These responses preceded and exceeded HIV prevention. However, where they were built on by distinctive HIV policies, HIV prevention has been scaled and led to national level declines in HIV. It is not easy to transfer the lessons of these successes. They require real social and political capital in addition to financial capital. Nevertheless, similar characteristics are present in community responses in Africa, Asia and USA, and even in fragmented signs of HIV declines in other African cities. Only in a few situations has this behaviour and communication process been recognised, mobilised and built on by HIV prevention policy. Where this has occurred, HIV prevention success has been greater than biomedical approaches or methods introduced from outside. It represents a social vaccine for HIV from Africa, and is available now.

BackgroundPublic health triangulation is a process for reviewing, synthesising and interpreting secondary data from multiple sources that bear on the same question to make public health decisions. It can be used to understand the dynamics of HIV transmission and to measure the impact of public health programs. While traditional intervention research and metaanalysis would be ideal sources of information for public health decision making, they are infrequently available, and often decisions can be based only on surveillance and survey data.MethodsThe process involves examination of a wide variety of data sources and both biological, behavioral and program data and seeks input from stakeholders to formulate meaningful public health questions. Finally and most importantly, it uses the results to inform public health decision-making. There are 12 discrete steps in the triangulation process, which included identification and assessment of key questions, identification of data sources, refining questions, gathering data and reports, assessing the quality of those data and reports, formulating hypotheses to explain trends in the data, corroborating or refining working hypotheses, drawing conclusions, communicating results and recommendations and taking public health action.ResultsTriangulation can be limited by the quality of the original data, the potentials for ecological fallacy and "data dredging" and reproducibility of results.ConclusionsNonetheless, we believe that public health triangulation allows for the interpretation of data sets that cannot be analyzed using meta-analysis and can be a helpful adjunct to surveillance, to formal public health intervention research and to monitoring and evaluation, which in turn lead to improved national strategic planning and resource allocation.