No abstract

SUMMARY We have entered a new era in HIV prevention whereby priorities have expanded from biomedical discovery to include implementation, effectiveness, and the effect of combination prevention at the population level. However, gaps in knowledge and implementation challenges remain. In this Review we analyse trends in the rapidly changing landscape of HIV prevention, and chart a new path for HIV prevention research that focuses on the implementation of effective and efficient combination prevention strategies to turn the tide on the HIV pandemic.

Each day close to 20,000 people become infected with the HIV virus worldwide; a large portion of whom are infected through unprotected sex with sex workers. While condoms are an effective defense against the transmission of HIV and other sexually transmitted infections, large numbers of sex workers are not using them with their clients. We argue that some sex workers are willing to take the risk because clients are willing to pay more to avoid using condoms. Using a panel data set from Mexico, we estimate that sex workers received a 23 percent premium for unprotected sex from clients who requested not to use a condom. However, this premium jumped to 46 percent if the sex worker was considered very attractive. These results suggest that the current policies aimed at educating sex workers about risk, empowering them and improving their access to condoms need to be complemented with interventions aimed at teaching clients about the "joy of safe sex" thereby increasing the demand for using condoms.

This high rate of unprotected penetrative sex by MSM with both men and women suggests that HIV prevention efforts in India should include a focus on MSM as well as their wives across many urban-rural locations and not only in large cities.

Background: Heterosexual contact is the most common mode of HIV transmission in India that is largely linked to sex work. We assessed the non-use of condoms in sex work and with regular sex partners by female sex workers (FSWs), and identified its associations that could assist in planning HIV prevention programmes.

The World Bank is publishing nine volumes of Disease Control Priorities, 3rd edition (DCP3) between 2015 and 2018. Volume 9, Improving Health and Reducing Poverty, summarises the main messages from all the volumes and contains cross-cutting analyses. This Review draws on all nine volumes to convey conclusions. The analysis in DCP3 is built around 21 essential packages that were developed in the nine volumes. Each essential package addresses the concerns of a major professional community (eg, child health or surgery) and contains a mix of intersectoral policies and health-sector interventions. 71 intersectoral prevention policies were identified in total, 29 of which are priorities for early introduction. Interventions within the health sector were grouped onto five platforms (population based, community level, health centre, first-level hospital, and referral hospital). DCP3 defines a model concept of essential universal health coverage (EUHC) with 218 interventions that provides a starting point for country-specific analysis of priorities. Assuming steady-state implementation by 2030, EUHC in lower-middle-income countries would reduce premature deaths by an estimated 4·2 million per year. Estimated total costs prove substantial: about 9·1% of (current) gross national income (GNI) in low-income countries and 5·2% of GNI in lower-middle-income countries. Financing provision of continuing intervention against chronic conditions accounts for about half of estimated incremental costs. For lower-middle-income countries, the mortality reduction from implementing the EUHC can only reach about half the mortality reduction in non-communicable diseases called for by the Sustainable Development Goals. Full achievement will require increased investment or sustained intersectoral action, and actions by finance ministries to tax smoking and polluting emissions and to reduce or eliminate (often large) subsidies on fossil fuels appear of central importance. DCP3 is intended to be a model starting point for analyses at the country level, but country-specific cost structures, epidemiological needs, and national priorities will generally lead to definitions of EUHC that differ from country to country and from the model in this Review. DCP3 is particularly relevant as achievement of EUHC relies increasingly on greater domestic finance, with global developmental assistance in health focusing more on global public goods. In addition to assessing effects on mortality, DCP3 looked at outcomes of EUHC not encompassed by the disability-adjusted life-year metric and related cost-effectiveness analyses. The other objectives included financial protection (potentially better provided upstream by keeping people out of the hospital rather than downstream by paying their hospital bills for them), stillbirths averted, palliative care, contraception, and child physical and intellectual growth. The first 1000 days after conception are highly important for child development, but the next 7000 days are likewise important and often neglected.

Tijuana, Mexico, just south of San Diego, California, is located by the busiest land border crossing in the world. Although UNAIDS considers Mexico to be a country of "low prevalence, high risk," recent surveillance data among sentinel populations in Tijuana suggests HIV prevalence is increasing. The aim of this study was to estimate the number of men and women aged 15 to 49 years infected with HIV in Tijuana. Gender and age-specific estimates of the Tijuana population were obtained from the 2000 Mexican census. Population and HIV prevalence estimates for at-risk groups were obtained from published reports, community based studies, and data from the Centro Nacional para la Prevención y Control del VIH/SIDA (CENSIDA). Age-specific fertility rates for Mexico were used to derive the number of low and high-risk pregnant women. Numbers of HIV-positive men and women were estimated for each at-risk group and then aggregated. A high growth scenario based on current HIV prevalence and a conservative, low growth estimate were determined. A total of 686,600 men and women in Tijuana were aged 15 to 49 years at the time of the 2000 census. Considering both scenarios, the number of infected persons ranged from 1,803 to 5,472 (HIV prevalence: 0.26 to 0.80%). The majority of these persons were men (>70%). The largest number of infected persons were MSM (N = 1,146 to 3,300) and IDUs (N = 147 to 650). Our data suggest that up to one in every 125 persons aged 15-49 years in Tijuana is HIV-infected. Interventions to reduce ongoing spread of HIV are urgently needed.

Agnes Binagwaho and colleagues predict that circumcision of newborn boys would be effective and cost-saving as a long-term strategy to prevent HIV in Rwanda.