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Behavior’s Role in an AIDS-Free Generation

Why behavior change is essential to the epidemic’s trajectory

By Joshua Brooks

Published October 11, 2012

People are sick of AIDS.

No, not just sick with AIDS, sick of AIDS. They want it gone.

In a new stage of the thirty-one-year-old epidemic, experts like the head of the National Institute of Allergy and Infectious Disease, Dr. Anthony Fauci, and the Secretary of State, Hillary Clinton shared their vision of a coming generation without AIDS.

A generation without AIDS, Clinton said, would be one where “no child anywhere will be born with the virus.” The risk of becoming infected in children, teenagers and adults, no matter where they live, she added, would decrease. Patients living with HIV would have access to antiretroviral therapy—a cocktail of drugs, which prolongs the virus’s progression to AIDS.

A noble goal, to be sure, but it won’t be easy.

As of 2010, more than 34 million people in the world were living with HIV/AIDS. In that same year, 2.7 million people became newly infected. From 2007 to 2012, the U.S. alone spent between $21.2 and $28.4 billion a year to fund the fight against HIV/AIDS globally.

Yet, the epidemic lingers on.

What makes policymakers think they can eliminate AIDS now?

Well, they see a new dawn: Drug substitution therapies, needle exchange programs, condom-use, male circumcision, spermicides and antiretroviral therapy (ART) represent new evidence-based interventions, which could put an AIDS-free generation in sight.

With the promise of ART, HIV patients can prolong the virus from progressing to full-blown AIDS and greatly improve their health; mothers with HIV can prevent viral transmission to their newborns; and patients in high-risk areas can reduce the risk of acquiring HIV by taking ART before they are exposed. Collectively, experts hope that ART will stop patients with HIV from developing AIDS, effectively eliminating the disease altogether.

But, the road to a generation without AIDS depends on one pesky uncertainty—human behavior.

All of these interventions depend on patient adherence. Patients keep up with interventions differently in different settings, making it difficult to know, at times, how to maximize adherence.

If patients and the public don’t use condoms when government prevention programs depend on them, women forget to apply spermicidal gel prior to sex, men don’t like the idea of being circumcised or HIV patients fail to take their ART regularly, the idea of a generation without AIDS will vanish like Michael J. Fox’s brother in Back to the Future.

So in order for these interventions to work, public health researchers and policymakers need to understand the most effective ways to implement them. This often requires that they conduct behavioral studies in a variety of settings where different geographical, social, environmental and cultural contexts may influence their outcomes.

But some have no trust in our ability to understand—or manipulate—human behavior. They point to failed interventions and varying research findings to show that relying on interventions that require behavior change isn’t worth the time or money. Rather, they argue that investments should be made in research and design of drugs, for example, that patients only have to take once a month, instead of multiple times—eliminating the behavioral piece of the equation altogether.

But, this outlook is problematic.

First of all, even a pill taken once a month requires interventions that ensure adherence.

Moreover, varied results and failure to achieve long-term behavioral change in some circumstances is not a condemnation of the interventions as a whole. Rather, it demonstrates the need to implement interventions that have been broadly effective, as much in high-income Americans, for example, as in rural China—adapting them when necessary.

And, it shows the need to monitor and maintain some interventions, say, for much longer than one or two years. In fact, both the Centers for Disease Control and Prevention (CDC) and the Global HIV Prevention Working Group have provided suggestions to ensure researchers are pursuing the most long-term, evidence-based approaches.

More importantly, this pessimism about the ability to measure and change the behavior of HIV patients and at-risk populations is unfounded because it’s not supported by the data.

Demonstrable behavioral change is achievable.

Meta-analyses—compilations of the highest quality research in an area—have found evidence of efficacy in changing behavior in at-risk populations, like young people, men who have sex with men, sex workers and injection drug users. One meta-analysis from the World Health Organization, for example, indicated that national implementation of various evidence-based combination HIV prevention programs in the 1990s was associated with a decline in HIV incidence and prevalence of between 50 and 90 percent in several communities worldwide. Another review of studies implementing behavioral interventions to increase ART adherence in sub-Saharan Africa, showed that things like treatment supports, directly observed therapy, mobile-phone text messages, diary cards and food rations do improve adherence.

Moreover, the proof is in the pudding: in countries like Australia, Brazil, Thailand and Uganda, where early prevention initiatives based on behavior change were instituted, the rate of HIV infection decreased markedly.

Those viewing the fight against HIV/AIDS with more optimism “because powerful interventions have been developed” may want to temper the pessimism of behavioral change opponents. In the very least, researchers studying the subject and policymakers funding this work should not overlook its importance.

After all, a generation lacking the firm belief in HIV prevention programs and approaches to ART adherence is unlikely to be that which we’re all after: a generation without AIDS.

Edited by Abdul El-Sayed. Additional research by Lauren Weisenfluh.

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The views and opinions expressed on this website are solely those of the authors and do not represent those of the Department of Epidemiology, the Mailman School of Public Health, or Columbia University.