Looking Back While Looking Ahead

World AIDS Day offers all of us the opportunity to remember people who died of AIDS and who are living with HIV and AIDS, and reflect on the work ahead of us in 2011, the 30th year of the HIV/AIDS epidemic. Through the challenges in preventing new infections while caring for those living with HIV/AIDS, there have been some great strides made since the onset of the epidemic in the early 1980s. Recently, the United Nations reported that new HIV infections have dropped nearly 20% globally over the last decade. Further, a study by Farnham et al. estimated that HIV prevention programs had averted more than 350,000 new infections in the U.S. between 1991 and 2006. These statistics are testaments to the advancements in HIV prevention methods and strategies that are continuing to be tailored to those most vulnerable to the virus. In July, many applauded the unveiling of the U.S. National HIV/AIDS Strategy, an unprecedented plan of action to address the nation's epidemic and reduce new infections. The plan will employ evidence-based approaches specifically targeting those groups most adversely affected by the virus, including people of color and gay men of all races. With an aim to reduce HIV incidence in the country 25% by 2015, the National HIV/AIDS Strategy is a long overdue commitment to the American people. HIV advocates have also rejoiced in the recent findings which prove antiretroviral drugs an effective tool against HIV infection. Earlier this year, findings from the CAPRISA 004 study revealed that antiretroviral drugs in the form of a vaginal gel, also known as a microbicide, were effective in reducing HIV infection in heterosexual women. The study, which was conducted on 889 women in South Africa, utilized a 1% tenofovir gel that was applied topically before and after sex. Results concluded a 39% reduction in HIV infection among women who used the gel. Most recently, a study conducted on 2,499 men who have sex with men from six different countries, known as the iPrEX study, reported a 44% reduction of HIV transmission overall among participants who received a daily oral antiretroviral drug compared to those participants who received a placebo. Efficacy proved even higher among participants who consistently took the drug. Results of these studies stand to change the landscape of HIV prevention. However, despite these promising new technologies, the work is far from over. In order to effectively reduce HIV incidence in the U.S., we must change how we think about, and implement HIV prevention efforts including policy and research. We must develop a refined prevention approach learning from other more evolved health-related prevention approaches. For example, smoking prevention programs combine pharmacological interventions, behavior modification, social persuasion techniques (including the use of social marketing to influence community norms), and structural change (like policy reform and legislative initiatives) designed to discourage nicotine use. Nicotine addiction and HIV infection are vastly different and we must exercise caution in comparing the two. Yet, the comparison raises important questions about contemporary HIV prevention efforts in the U.S. As we look to 2011, we have to ensure that our prevention approaches are the following: Strengths-based: This values individuals and communities as key social agents of change not only with dilemmas, uncertainties, and responsibilities but also with considerable brilliance, resilience and creativity. It allows space for community members to see themselves as the solution rather than the problem. Participatory: The process of creating programs and policy efforts must include community input which can be imperfect, messy, and time-consuming. Yet it can also be deeply invigorating, inspiring, and necessary if service providers are to remain anchored in the realities of the communities they profess to serve. Sex Positive:This means being uncritical of desire, disease, or power while engaging in discussion about community sexual ethics. It is essential to focus on the sex people are having; how they feel about sex; how they seek to experience and learn about sex and bodies before, during and after sex. Sometimes sex happens in irreverent celebration, communion and joy, and other times it happens in the silence of self-reflection or in the poetry of anonymous park sex. Sex cannot be turned into a two-dimensional, unexciting activity because we are trying to reduce new infections. We must address desire not repress desire. Self-Reflective: Sitting with unanswered questions is often uncomfortable, but the process can support our work. We agree. We disagree. Sometimes we argue stubbornly and defend our positions. Again and again, we challenge one another and our community partners with fundamental questions which can then lead to solutions. Staying anchored in a simplified approach to HIV prevention with messages about using condoms and getting tested is not enough. Flexibility and openness will be key in the continuing development of new efforts to reduce new infections.