Biomedical Interventions:

Physical Barriers:
Physical barrier methods are an efficacious and important aspect of biomedical
interventions against HIV. The most popular of these is the male condom. These condoms
function by essentially being impenetrable to particles the size of sexually transmitted pathogens.
Numerous studies have been done on the efficacy of the male condom and results indicate that
they are 85%-95% effective in preventing HIV transmission. However very few studies have
been conducted at the population level and they are not very conclusive. Behavioral practices in
the use of the male condom, such as if they are used only in sexual intercourse with certain
partners and not with all partners, have a large impact on how successful their use can be.
Female condoms, on the other hand, have not seen such widespread adoption. Female
condoms are currently the only female-initiated biomedical available. They function by
providing a physical barrier that prevents exposure to genital secretions. Many clinical studies
have been done on female condoms and the results indicate that female condoms are just as
effective as male condoms in curtailing the spread of HIV.
Cervical barriers, originally developed as a contraceptive, are now believed to also
protect against HIV acquisition. Only one study has been conducted on cervical barriers and it
found their HIV prevention rate to be similar to that of male and female condoms. Additionally
cervical barriers are currently being studied as potential mechanisms for tropical delivery of
antiretroviral and antimicrobial products.
Control of Other Sexually Transmitted Infections:
Numerous longitudinal epidemiological studies have shown that sexually transmitted
infections in HIV-uninfected men and women greatly increase their susceptibility to HIV

infection. The most notable of these are genital ulcerative diseases, such as syphilis, chancroid,
and genital herpes. Numerous randomized trials studying the effect of interventions designed to
control the most common sexually transmitted infections found that there was a significant
reduction in HIV incidence. However the researchers also found that the success of these
interventions decreased with time as the HIV epidemic became established.
Male Circumcision:
Male circumcision has been shown to reduce HIV acquisition in men. This occurs
because the inner foreskin contains a large number of HIV target cells that are susceptible to
microscopic tears. These tears cause them to be exposed to vaginal secretions during colitis and
provide an environment that may sustain the viability of pathogens. Randomized trials have
concluded that the protective effect of male circumcision was close to 58% when the intercourse
was between a man and a woman. Male circumcision, however, is less effective in preventing the
spread of HIV transmission between men who have intercourse with men. On the basis of these
clinical trails, the WHO and UNAIDS recommended that male circumcision be recognized as an
effective intervention for HIV prevention in heterosexual acquisition in men. The other
advantages of male circumcision include its cost effectiveness due to its one time procedure that
is not coitally dependent. Unfortunately, while male circumcision does decrease the rate of HIV
transmission, it does not make one immune to the infection. Safe sex practices must continue to
be followed by circumcised men or the increase in risky sexual behavior can offset the beneficial
effects of circumcision.
Antimicrobial and Antiretroviral Products for HIV prevention:
Currently there are no antimicrobial products that have been proven to protect against
vaginal or rectal HIV acquisition.

Antiretroviral drugs have been shown to reduce mother-to-child transmission by reducing

the infectiousness of the maternal viral load. Antiretroviral therapy is also being studied as a
strategy to reduce transmission during intercourse by reducing the infectiousness of the infected
individual. Antiretroviral drugs accomplish this decrease in infectiousness by reducing both the
plasma and genital viral loads, high levels of both of which are associated with increased
infectiousness.
Vaccines
Currently there are no vaccines available for HIV and it is estimated that it will take
another twenty years before one can be developed.
Behavioral Strategies to Reduce HIV Transmission:
It is important to acknowledge that there is no one solution for prevention. Instead,
combination prevention packages need to be used which target specific individuals. These
packages bring together both the partially effective biomedical methods and the behavioral
strategies in order to change behavior of the individuals.
There are three important lessons that can be derived from successful HIV prevention
campaigns, such as those in Uganda and in the Mbeya region of Tanzania. First, the behavioral
changes need to be adopted by a wide part of the community and these changes need to be
maintained for a long time. Second, a mix of communication channels in order to disseminate
information about risk reduction is needed. Third, local involvement in the designing of the
messages, their production, and their dissemination, is required.
Behavioral strategies need to be tailored for the community in which they are being
implemented. Similarly, there needs to be adoption of a comprehensive framework of behavioral

strategies which combine many strategies together, as there is no one silver bullet strategy that
reduces HIV transmission.
Some of the recommended behavioral strategies include: stigma reduction; encouraging
access to services; improving attitudes toward safer sexual practices; delaying onset of
intercourse; decreasing number of partners; reducing use of sex workers; increasing condom
sales; recognition of early symptoms of sexually transmitted infections or HIV; recognition of the
benefits and limitations of male circumcision for protection against HIV; disclosure of HIV
serostatus; harm reduction strategies; how to access treatment for HIV; the importance of
adherence to antiretroviral drugs; etc.
These strategies can be implemented in many ways. For example, one recommended
implementation of some of the above strategies is the counseling of couples in order to motivate
behavioral change within a primary or secondary relationship. These strategies understand that
HIV transmission is a social event between two people, and that change is required from both
individuals. Similarly, families are important in the HIV risk. Many studies in the USA have
documented the integral role of the family in promoting HIV-associated risk reduction strategies
in adolescents. These strategies help to open lines of communication between parents and
adolescents, improve family relations, and support continual risk education.
There are three primary approaches in using peer groups and networks to create change.
The first is peer education that is particularly effective in increasing participation and
collaboration with vulnerable groups who are normally alienated from these services and
government structures. These peer groups have been previously very successful in increasing
condom use and reducing sexually transmitted infections in high-risk groups, such as sex
workers and their clients. The second approach is using innovation and involving influential

leaders in the community. These leaders are trendsetters for the community and their opinions
and advice and normally widely respected. The third approach is using network-based
interventions, such as social network interventions, to lead to behavior change. Usually these
networks are gained access to through key individuals, normally network leaders, and then by
training them to disseminate HIV reduction messages through their network. This method has
been quite successful in both reducing sharing of injection equipment between drug users and
reducing unprotected intercourse between men, in Eastern Europe.
Another important point regarding interventions for HIV prevention is their delivery
through social institutions, such as workplaces, prisons, the military, faith based organizations,
and schools. This approach not only is able to reach a large number of people but also utilizes the
previously discussed strategies of using peer networks and leaders in the community. Out of
these, the workplace is the favored setting because it reaches a general population of men and
women of reproductive age and is usually regarded as an effective means of delivering voluntary
counseling and testing. A study conducted in the Thai military found that these workplace
interventions reduced the HIV incidence by 50%.
One of the major tasks for stopping the spread of HIV in the developing world is
increasing the number people who know that they are infected with HIV. Many studies have
shown that once an individual becomes aware of their serostatus, they are more like to take
precautions to protect their partners. It is the individuals who are unaware of their serostatus who
are most likely to transmit a high proportion of infections. Along the same lines, increasing
adherence to HIV treatment is an equally important part of stopping the spread of HIV. These
treatments not only increase the length and quality of the infected individuals life, but it also
decreases their infectiousness, lowering their chances of spreading it to others. Similarly,

preventive biomedical methods must also be accompanied by information about safer sexual
practices. None of the biomedical methods currently available make one immune to HIV and so
risk reduction techniques are a must for all individuals.
Structural Approaches to HIV Prevention:
Structural factors have no one clear definition but are generally regarded as physical,
social, cultural, organizational, community, economic, legal, or policy aspects of the environment
that impede or facilitate efforts to avoid HIV infection. These factors are normally difficult to
incorporate into HIV prevention packages due to how difficult they are to change since they are
strongly ingrained in the cultures.
Over 90% of the worlds HIV infections occur in developing countries. Numerous studies
have found both correlational and direct mechanisms by which structural factors affect HIV risk.
For example, sexual violence, a mark of gender inequality, has been directly linked to an increase
in HIV transmission. These structural approaches can also can act barriers to individually
oriented HIV prevention and care services and the adoption of HIV-preventive behavior. For
instance, fear of HIV-related stigma and discrimination discourages people from utilizing HIV
counseling and testing, and even from disclosing their status to their partner.
On the other hand, the relation of structural factors to HIV vulnerability can also be
complex and variable. Case in point, while many of the worlds poorest countries deal with high
HIV rates, many of the wealthiest nations within Sub-Saharan Africa are the most affected by
HIV/AIDS. Not to mention that structural factors are also static and change both their form and
effect as the epidemic evolves.
Structural approaches are structural actions implemented as policies or programs that aim
to change the condition in which people live. These approaches can also be directed at

individuals, but are aimed in such a way that they address factors affecting the specific behaviors
rather than addressing the behaviors themselves. The defining characteristic of structural
approaches is that they aim to change the social, economic, political, or environmental factors
that determine HIV risk and vulnerability. A great example of a structural approach was the
100% condom use policy implemented in Thailand and the Dominican Republic, requiring
brothel managers and bar managers to promote condom use.
In order to implement a structural approach, the social, political, economic, and
environmental factors influencing both vulnerability and risk must be identified along with the
pathways between these factors and the behaviors that need to change. All of this requires
contextual analyses in order to assess what is the best way these structural factors can be
addressed. Structural approaches need to take the context of the population into consideration,
understanding what the needs of the population are and how they can best be met.
In order to have sustained progress in HIV prevention, a structural approach is required
rather than a continuing to address individual-level factors approach. However, structural
approaches must be done with the context of the population in mind, as this context has a large
effect of the efficacy of the structural approaches in accomplishing their goals.
Making HIV Prevention Programs Work
National HIV programs, despite their years of experience, still remain largely
unsuccessful. There are four areas of important that these programs need to refocus their efforts
on: improvement of targeting, selection, delivery of prevention interventions, and optimization of
funding.
The effectiveness of a prevention program rests upon its success in effectively
intervening in populations at high risk of contacting the virus. HIV is spread in many different

ways and the risk of contracting and transmitting HIV varies widely. In order to improve their
targeting, these programs need to study current patterns and trends in order to predict where
infections are likely to occur in the future. This also includes understanding the context of the
populations in order to predict whether a certain intervention will be successful there, as well as
using resources for the population at greatest risk.
Similar to targeting the right population, selecting the correct intervention is an integral
part of any strong prevention program. Prevention programs must includes a complex set of
interventions and approaches-biomedical, behavioral, and community-tailored to the specific
context. Each community is different and so the prevention program must recognize this and take
the differences into account when choosing the intervention. An important aspect of this includes
appropriately assessing the intervention in order to study its efficacy and accurately predict its
success in high-risk populations.
Once the intervention and the population to which it must be delivered are finalized, the
focus must turn to how to implement the intervention in order to maximize its effectiveness. Due
to the lack of market pressure forcing these prevention programs to increase their efficiency,
explicit regulation and incentives are required. A good example of these incentives can be donor
conditioning their donations with certain result or performance markers. Additionally, the
managerial system must also be reformed in order to cut unneeded costs.
Finally, optimization of funding is perhaps the most critical question for a prevention
program. At the most basic level, managers need to know how much prevention of an additional
HIV infection costs, and how much prevention of that infection is worth in the country of
question. If cost is less than the value, then the funds should be provided for prevention.
Conclusion:

While the large number of people infected with HIV around the world coupled with our
lack of silver bullet treatment does make HIV seem like an undefeatable infection, HIV research
has shown that the infections spread can be stopped. Most of the studies and research conducted
conclude that it is possible to fight this epidemic if current resources are used efficiently and
applied to where they are most needed. It needs to be reiterated though that the best results have
been observed when a combination of a complex set of interventions and approaches-biomedical,
behavioral, and community- are used, tailored to the specific context of the community in which
they are being applied.