Back to basics in HIV prevention: focus on exposure

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Abstract
Despite worldwide efforts to prevent HIV infection, the number of people affected continues to rise. The authors of this article argue that a commonsense approach based on simple country by country analyses could improve the situation Every year, the United Nations releases new estimates of the number of people living with HIV infection. Despite 20 years of experience with prevention programmes, this number continues to rise. To date, around 60 million people have been infected with this preventable, fatal viral infection-a sad indictment of the world's prevention efforts so far.1 Why have we not done better? Some people suggest that we have focused too much on the behaviours that spread the virus, rather than on the social and economic conditions that promote such behaviours.2 We believe, rather, that many countries are failing because they are not paying enough attention to who is becoming infected and how. Plans for prevention are often built on broad categorisations of type of epidemic rather than on a careful analysis of where new infections are occurring. Countries do need to tackle the structural factors that support risky behaviour. Structural change takes time, however, so even this work must be focused on the factors that are most likely to enable people in a particular country to reduce their exposure to HIV. Almost all new HIV infections occur when an infected person shares body fluids with an uninfected person, so prevention programmes must focus on situations in which this is happening.3 4 This should be obvious, but many countries are being sold “off the peg” prevention packages based on arbitrary numerical thresholds: “If HIV is over 1% in pregnant women, do this; if not, do that.” This approach is no substitute for careful analysis of patterns of transmission within a country, and such analysis …