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These are among the conclusions of Professor Thomas Coates, University of California, Los Angeles, Professor Linda Richter, executive director of the Child, Youth, Family and Social Development research programme at the HSRC, and Professor Carlos Caceres, University of Peruana Cayetano Heredia, Lima, Peru, authors of a third paper in The Lancet Series on HIV prevention, which was presented at the XVII International AIDS Conference in Mexico City. The authors said varieties of sexual expression are infinitely greater than what is acknowledged or sanctioned by most societies' defined legal and moral systems. And substance use to the point of intoxication is not only allowed, but is central to many countries' economies - little wonder that attempts to control such substances, especially alcohol, stimulants, and injecting drugs, have met with little success. Behavioural strategies are those that attempt to delay first intercourse, decrease the number of sexual partners, increase the number of protected sexual acts, provide HIV counselling and testing and give access to treatment for those who are infected with HIV. Add to these providing access to male circumcision, decrease the sharing of needles and syringes, and decrease substance abuse. The authors called for new initiatives based on behavioural science to add to those based on communications, peer education and others, as part of a combination framework. It is essential that the right programmes are initiated. They discussed programmes such as the ‘Abstain, Be faithful, use Condoms' (ABC) of the US President's Emergency Plan for AIDS Relief (PEPFAR), which until recently insisted a third of its funding be spent on abstinence before marriage instead of where the evidence suggested funds were most needed. But advocacy has seen these restrictions removed from the 2008 PEPFAR legislation, so that the money can be better directed. There are many challenges facing behavioural change for HIV prevention. Many people with HIV do not know they are infected - thus one of the major tasks for HIV prevention in the developing world must involve increasing the number of people who know they are infected. Risk compensation - where advances in HIV prevention are undone by increases in risky behaviour - must also be addressed. HIV prevention counselling and services need to be a regular part of treatment for persons with HIV, the authors said. Major focus on young people is essential There is a shocking gulf in the knowledge that young people have in HIV knowledge, with indications that the United Nations General Assembly Special Session (UNGASS) target of 90% of young people having comprehensive HIV knowledge by 2010 will not even be half-met. The authors say: ‘Nothing should be more important than a major focus on young people, not only in sub-Saharan Africa but in many other parts of the world as well.' Injecting drug use remains a controversial area, and while many governments will not object to their HIV-infected population receiving antiretroviral drugs, they can and do refuse to implement harm-reduction policies to prevent HIV transmission in injecting drug users. The authors conclude: ‘The radical behavioural change that is needed to reduce HIV transmission requires radical commitment. Prevention strategies will never work if they are not implemented completely, with appropriate resources and benchmarks, and with a view toward sustainability. The fundamentals of HIV prevention need to be agreed upon, funded, implemented, measured, and achieved. That, presently, is not the case.'
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