KEY ELEMENTS FOR SUCCESSFUL INTERVENTION Mobilization of political will and commitment Good surveillance Learn and adapt from past experiences Unified national planning Rapid implementation Focused intervention especially to marginalized groups Access to intervention tools e.g. condoms, testing Community involvement Reduce stigmatization and discrimination

MODES OF TRANSMISSION Blood Sexual activities Mother to child

NEED TO RETURN TO PUBLIC HEALTH PRINCIPLES Discard concept of exceptionalism Primary responsibility to protect the uninfected Promote (risk-free) testing Prevention of transmission

USING ANXIETY AS A PUBLIC HEALTH TOOL Level of Anxiety Too little  Sufficient  Too much  Consequences No action Appropriate action Fatalism and no action

FACTORS PROMOTING SEXUAL TRANSMISSION Rate of partner exchange Sexual mixing patterns (multiple concurrent partners vs. serial monogamy) Sexual practices (vaginal, anal, etc) Condom use Willingness to reduce partners/delay intercourse

TARGET GROUPS FOR INTERVENTION STRATEGIES Homosexual/bisexual men Intravenous drug users Promiscuous heterosexuals Health care workers Biomedical laboratory workers Blood/plasma donors Pregnant women in high-risk populations Youth years

DETERMINANTS OF TRANSMISSION FROM AN INFECTED PERSON Duration of infection/stage of disease Risk of transmission per sexual act Presence/absence of concurrent STD infection Condom use Circumcision Partner exchange rate mixing pattern patterns of sexual behavior (anal, vaginal, etc.)

STRATEGIES TO PREVENT HIV INFECTION Blood 1.Prevent drug use 2.Reduced use of whole blood 3.Screening of blood donors 4.Screening of blood donations 5.Processing of blood products 6.Institutionalization of routine safety procedures for health workers and biomedical laboratory technicians

STRATEGIES TO PREVENT HIV INFECTION Injecting Drug Users 1.Reduce needle sharing 2.Use of bleach or boiling 3.Needle exchange programs 4.Methadone clinics 5.Health education/behavioral intervention for intravenous drug users 6.Improve access to and acceptability of testing

STRATEGIES TO PREVENT HIV INFECTION (1) Sexual activities (male-female, male-male) Health education/behavioral intervention increase knowledge of HIV/AIDS at an early age eliminate/reduce high-risk practices promote use of condoms with every intercourse promote monogamy/celibacy improve sex education in schools

STRATEGIES TO PREVENT HIV INFECTION (2) Sexual activities (male-female, male-male) Reduce opportunities for promiscuity (e.g., close bath houses, reduce number of partners, avoid anonymous partners) Regular screening and treatment for sexually transmitted diseases Use of syndromic approach to treat STDs premarital testing Improve access to and acceptability of testing voluntary partner notification

STRATEGIES TO PREVENT HIV INFECTION High-Risk High-Fertility Women 1.Selection of marital partners 2.Testing before marriage and pregnancy 3.Monogamy 4.Education of spouses 5.Screening and effective treatment of STDs 6.Improve access to and acceptability of testing

STRATEGIES TO PREVENT HIV INFECTION Mother to Infant Screening of women in high-risk groups Pre-pregnancy testing Routine screening of pregnant women Counseling and abortion Antiretroviral treatment -- prenatal PCR/isolation/IgA screening of infants

STRATEGIES TO PREVENT HIV INFECTION Mother to Infant (continued) Postnatal treatment Education Breast feeding only if no access to clean formula Prophylaxis during breast feeding Screening and effective treatment of STDs

STRATEGIES TO PREVENT HIV INFECTION Commercial Sex Workers Education on risk activities Use of condoms Persuasion of brothel owners/managers Regular screening and effective treatment for STDs Regular testing for HIV Monitoring, not persecuting

STRATEGIES TO PREVENT HIV INFECTION AIDS Developed countries Initiate HAART CD4 + cell <250, regardless of symptoms Symptoms of HIV infection present regardless of CD4 + cell level CD4 + cell >250, viral load >30,000 Diagnosis of AIDS

STRATEGIES TO PREVENT HIV INFECTION AIDS (continued) Developing countries Pre-AIDS Prophylaxis for most common opportunistic infections that constitute an AIDS diagnosis in the country Post-AIDS Multiple retroviral drugs, if possible Treatment of specific opportunistic infection

TARGET POPULATIONS Vulnerable groups  Poor  Minorities  Homosexuals Adolescents In utero/breast-feeding infants (mothers) School children

INTERVENTION STRATEGIES Educational approaches Behavioral (theory-based) “Empower” young people Harm reduction Community intervention

EDUCATIONAL APPROACHES School-based Media: newspapers, posters, radio/TV Internet Health professionals –Train the trainers –Researchers –Administrators

BEHAVIORAL (THEORY-BASED): “EMPOWER” YOUNG PEOPLE Stages of behavior change –Knowledge –Persusion –Decision –Implementation –Confirmation

ROLE MODELS Popular opinion leaders Recruitment Training

HARM REDUCTION Condoms Needle exchange Methadone and other drug alternatives

COMMUNITY INTERVENTION Have community accept responsibility and initiate appropriate intervention activities Recruit community leaders, teachers, health workers, peer leaders, media

EDUCATION IS ESSENTIAL BUT INSUFFICIENT

EVALUATION OF INTERVENTION STRATEGIES Are the appropriate risk groups and areas targeted? Is the intervention strategy culturally/ economically appropriate for the specific risk group/area? How is effectiveness of intervention strategies measured? Is the sentinel surveillance system a part of the evaluation scheme? Is the strategy cost-effective?

OBJECTIVES OF VACCINATION Prevent infection Prevent disease Prevent transmission

TARGET GROUPS FOR VACCINATION Homosexual/bisexual men Intravenous drug users Promiscuous heterosexuals Sex workers Health workers Biomedical laboratory workers Spouses of risk group members

REQUIREMENTS FOR A VACCINE Must be safe Must elicit a protective immune response Must stimulate both humoral and cellular immunity Must protect against different clades of HIV Must provide long-lasting immunity Must be practical to produce, transport and administer Should stimulate mucosal immunity in genital tract, rectum and oral activity

PRIMARY ISSUES FOR CONSIDERATION IN VACCINE DEVELOPMENT (1) No long-lasting natural immunity yet demonstrated in humans Disease progresses despite presence of neutralizing antibody Variability of viral genome Can a group antigen be found to induce immunity? Clades? Antigenic drift Need to induce humoral and especially cytotoxic cellular immunity Potential of some vaccine candidates to induce enhancing antibodies

PRIMARY ISSUES FOR CONSIDERATION IN VACCINE DEVELOPMENT (2) Applicability of animals to HIV in humans Ethics and sources of volunteers for safety and efficacy trials Efficacy –Against infection –Against disease –Against transmissibility –Acceptable level Who will be vaccinated? Selection of optimal vaccine: safety vs. efficacy

TYPES OF VACCINES Non-live –Whole virus, killed –Subunit with adjuvant Fractionation and use of specific particles Synthetic Anti-idiotypic Live –Whole virus, attentuated –Subunit, recombinant Viral substrate Non-viral substrate (e.g., yeast) Intracellular genetic transfer of “resistance”

STAGES IN VACCINE RESEARCH AND DEVELOPMENT Basic research Animal studies –Safety –Immunogenicity (humoral and cell-mediated) –Efficacy Clinical trials –Phase I – safety and immunogenicity in humans – small numbers of subjects Who should be the guinea pigs? –Phase II – safety and immune response in humans – small trials –Phase III – larger population-based trials for efficacy

SOCIOPOLITICAL CONSIDERATIONS Cost of development – federal government and/or private industry? Responsibility for liability – federal government, industry or insurance companies? Priorities for funding and distribution of vaccine

SUGGESTED FUTURE DIRECTIONS (1)  Implement public health principles and eliminate concept of “exceptionalism”  Recruit political will and intervention priority of HIV/AIDS  International level  National level  Local level # Increase community awareness and acceptance of health threat # Promote community responsibility for intervention # Implement community intervention strategies  Lower cost and improve quality of surveillance, especially of low-risk groups

SUGGESTED FUTURE DIRECTIONS (2)  Promote health education for  Health professionals  Media  Public, especially young, sexually active men and women  School children before majority leave school  Develop, implement, and evaluate culturally sensitive, economically feasible behavioral intervention strategies  Improve treatment potential, especially in developing countries  Promote concept of wealthy nation responsibility towards poorer nations, e.g. drug patent relief  Implement mechanisms for distribution of low cost treatments

SUGGESTED FUTURE DIRECTIONS (3)  Implement “risk-free” testing (e.g. rapid saliva and urine testing with resources for confirmation of positives)  Promote widespread testing  Reduce stigmatization associated with being HIV- infected and with belonging to a “risk group”  Increases willingness to learn HIV status  Increases testing acceptability  Facilitates earlier identification # Improves treatment effectiveness # Reduces period of unknowing transmissibility # Facilitates premarital testing

SUGGESTED FUTURE DIRECTIONS (4)  Improve control of sexually transmitted diseases  Implement early health and sex education before majority of young people leave school  Promote education of women  Promote harm reduction  Needle exchange, etc.  Condom promotion  Reduce cost of screening blood  Reduce acceptance of multiple sexual partners

SUGGESTED FUTURE DIRECTIONS (5) Change gender realities (role of men and women) Develop and promote an effective microbicide Develop strategies to evaluate behavioral interventions Continue intense efforts to develop an effective “vaccine”