In the last 20 years, HIV/AIDS has become part of the history of mankind. How could the world have imagined that by the year 2001, 22 million people would have died of AIDS, while 33 million would be living with HIV/AIDS, the majority of them suffering from discrimination, stigmatisation, exclusion and lack of care and treatment. We speak of "concentrated" epidemics where HIV rates among the most vulnerable groups are more than 5%, while the rate among the general population is below 1%. This is the case in many Latin American countries, Eastern and Central Europe and the Newly Independent States of the former Soviet Union, Asia and the Pacific, as well as North America. On the other hand, in most sub-Saharan African countries, the HIV epidemic is characterised as "generalised", with more than 5% HIV prevalence rates among the general population.

Finding timely answers to HIV/AIDS

Many countries with concentrated epidemics have based their efforts on the experiences in sub-Saharan Africa, although these may not always represent an appropriate model for other parts of the world. For an adequate local response, the different reasons underlying current low HIV prevalence must be understood: is it because of some ‘inherent' protective factors in the social, cultural or religious make-up of society, or is it merely due to a delayed arrival of HIV, and will it just be a matter of time before HIV rates will rise sharply?

In either case, a thorough analysis of protective and risk factors is necessary to be able to define the key elements of an effective response to HIV/AIDS. Whatever the outcome of this analysis, complacency is ill-advised. Even when ‘protective' factors seem to predominate, it is important to take measures to ensure these factors will continue to provide protection, as long as they do not violate the human rights of individuals: e.g., strict societal rules that mainly limit female sexuality in some societies may have a certain protective effect, but are not necessarily an appropriate element of HIV prevention strategies.

On the other hand, where the socio-cultural, political and economic characteristics of a country seem to provide an ideal context for rapid HIV spread, the response needs to be quick and decisive, building on strong political commitment and leadership, and rapid mobilisation of key sectors of society, especially the most vulnerable. The hard-learned lessons from sub-Saharan Africa need to be built upon, adapting them to local realities and needs.
Wherever the balance between so-called ‘protective' and ‘risk' factors may lie, no country or person can claim not to be at risk: every country has specific groups with a particular vulnerability or risk for HIV infection, and in many there is a potential for concentrated epidemics to become generalised ones.

A key lesson learned worldwide is the need to openly address the underlying structural and behavioural factors that contribute to the spread of HIV. Many countries with generalised epidemics have learned the hard way – through thousands of unnecessary HIV infections – that AIDS cannot be contained through secrecy, denial and discrimination. While this lesson applies to all low-prevalence countries discussed in this issue of the Sexual Health Exchange, it will be illustrated with examples from Central America.

The HIV epidemic in Central America

Central America has HIV epidemics ranging from beginning (Nicaragua) to concentrated, with a tendency towards generalisation (Honduras). Though current HIV rates are relatively low, most countries are at a serious risk. Overall, the responses so far have been insufficient: there is a tendency to prioritise prevention among the general population – especially young people – rather than among the most vulnerable and affected groups.

A major problem is the lack of information and insufficient analysis of data. Most HIV surveillance studies have been done among pregnant women and female sex workers, leading to a tendency to "feminise" the epidemic, although in most countries the epidemic is concentrated among men. Very few studies have focused on groups traditionally defined as "highly vulnerable", such as men who have sex with men (MSM), mobile populations, street children and persons confined in prisons or institutions. The dynamics of transmission in the context of men's vulnerability have received little attention. Subsequently, prevention has concentrated on women and school children, while prevention efforts among particularly vulnerable groups have not been taken to scale.

Obstacles for an adequate response

The stigma associated with vulnerable groups has been a major obstacle for an effective response to AIDS. In public discourse, AIDS is being converted into everybody's problem, while the most-affected populations are made "invisible". Among vulnerable groups, this has led to a certain relief and distancing oneself from individual and collective responsibilities. The subsequent low-risk perception has led to a lack of effective prevention measures. Mass media campaigns have had limited effect and for most people HIV continues to be a problem for certain vulnerable groups only.
Religious and cultural reasons strengthen the existing stigma and rejection associated with condoms, which makes it very difficult to promote them among the general population or vulnerable groups. Many officially endorsed prevention strategies continue to emphasise family values, abstinence and faithfulness to one sexual partner, leaving out condoms as an appropriate option. At the same time, institutions promoting condom use face cultural obstacles such as the widespread machismo, which associates condoms with a lack of virility, loss of power and distrust among couples, while questioning the effectiveness of condoms.

Decision makers have failed to make firm commitments against the epidemic, partly because the discussion is based on officially registered cases, reflecting severe underreporting. Experts have failed to reach consensus on the interpretation of other epidemiological data, mainly UNAIDS estimates of adult HIV rates, and particularly the unreported estimate of adult male HIV rates. Epidemics of other, highly-visible, infectious diseases, such as cholera and dengue fever, have kept HIV/AIDS low on the list of public health priorities.

With support from UNAIDS and the international community, most central American countries have now developed National Strategic HIV/AIDS Plans. However, the generally low involvement of NGOs and civil society in developing these plans has prevented their ownership. In addition, these Plans lack sufficient budgetary allocations for effective implementation and fail to adequately consider care and support for people living with HIV/AIDS (PLWHAs).

General laws to facilitate dealing with AIDS have been adopted in most countries, but usually they do not guarantee respect for human rights of the most affected populations. Some laws penalise sexual transmission of HIV and in some cases violate the rights of PLWHAs.

Civil society in Central America and other parts of the world has led public debate in the fight against AIDS, but their efforts lack coordination and are small-scale. There is much distrust between governments and civil society. The international cooperation has made some efforts to support the response to AIDS, but these efforts are not always coordinated, easily lead to duplication of efforts and do not always take locally defined priorities into account. However, throughout Central America, PLWHA organisations have come up to challenge the insufficient efforts by governments and civil society to provide integrated care and support to PLWHAs.

Facing the challenge of HIV/AIDS in low-prevalence countries

There is an urgent need for prevention efforts tailored to the specific context and needs of the most vulnerable groups, including condom promotion. This is impossible unless specific legislation guarantees and protects equity of rights of these groups. This requires leadership at high political levels and among social movement leaders. Young people need sex education appropriate for their age and before they become sexually active.

Coordination teams for the design, implementation and evaluation of Strategic AIDS Workplans need active and balanced involvement by government, organised civil society and PLWHA groups. Government needs to guarantee sufficient funds to implement these plans.

Research is needed for a better theoretical foundation of prevention activities among the most affected populations, including mobile populations, sex workers and MSM. We also need to know more about women's vulnerability in relation to their male partners' sexual behaviours, including the impact of ‘machismo' and the reasons for rejecting condom use.

In low-prevalence countries, efforts to prevent HIV transmission from mother to child (MTCT) – as shown by the Ukraine experience – can be very effective in bringing down HIV infection among new-borns; they should also guarantee survival and comprehensive care for mothers and the integrity of the family. Similarly, it is necessary to initiate or expand access to anti-retroviral treatment for the majority of the affected population, based on internationally-accepted treatment standards. Joint negotiations and purchase of drugs on a regional level is a valid option to secure wide access to drugs.

Low-prevalence countries can still act timely to minimise the impact of AIDS on their societies. This requires a clear political and social commitment to fight AIDS, not the affected and vulnerable groups. HIV/AIDS has caused, and continues to cause enormous pain and suffering in many parts of the world. Millions of painful deaths can still be prevented provided that appropriate action is urgently taken.