Preventing HIV infection

HIV can be transmitted in three main ways:

Sexual transmission
Transmission through blood
Mother-to-child transmission

Wherever there is HIV, all three routes of transmission will take place. However the number of infections resulting from each route will vary greatly between countries and population groups.

For each route of transmission there are things that an individual can do to reduce or eliminate risk. There are also interventions that have been proven to work at the community, local and national level.

To be successful, an HIV prevention programme must make use of all approaches known to be effective, rather than just implementing one or a few select actions in isolation.

Although most of this page looks separately at each transmission route, it should be remembered that many people don’t fit into only one "risk category". For example, injecting drug users need access to condoms and safer sex counselling as well as help to reduce the risk of transmission through blood.

First requirements

There are three key things that can be done to help prevent all forms of HIV transmission. First among these is promoting widespread awareness of HIV and how it can be spread. Media campaigns and education in schools are among the best ways to do this.

Another essential part of a prevention programme is HIV counselling and testing. People living with HIV are less likely to transmit the virus to others if they know they are infected and if they have received counselling about safer behaviour. In particular, a pregnant woman who has HIV will not be able to benefit from interventions to protect her child unless her infection is diagnosed. Those who discover they are uninfected can also benefit, by receiving counselling about how to remain that way.

The third key factor is providing antiretroviral treatment. This treatment enables people living with HIV to enjoy longer, healthier lives, and as such it acts as an incentive for people to volunteer for HIV testing. It also brings people into contact with health care workers who can deliver prevention messages and interventions. However, it is important that people understand the limitations of the treatment, and that reduced fear of HIV doesn’t lead to more risky behaviour.

Sexual transmission

What works?

Someone can eliminate or reduce their risk of becoming infected with HIV during sex by choosing to:

Abstain from sex or delay first sex
Be faithful to one partner or have fewer partners
Condomise, which means using male or female condoms consistently and correctly

There are a number of effective ways to encourage people to adopt safer sexual behaviour, including media campaigns, social marketing, peer education and small group counselling. These activities should be carefully tailored to the needs and circumstances of the people they intend to help. Specific programmes should target key groups such as young people, women, men who have sex with men, injecting drug users and sex workers.

Comprehensive sex education for young people is an essential part of HIV prevention. This should include training in life skills such as negotiating healthy sexual relationships, as well as accurate and explicit information about how to practise safer sex. Studies have shown that this kind of comprehensive sex education is more effective at preventing sexually transmitted infections than education that focuses solely on teaching abstinence until marriage.

Numerous studies have shown that condoms, if used consistently and correctly, are highly effective at preventing HIV infection. Also there is no evidence that promoting condoms leads to increased sexual activity among young people. Therefore condoms should be made readily and consistently available to all those who need them.

Another significant intervention is providing treatment for sexually transmitted infections, such as chlamydia and gonorrhoea. This is because such infections, if left untreated, have been found to facilitate HIV transmission during sex.

A number of studies have found male circumcision to be associated with a lower rate of HIV infection. However, it is not yet clear to what extent this is an effect of circumcision itself, or whether other factors may also play a role, and the World Health Organisation has yet to recommend circumcision for HIV prevention. Further research on this issue is ongoing.

One group that shouldn’t be overlooked by HIV prevention programmes is those who are already living with the virus. Regular counselling can help HIV positive people to sustain safer sexual behaviour, and so avoid onward transmission.

What are the obstacles?

It is usually not easy for people to sustain changes in sexual behaviour. In particular, young people often have difficulty remaining abstinent, and women in male-dominated societies are frequently unable to negotiate condom use, let alone abstinence. Many couples are obliged to practise unprotected sex in order to have children.

Some societies find it difficult to discuss sex openly, and some authorities restrict what can be taught about sex in schools for moral or religious reasons. Particularly contentious subjects include premarital sex, condoms and homosexuality, the last of which is illegal or taboo in much of the world.

Marginalisation of groups at high risk, such as sex workers and men who have sex with men, can be another hindrance to HIV prevention efforts.

Transmission through blood

What works?

People who share equipment to inject recreational drugs risk becoming infected with HIV from other drug users. Methadone maintenance and other drug treatment programmes are effective ways to help people eliminate this risk by giving up injected drugs altogether. However, there will always be some injecting drug users who are unwilling or unable to end their habit, and these people should be encouraged to minimise the risk of infection by not sharing equipment.

Needle exchange programmes have been shown to reduce the number of new HIV infections without encouraging drug use. These programmes distribute clean needles and safely dispose of used ones, and also offer related services such as referrals to drug treatment centres and HIV counselling and testing. Needle exchanges are a necessary part of HIV prevention in any community that contains injecting drug users.16

Also important for injecting drug users are community outreach, small group counselling and other activities that encourage safer behaviour and access to available prevention options.

Transfusion of infected blood or blood products is the most efficient of all ways to transmit HIV. However, the chances of this happening can be greatly reduced by screening all blood supplies for the virus, and by heat-treating blood products where possible. In addition, because screening is not quite 100% accurate, it is sensible to place some restrictions on who is eligible to donate, provided that these are justified by epidemiological evidence, and don’t unnecessarily limit supply or fuel prejudice. Reducing the number of unnecessary transfusions also helps to minimise risk.

The safety of medical procedures and other activities that involve contact with blood, such as tattooing and circumcision, can be improved by routinely sterilising equipment. An even better option is to dispose of equipment after each use, and this is highly recommended if at all possible.

Health care workers themselves run a risk of HIV infection through contact with infected blood. The most effective way for staff to limit this risk is to practise universal precautions, which means acting as though every patient is potentially infected. Universal precautions include washing hands and using protective barriers for direct contact with blood and other body fluids.

What are the obstacles?

Despite the evidence that they do not encourage drug use, some authorities still refuse to support needle exchanges and other programmes to help injecting drug users. Restrictions on pharmacies selling syringes without prescriptions, and on possession of drug paraphernalia, can also hamper HIV prevention programmes by making it harder for drug users to avoid sharing equipment.

Many resource-poor countries lack facilities for rigorously screening blood supplies. In addition a lot of countries have difficulty recruiting enough donors, and so have to resort to importing blood or paying their citizens to donate, which is not the best way to ensure safety.

In much of the world the safety of medical procedures in general is compromised by lack of resources, and this may put both patients and staff at greater risk of HIV infection.

Mother-to-child transmission

What works?

HIV can be transmitted from a mother to her baby during pregnancy, labour and delivery, and later through breastfeeding. The first step towards reducing the number of babies infected in this way is to prevent HIV infection in women, and to prevent unwanted pregnancies.

There are a number of things that can be done to help a pregnant woman with HIV to avoid passing her infection to her child. A course of antiretroviral drugs given to her during pregnancy and labour as well as to her newborn baby can greatly reduce the chances of the child becoming infected. Although the most effective treatment involves a combination of drugs taken over a long period, even a single dose of treatment can cut the transmission rate by half.

A caesarean section is an operation to deliver a baby through its mother’s abdominal wall, which reduces the baby’s exposure to its mother’s body fluids. This procedure lowers the risk of HIV transmission, but is likely to be recommended only if the mother has a high level of HIV in her blood, and if the benefit to her baby outweighs the risk of the intervention.

Weighing risks against benefits is also critical when selecting the best feeding option. The World Health Organisation advises mothers with HIV not to breastfeed whenever the use of breast milk substitutes (formula) is acceptable, feasible, affordable, sustainable and safe. However, if safe water is not available then the risk of life-threatening conditions from formula feeding may be higher than the risk from breastfeeding. An HIV positive mother should be counselled on the risks and benefits of different infant feeding options and should be helped to select the most suitable option for her situation.

What are the obstacles?

In much of the world a lack of drugs and medical facilities limits what can be done to prevent mother-to-child transmission of HIV. Antiretroviral drugs are not widely available in many resource-poor countries, caesarean section is often impractical, and many women lack the resources needed to avoid breastfeeding their babies.

HIV-related stigma is another obstacle to preventing mother-to-child transmission. Some women are afraid to attend clinics that distribute antiretroviral drugs, or to feed their babies on formula, in case by doing so they reveal their HIV status.

Policy measures

To be successful, a comprehensive HIV prevention programme needs strong political leadership. This means politicians and leaders in all sectors must speak out openly about AIDS and not shy away from difficult issues like sex, sexuality and drug use.

An effective response to HIV also requires strategic planning based on good quality science and surveillance. Many sectors of society should be actively involved in the response, including employers, religious groups, non-governmental organisations and HIV-positive people.

HIV epidemics thrive on stigma and discrimination related to people living with the virus and to marginalised groups such as sex workers. Its spread is also fuelled by gender inequality, which restricts what women can do to protect themselves from infection. Protecting and promoting human rights should be an essential part of any comprehensive HIV prevention strategy. This includes legislating against the many forms of stigma and discrimination that increase vulnerability.