HIV prevention strategies are most effective when multifaceted and focused on mitigating the economic, political, and social foundations of HIV epidemics rather than solely the individual level determinants of this disease.  These structural risk factors contextualize, and are intimately linked, to the individual risk of HIV infection.  HIV interventions should include a structural approach, even though the benefit of these approaches is difficult to demonstrate in either epidemiologic or evaluative research. 

We have known for over a dozen years that efficacious suppression of HIV replication requires multiple antiretroviral medications.  Treatment with a single medication is generally a failed strategy, and in the long term will likely do more harm than good.  This may hold true for the application of single prevention strategies, which has been the norm to date.  There is consensus that there exists no single magic prevention bullet and all possible combinations of biomedical and behavioural interventions need to be evaluated with different combinations likely appropriate for different populations in different regions.

While there may be some positive news about advances in prevention, the reality is that we continue to fail at preventing HIV infection.  And even when programs do prevent HIV infection, rarely is the effectiveness adequately evaluated.  There are important lessons to be learned from the private sector in the area of monitoring and evaluation that will maximize the efficiency of prevention programming, which should translate into more infections averted and lives saved.

Peter Piot: “A failure of confidence now in our collective capacity to deliver full-scale and effective HIV prevention would be devastating.”

As a note, immediately after delivering this quote and showing a slide which called for political courage to adddress prevention wioth sex workers, MSM and drug users, Dr. Piot was asked about the lack of UNAIDS leadership and guidance on HIV prevention programming among sex workers.  Unfortunately, the question was ignored and this notable issue remains unresolved.