Organising for Access
Although they are at various stages of development, the HIV prevention methods discussed in this section face similar challenges to their progress. Efforts to promote access to existing methods like the female condom may be different from advocacy for future technologies like HIV vaccines, but ultimately all share the same goal: to help prevent HIV infections and stop the AIDS pandemic. It is helpful to think about overcoming common obstacles to new prevention methods by applying advocacy messages and strategies to a range of technologies, both existing and emerging.
Obstacle Number One: Lack of Resources
The most common obstacle to progress in HIV and AIDS work, (as well as to issues of health and development in general) is the lack of resources. International and federally-funded health and family planning programs must struggle each year to maintain funding levels, let alone expand and improve services. Governments of poorer nations must make tough decisions with severely limited health budgets. Market forces in industrialized countries fail to deliver public health goods, which must be financed by the public sector.
Butů As awareness of the global AIDS pandemic increases in industrialized countries, the possibilities for mobilizing greater resources expand. Funding for global AIDS programs through the US Agency for International Development (USAID) has tripled over the last four years, largely in response to advocates' efforts to raise awareness and political will in the US Congress. The Global Fund for AIDS, TB and Malaria, initiated by the former Secretary General of the United Nations Kofi Annan, has the potential to mobilize billions of dollars.
These new resources should enable countries to greatly expand their national AIDS response, including the possibility of adding female condom procurement, introduction, and provider training to their HIV prevention programs. Private foundations, notably the Bill and Melinda Gates Foundation, have raised the bar for donor funding of research, donating hundreds of millions dollars for the development of vaccines, microbicides, and prevention options for women.
TAKE HOME ADVOCACY MESSAGE: "Lack of Available Resources" is no longer an acceptable excuse for failing to actively pursue and provide a broad range of HIV prevention options.
Obstacle Number Two: Scientific Unknowns
Does providing female condoms result in decreased rates of HIV transmission in a community or a population? Do cervical barriers reduce women's risk of sexually transmitted infections? Is it possible to mount an immune response to a virus that attacks the immune system? In the absence of definitive answers to these questions, why should we pursue options based on these assumptions? Policy makers, programmers and doners easily dismiss promising interventions because there is no proof that they will work, or because the success of a pilot project may not translate into success once "scaled up."
Butů While we may not have perfect knowledge of these issues, we do have evidence suggesting optimism over pessimism. Initial efforts to introduce the female condom have met with mixed success, but both successes and failures have generated useful lessons and consensus around what it takes to introduce a new prevention method in order to have an impact. Though our knowledge of vaginal physiology and the heterosexual acquisition of HIV is inadequate relative to other areas of HIV virology and immunology, existing ideas about the vulnerability of the cervix are sufficient to justify further basic and applied research to determine whether cervical barrier methods would indeed reduce women's risk of HIV. Despite several disappointments, HIV vaccine research plows full steam ahead.
TAKE HOME ADVOCACY MESSAGE: We know enough to justify the accelerated pursuit of prevention options. Progress can, and must, be made even in the absence of perfect knowledge.
Obstacle Number Three: Provider Bias
As the field of medicine has matured, health care providers have increasingly favored technological "fixes" rather than interventions that depend on individual initiative. Global family planning programs have focused heavily on long-acting pharmaceutical methods like oral contraceptives and IUDs rather than on user-controlled barrier methods like condoms or diaphragms. Providers often don't feel confident that their clients will be able to use barrier methods regularly enough to protect themselves. Also, long-acting or "one-shot" methods enable providers to provide family planning and HIV prevention services without having to talk about sex with their clients.
Butů Family planning programs are beginning to recognize that they must focus on dual-protection methods that will prevent unwanted pregnancy and HIV or STDs. Difficulties women have in using barrier methods can be overcome by new designs that involve women in the development process and take their preferences and needs into account.
TAKE HOME ADVOCACY MESSAGE: Frontline providers need to be aware of recent and upcoming developments in HIV prevention and be prepared to respond to their clients' needs with a range of options and strategies.
What can be done?
These obstacles can be overcome, by targeted advocacy directed at different audiences. For example:
- Public awareness-raising to increase and demonstrate broader demand for HIV prevention options.
- Advocacy with donors to fund the introduction and programming of the female condom, barrier methods, and other technologies as they become available.
- Pressure on programmers to broaden the range of HIV prevention strategies they include in their programs.
- Advocacy with policy makers and leaders to fund the simultaneous research and development of a range of prevention technologies.