FOCUS 1 Despite several decades of rigorous clinical trials, no single biomedical, behavioral, or structural HIV prevention intervention alone has proven sufficient to address the growing HIV pandemic. Instead, combination prevention packages of partially effective interventions address both the biological and behavioral factors associated with transmission as well as the structural determinants—social, economic, political, or environmental factors— that can aid or impede the success of HIV prevention programming. This article reviews the latest research regarding biomedical HIV prevention approaches, in particular, sexually transmitted infection (STI) control, male circumcision, microbicides, the prophylactic use of HIV antiretroviral drugs, and HIV vaccines.
FOCUS 1 Since the beginning of the HIV epidemic, researchers and clinicians have known that HIV can enter the central nervous system early in the course of the disease and, over time, may cause changes in thinking, emotions, and behaviors. Among these changes are “cognitive impairments”: problems with processing, learning, and remembering information. “Dementia,” in which a person has severe cognitive impairments that markedly affect activities of daily living, was the most frightening and obvious cognitive consequence of HIV. Yet less severe impairments were even more common, including difficulties in remembering things (such as appointments), problems in doing more than one task at a time, and slowed thinking. The advent of triple combination HIV antiviral treatment in 1996 led to a dramatic decrease in both HIVrelated medical conditions and deaths. But what impact have these treatments had on the cognitive effects of HIV infection? Prior to 1996, cognitive impairments occurred in approximately 30 percent of HIV-positive people who had no medical symptoms of HIV disease and in 55 percent of people who had AIDS-defining illnesses.1 At that time, the incidence of dementia was estimated at 7 percent per year in people who developed AIDS. Since 1996, the incidence of severe dementia has declined substantially, with one study finding it reduced by 50 percent.2 However, HIV-associated neurocognitive problems have not been eliminated. Preliminary data from CHARTER, a large, six-site study funded by the National Institutes of Health, suggest that even in the era of combination antiretroviral therapy, between one-third and one-half of HIV-positive individuals may have some form of cognitive impairment. It is not clear whether the continued presence of these disorders reflects an increase in the incidence of milder forms of impairment or the fact that people with impairments are living longer. Regardless, even these milder forms may affect medication adherence, vocational abilities, and complex activities of daily living such as financial management and automobile driving.3,4 This article reviews some of the ways that HIV disease affects the brain, the current diagnostic criteria for HIV-related cognitive disorders, and how HIV antiviral treatment affects the progression of these disorders. The focus is on the impact of HIV infection on the central nervous system, although the role of opportunistic infections and other cofactors in cognitive impairment is also addressed.
FOCUS 1 In 1999, several surveys indicated that only 30 percent of community-based HIV organizations were implementing risk reduction skills interventions. In response, the Division of HIV/AIDS Prevention of the Centers for Disease Control and Prevention (CDC) sought to make effective HIV prevention interventions accessible to frontline prevention programs. The result has been a division-wide process, made up of three CDC projects focusing on identifying, packaging, and disseminating evidencebased behavioral interventions (EBIs). Over the past four years, there has been tremendous demand for these proven interventions, known in the field as DEBIs (named for the CDC’s Diffusion of Evidence-Based Interventions Project). At the same time, the CDC recognizes that community-based organizations may need to adapt standardized evidence-based interventions to meet local needs. In some cases, community-based organizations develop their own interventions “organically” out of their own frontline experiences and unique local circumstances. This article reviews the CDC’s systematic process for translating scientific evidence into broadly applicable practice and describes its programs for identifying, packaging, and disseminating evidence-based interventions. It also highlights considerations and key practices that should guide both the adaptation and organic intervention process to ensure the greatest likelihood that interventions are achieving their stated goals. Prevention Research Synthesis
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