Show Summary Details

Page of

PRINTED FROM the OXFORD RESEARCH ENCYCLOPEDIA, GLOBAL PUBLIC HEALTH ( (c) Oxford University Press USA, 2016. All Rights Reserved. Personal use only; commercial use is strictly prohibited. Please see applicable Privacy Policy and Legal Notice (for details see Privacy Policy and Legal Notice).

date: 14 August 2018

HIV Ed: A Global Perspective

Summary and Keywords

At the end of 2016, there were approximately 36.7 million people living with HIV worldwide with 1.6 million people being newly infected. In the same year, 1 million people died from HIV-related causes globally. The vast prevalence of HIV calls for an urgent need to develop and implement prevention programs aimed at reducing risk behaviors. Bronfenbrenner’s socio-ecological model provides an organizing framework to discuss HIV prevention interventions implemented at the individual, relational, community, and societal level. Historically, many interventions in the field of public health have targeted the individual level. Individual-level interventions promote behavior change by enhancing HIV knowledge, attitudes, and beliefs and by motivating the adoption of preventative behaviors. Relational-level interventions focus on behavior change by using peers, partners, or family members to encourage HIV-preventative practices. At the community-level, prevention interventions aim to reduce HIV vulnerability by changing HIV-risk behaviors within schools, workplaces, or neighborhoods. Lastly, societal interventions attempt to change policies and laws to enable HIV-preventative practices.

While previous interventions implemented in each of these domains have proven to be effective, a multipronged approach to HIV prevention is needed such that it tackles the complex interplay between the individual and their social and physical environment. Ideally, a multipronged intervention strategy would consist of interventions at different levels that complement each other to synergistically reinforce risk reduction while simultaneously creating an environment that promotes behavior change. Multilevel interventions provide a promising avenue for researchers and program developers to consider all levels of influences on an individual’s behavior and design a comprehensive HIV risk-reduction program.

Keywords: HIV prevention, socio-ecological model, HIV interventions, global HIV epidemic, HIV regional trends

Global Epidemiology

Since the start of the Human Immunodeficiency Virus (HIV) epidemic, there have been almost 76.1 million people infected and 35 million people who have died from HIV-related causes. In the 1990s, there was a substantial increase in the number of people infected with HIV, with 1997 reaching an all-time peak with almost 3.5 million newly diagnosed individuals. Since then, the number of newly infected people with HIV has declined, and in 2016, it was reduced to 1.8 million people.

In 2001, there were approximately 30 million people living with HIV globally. The numbers of people living with HIV globally have been increasing incrementally, with 2016 showing approximately 36.7 million people living with HIV globally. Since the peak in 2005, AIDS-related deaths have declined by 48% (UNAIDS, 2017). These declining trends in AIDS-related deaths can be attributed widely to the availability of anti-retroviral treatment (ART). There has been a significant increase in the number of people accessing treatment from 1.3 million in 2005 to 19.5 million in 2016. Figure 1 shows the number of people living with HIV from 2001 to 2016 worldwide.

HIV Ed: A Global PerspectiveClick to view larger

Figure 1. Number of people living with HIV worldwide (in Millions).

Source: Extracted from UNAIDS (2013).

Regional Trends

This section will provide information on regional trends and statistics for HIV, including the number of people living with HIV (PLHIV), newly infected individuals, treatment coverage, and primary means of HIV transmission. Table 1 shows the regional statistics for PLHIV and newly infected with HIV at the end of 2016.

Table 1. HIV Statistics (People Living With HIV and Newly Infected With HIV), End of 2016


Adults and Children Living with HIV

Adults and Children Newly Infected in 2016

Eastern and Southern Africa

19.4 million


Western and Central Africa

6.1 million


Asia and the Pacific

5.1 million


Western and Central Europe and North America

2.1 million


Latin America and the Caribbean

2.1 million


Eastern Europe and central Asia

1.6 million


Middle East and North Africa



Source: Data extracted from UNAIDS (2017).

Sub-Saharan Africa

When looking at regional HIV statistics, sub-Saharan Africa is disproportionately affected with an estimated 25.5 million PLHIV. In eastern and southern Africa, women and girls account for 59% of the total number of individuals living with HIV (UNAIDS, 2017). While new HIV infections have declined by 29% from 2010 to 2016, there is still an estimated 790,000 new HIV infections in eastern and southern Africa. There has also been a 9% decline in new HIV infections from 2010 to 2016 in the western and central region of Africa by 2017. Furthermore, the number of AIDS-related deaths in 2016 fell by 42% and 21% in eastern and southern Africa and western and central Africa, respectively. The majority of individuals acquired HIV through unprotected heterosexual intercourse and mother-to-child transmission (UNAIDS, 2011).

Asia and the Pacific

Asia and the Pacific account for the second largest proportion of PLHIV at 6.1 million, with 270,000 people being newly infected in 2016. The HIV epidemic is seeing a 13% decline in this region between 2010 and 2016 (UNAIDS, 2017) for new HIV infections. Furthermore, there has been a 30% decline in the number of AIDS-related deaths. Part of this could be attributed to expanded ART access. Treatment coverage is estimated at 47% for PLHIV. The primary means of HIV transmission is unprotected heterosexual sex. Additionally, IV drug use is also another major contributor of HIV transmission in Asian countries (UNAIDS, 2011). The HIV epidemic has also been growing among men who have sex with men (MSM) (Brahmam et al., 2008; Morineau et al., 2011).

Eastern Europe and Central Asia

There were approximately 1.6 million PLHIV in Eastern Europe and central Asia, with 190,000 newly infected people in 2016. Since 2010, this region has witnessed a sharp increase in new HIV infections by 60% (UNAIDS, 2017). Concurrently, there has also been an increase in the number of AIDS-related deaths at 27%. Treatment coverage is estimated to be at 28% (2017). Initially, IV drug use was the primary source of new infections in this region; however, unprotected heterosexual sex has become the major driver recently (DeHovitz et al., 2014).

Latin America and the Caribbean

Latin America and the Caribbean account for 2.1 million PLHIV in 2016 with 115,000 people being newly infected. In Latin America, the number of new HIV infections did not vary between 2000 and 2016 (UNAIDS, 2017). However, the number of AIDS-related deaths in the region did fall by 12% during the same period. In the Caribbean, the number of AIDS-related deaths fell by 28% between 2010 and 2016. Treatment coverage was 58% and 52% for Latin America and the Caribbean, respectively. The primary source of transmission is sexual intercourse among both heterosexuals and MSM (Tomlinson, 2010).

Western and Central Europe and North America

In 2016, there was a total of 2.1 million PLHIV in western and central Europe and North America with an estimated 73,000 newly infected individuals. The number of AIDS-related deaths decreased by 32% since 2010. Approximately half (1.1 million) of PLHIV in this region are living in the United States, where gay and bisexual men, particularly African American gay and bisexual men, are disproportionately affected (CDC, 2017). The primary source of transmission in this region continues to be unprotected intercourse between MSM (UNAIDS, 2016).

Middle East and North Africa

The lowest regional rates of PLHIV can be found in the Middle East and North Africa at 230,000, with 18,000 people being newly infected in 2016. New HIV infections decreased by 4% from 2010 and 2016 (UNAIDS, 2017). However, the number of AIDS-related deaths has increased by 19% between 2010 and 2016. In comparison with other regions, treatment coverage in the Middle East and North Africa is estimated to be only 24%. The primary driver of HIV transmission is condom-less sex, including MSM, and sharing needles (Abu-Raddad et al., 2010). Figure 2 provides a regional breakdown of the number of people who died of AIDS-related illnesses in 2016.

HIV Ed: A Global PerspectiveClick to view larger

Figure 2. Regional HIV statistics: Deaths due to AIDS-related illness at the end of 2016.

Source: Data extracted from UNAIDS Global HIV Fact Sheet (2017).

A Framework for HIV Prevention Strategies: The Socio-Ecological Model

Given the global burden of HIV, there is a pressing need to develop and implement prevention interventions aimed at decreasing risk behaviors. Since the 1990s, numerous HIV interventions have been implemented with the hopes of reducing the prevalence of HIV. It is particularly important for researchers and program developers to understand the regional epidemic thoroughly and the cultural context of specific populations to be successful in reducing the incidence of HIV. This section will use the socio-ecological perspective as an organizing framework to discuss the different HIV prevention interventions that have previously been implemented.

Socio-Ecological Perspective

In the past several years, public health professionals have begun to recognize the value in adopting a socio-ecological perspective (DiClemente, Crosby, & Kegler, 2002). The socio-ecological perspective inspects individual behavior in the context of social and physical environment, including familial, relational, peer, and societal influences (Bronfenbrenner, 1979; DiClemente et al., 2005; Bronfenbrenner, 1979).

Figure 3 shows a representation of an adaptation of Bronfenbrenner’s ecological model (Bronfenbrenner, 1979). This figure highlights the complex interplay between the different spheres of influences: individual (illustrated as an “I” in Figure 3), relational, community, and societal. The innermost sphere is depicted by the individual, consisting of psychological influences and behaviors. The second level—relational—shows the interaction between the individual, family, closest peers, and intimate partners. This suggests that relationships have a strong influence on an individual’s behaviors. Community level is the third sphere of influence, consisting of settings such as school, work, and neighborhoods, along with norms and practices, that influence the individual. The outermost sphere of influence is the society at large, including factors such as socioeconomic status, policies, and media, which may influence an individual’s behavior.

The socio-ecological model is a particularly helpful framework when looking at the various prevention efforts that have been made. The following section will break down HIV interventions in each of these four domains. Table 2 provides a general overview of the different levels of interventions with examples.

HIV Ed: A Global PerspectiveClick to view larger

Figure 3. Bronfenbrenner’s Ecological Model.

Source: Adapted from CDC (2017).

Table 2. Levels of Intervention With a General Overview and Examples

Intervention Levels

General Overview With Examples


  • Promote attitudes, behaviors, and beliefs in an individual to prevent HIV

  • Examples include:

    • o delaying initiation of first intercourse

    • o reducing in the number of sexual partners

    • o increasing in the number of protected sexual acts

    • o reducing in sharing needles or syringes


  • Target families or couples to promote HIV prevention

  • Examples include:

    • o family-based HIV screening

    • o enhancing role of the family in promoting safer sex

    • o promoting healthier relationships

    • o encouraging partner communication for condom use


  • Change community norms and behaviors to encourage an individual’s desire to change

  • Examples include:

    • o community-based media campaigns to reduce HIV prevalence

    • o school outreaches to promote condom use

    • o group-based health education programs


  • Macroscale interventions aimed at addressing social, economic, political or cultural problems

  • Examples include:

    • o mass media campaigns

    • o national and state policies

    • o increasing access to HIV testing and screening

Individual-Level Interventions

In the 21st century, numerous individual-level interventions have been created as a method to decrease risk behaviors. Interventions at the individual-level seek to change behavior by promoting attitudes, behaviors, and beliefs to prevent HIV infection. Interventions may include delayed initiation of first intercourse, reduction in the number of sexual partners, increase in the number of protected sexual acts, adherence to regimens that prevent HIV transmission, and reduction in sharing needles or syringes (Coates, Richter, & Caceres, 2008).

An example of an individual-level intervention is the use of counselors in reducing HIV risk behaviors. One particular study evaluated whether utilizing a lay counselor during routine care can reduce risky sex among PLHIV in South Africa on antiretroviral therapy (ART) (Fisher et al., 2014). The intervention consisted of lay counselors delivering a brief intervention using approaches from an Information-Motivation-Behavioral Skills (IMB) model during an HIV clinical care visit. Results from the intervention show that participants who received the intervention reported significant reductions in the number of sex events without a condom with any partner, regardless of serostatus, and in the number of sex events without a condom with partners perceived to be HIV-negative, or an unknown status in comparison with the control group.

Individual-level interventions have been conducted in sub-populations such as MSM as well. Herbst et al. (2007) conducted a systematic review to evaluate whether one-on-one counseling with a peer or professional counselor can modify risk behavior. The review criteria included studies that wanted to modify HIV risk behavior through changing attitudes, beliefs, and self-efficacy; providing STI or HIV/AIDs knowledge and information; or influencing emotions or feelings. The four studies that met the criteria showed a statistically significant effect size, with 43% reduced odds of engaging in unprotected anal intercourse among the intervention groups in comparison to the control groups. This study provides evidence that interventions at the individual level can be effective in changing HIV-risk behaviors.

An exciting avenue to deliver HIV prevention interventions has been the use of computer technology as the main or only means of delivering an intervention (Ybarra & Bull, 2007). The use of computer technology is particularly promising for various reasons: the low cost of implementing computer-based programs; content that can be standardized to ensure fidelity; computer algorithms that allow for customization of the intervention; and multimedia and activity features that may assist in encouraging behavior change (Cassel, Jackson, & Cheuvront, 1998; Bickmore & Giorgino, 2006). A meta-analysis conducted by Noar et al. (2009) evaluated the effectiveness of 12 computer-technology-based behavioral interventions for an at-risk population. Findings from the study suggest that computer-based HIV prevention interventions were statistically significant in increasing condom use and decreasing sexual activity, the number of sexual partners, and incidence of STDs. This study also found that computer-based interventions have been as successful as many other human-delivered HIV prevention interventions.

It is important to note that when focusing on interventions at the individual level researchers should stray away from fear-inducing arguments. Fear-based arguments center around describing the threat of HIV as significant or extremely likely (Fisher et al., 2002). Results from meta-analytical research conducted by Earl and Albarracin (2007) indicated that fear-inducing arguments about HIV transmission and prevention decreased knowledge and condom use.

Individual-level interventions are a common means of providing HIV prevention intervention since they are relatively easy and cost-effective. Interventions in this domain are particularly beneficial when applied consistently and repeatedly (Frieden, 2010).

Relational-Level Interventions

While many HIV interventions are conducted at the individual level, it is also important to focus on relational-level interventions as well. Relational-level interventions can be further broken down into family-focused and couples-focused intervention. Some examples of prevention interventions in this domain include family-based HIV screening, enhancing the role of the family in promoting safer sex, promoting healthy relationships, and encouraging partner communication for condom use.

While family-based interventions are effective for HIV detection, prevention, and care, they are not broadly dispersed (Rotheram-Borus et al., 2011). Many HIV-prevention programs narrowly target the individual level, which creates challenges and stereotypes of families affected with HIV (Rotheram-Borus, Swendeman, & Chovnick, 2009; Rotheram-Borus, Swendeman, & Flannery, 2009; Rotheram-Borus et al., 2009). For example, HIV interventions are delivered in many settings where HIV has been identified, including counseling centers, clinics, and hospitals. However, this can limit the use of services for families affected by HIV due to stigma (Mahajan et al., 2008). This suggests the need to focus on family specific intervention.

Rotheram-Borus et al. (2011) analyzed interventions for families affected by HIV (FAH) across randomized controlled trials in Thailand and the United States. In Thailand, FAH were randomized to a family group session or a control group. The experimental group had family-focused sessions on Thai and Buddhist values, including “sound body and sound mind,” and the importance of family and community in well-being. The intervention group reported significant improvements in their physical and mental health, as well as their quality of life, compared to the control group. In Los Angeles, HIV-positive mothers and their children were randomized to either receiving Project TLAC (a three-module intervention) (which was focused on mental health, relationship, and transmission challenges) or to the control group that did not receive the intervention. Results from the study showed that mothers in the experimental group were more likely to monitor their health than those in the control group (Rotheram-Borus et al., 2004). Furthermore, their children were more likely to reduce drug use than the control group.

Couples-based prevention programs represent a promising avenue for HIV prevention, since HIV can be transmitted between partners in relationships. A systematic review done by Burton, Darbes, and Operario (2010) evaluated whether couples-focused behavioral interventions reduced HIV transmission and risk behavior. The review included six studies of couples-focused interventions conducted in three different regions—Africa (Kenya, Tanzania, Zambia), Caribbean (Trinidad), and the United States. A total of 1,084 couples were included in the review. Results indicated that couples-based intervention programs decreased unprotected sexual intercourse and increased condom use among the intervention group in comparison to the control groups. Jiwatram-Negron and Bassel (2014) also conducted a systematic review to analyze couples-focused biobehavioral (skills-building, voluntary counseling, testing, and adherence) and biomedical (ART, circumcision) interventions aimed at decreasing sexual- and drug-risk behaviors and HIV transmission and acquisition. Results from the study showed that couples-focused biobehavioral prevention programs were effective in decreasing sexual- and drug-risk behaviors, improving access to testing and care, and increasing adherence. Furthermore, biomedical prevention interventions were efficacious in decreasing the incidence of HIV among HIV-negative sex partners and viral load for HIV-positive partners. Some challenges in implementing couples-focused intervention include time constraints, increase in caseload, HIPPA regulations that may prevent information being shared with other individuals, and a lack of training in targeting couples.

As seen in the studies in this section, many relational-level interventions have proven efficacious for decreasing risk behaviors, improving quality of life, and improving adherence. Implementation of relational-level interventions represents an exciting opportunity in the field of HIV prevention.

Community-Level Interventions

Community-level interventions seek to change community norms and behaviors to influence an individual’s desires to change. The settings for community-level interventions range from schools and workplaces to neighborhoods and faith-based organizations. Interventions in this domain may include community-based media campaigns to reduce HIV prevalence, street outreaches, and group-based health education programs.

Fishbein et al. (1999) conducted a study to evaluate whether community-based interventions were effective in promoting consistent condom use in five U.S. cities. Stories highlighting how people from the community were changing (or beginning to change) their HIV-related risk behaviors, along with condoms, which were distributed to individuals within the community. The study showed statistically significant results in consistent condom use among primary and non-primary partners as well as an increase in the likelihood of carrying condoms in comparison with the control group.

In Belize, Kinsler, Sneed, Morisky, and Ang (2004) evaluated whether a school-based, peer-facilitated HIV education program would improve knowledge, attitudes, and behaviors among primary and secondary students. During a three-month intervention period, 75 students received the intervention while the other 75 served as controls. Follow-up assessment showed that the intervention group reported higher HIV knowledge, were more likely to increase condom use, and had more positive attitudes toward condoms.

A study done by Rou et al. (2007) among sex workers in China provides a more recent example of a community-level intervention. This study evaluated whether clinic-based outreach activities—including increasing sexual health awareness, condom-use promotion, and sexual health care—was effective in reducing sexually transmitted disease/HIV risk. Results from the study showed this intervention was successful in improving condom use and reducing STDs among sex workers.

Project Accept (HPTN 043) is another example of a successful community-based intervention program. Project Accept sought to reduce HIV incidence for at-risk populations in sub-Saharan Africa and Thailand. Khumalo-Sakutukwa et al. (2008) developed a multipronged community-based HIV intervention that included providing the community with mobile voluntary counseling and testing, community mobilization, and post-test support services. Forty-eight communities in Thailand, South Africa, Tanzania, and Zimbabwe were randomized to the intervention or the control group. Findings from the study show that within the first year there was a four-fold increase in testing in the intervention group in comparison to the control group.

Faith-based organizations provide a unique opportunity to deliver prevention interventions since they can reach community members by understanding felt needs and fostering their involvement in ways that public health sometimes cannot (Coyne-Beasley & Schoenbach, 2000; Tesoriero et al., 2000). A particularly successful faith-based intervention is Churches United to Stop HIV (CUSH) program, which was developed in a joint effort between the Broward County Health Department in Florida and local faith-based organizations (Agate et al., 2005). CUSH aimed to train faith-based leaders to develop HIV educational programs, outreach and referral services, and support programs for infected individuals. The CUSH staff created brochures, cards, and training manuals for the leaders. As a result, CUSH has provided HIV prevention to over 32,000 individuals, trained 2,850 faith leaders, tested and counseled over 825 participants, and provided technical assistance to 48 churches, which included assisting with the development of a HIV training manual.

While this section focused on interventions in the community and faith-based settings, there are numerous other settings in which community-level interventions can take place, including the workplace for adults. Numerous HIV prevention interventions have been conducted at the community level since it provides an opportunity to deliver behavior change interventions in a setting that is comfortable to the participant.

Societal-Level Interventions

Unlike individual-, relational-, and community-level interventions, societal-level interventions have the largest reach, since they are aimed at addressing social, economic, political, or cultural problems such as income disparities, gender inequality, and discrimination (Gupta et al., 2008). Examples of prevention programs at this level include mass media campaigns, national and state policy, decriminalization of sex workers and homosexuality, and increasing access to HIV testing and screening.

Government-directed HIV initiatives are promising since they are able to reach a wide number of people. One such program has been the government-funded needle exchange programs (NEPs) aimed at curbing the HIV epidemic. NEPs were rolled out in several countries, including Australia, Netherlands, and the United Kingdom (Stimson, 1989). MacDonald et al. (2003) studied the effectiveness of NEPs in preventing HIV transmission among injecting drug users. Through an ecological study design evaluating 99 cities globally, the researchers found that HIV prevalence decreased 18.6% by the year in cities that had NEPs.

National HIV-control programs backed by the government have also been promising. Thailand provides an example of a successful HIV-control program that was implemented almost three decades ago in 1989. In this program, the Thai government distributed condoms to protect against commercial sex, enabled sanctions in sex establishments where condoms were not regularly used, and created a mass media campaign encouraging condom use among men who have intercourse with prostitutes (Hanenberg et al., 1994). From 1989 to 1993, the use of condoms in commercial sex increased from 14% to 94%, and the number of cases of the five major sexually transmitted diseases decreased by 79% in men. Hanenberg et al. (1994) also estimated a decrease in the risk of HIV transmission for sex acts with prostitutes.

Mass media campaigns are also effective at reaching a wide array of individuals. A systematic review conducted by Bertrand and Anhang (2006) evaluated mass media campaigns that provided information about sexual health or HIV/AIDS between 1990 and 2004 across the globe. Study results showed that mass media intervention increased knowledge of HIV transmission, improved the amount of interpersonal communication, and increased condom use. Specifically, in China, mass media coverage of HIV had increased substantially between 1995 and 2001 as an effort to curb HIV risk behaviors (Bu & Liu, 2004). In their study, Li et al. (2009) found that mass media sources in China had become a major source of information about HIV to the public in comparison to interpersonal sources, such as friends.

Since HIV is transmitted from an infected person passing the virus to an uninfected person, it is particularly important to target societal-level factors for people living with HIV (PLHIV). Shriver et al. (2000) analyzed societal-level barriers to HIV prevention among PLHIV, including laws against nondisclosures, travel bans into the United States by infected individuals, name-based HIV surveillance, and stigma. The researchers suggested that previous successful societal-level interventions facilitated HIV prevention by expanding HIV primary care, reducing discrimination, and ensuring confidentiality for HIV-infected individuals. Societal-level interventions can also target housing status as a means of reducing HIV risk behaviors. Analysis conducted Aidala et al. (2005) showed that improving housing status among HIV-positive people who are homeless or have unstable housing significantly reduced their risk of needle and drug use, needle sharing, and unprotected sex by half in comparison to those whose housing status remained the same. Since inequalities within the legal, social and economic structures of society can fuel HIV-related vulnerabilities (UNAIDS, 2016), a societal approach provides an effective tool for HIV prevention.

The Need for an Integrated HIV-Prevention Approach

HIV prevention interventions at each of these levels have proven to be effective. While individual-level interventions are easier to roll out in comparison to interventions at the other levels, a challenge here is the minimal level of impact. Contrastingly, societal-level interventions, which are able to reach a wider audience, often involve a lot of money and resources that might not be readily available.

To maximize prevention efforts, the field of HIV prevention can benefit from using an integrated approach that uses a broad array of HIV interventions at multiple and complementary levels (DiClemente & Wingood, 2000). Preferably, a multipronged approach would consist of interventions at different levels that work in conjunction with each other to reinforce HIV-preventative behaviors while enabling an environment that supports behavior change.

One of the most promising examples of a successful multipronged approach for HIV prevention occurred in Brazil. The Brazilian response to the AIDS pandemic has been described as all-inclusive and progressive (Berkman et al., 2005). To tackle HIV, community grassroots movements were designed to destigmatize AIDS and demand change and support from lawmakers. Through advocacy and organization of political parties, NGOs, and trade unions collaborating with the government, significant social changes were made. As a result, historically rooted cultural values related to sexual behaviors (e.g., demoralizing premarital sex) faded away, making way for open and honest discussions around HIV and AIDS. During this time, condom sales and distribution of condoms rose significantly in the general population, especially in young adults. Furthermore, sexual risk-reduction education programs became more accepted and were implemented within various populations such as sex workers and adolescents. Simultaneously, HIV testing also became more socially acceptable. Brazil was able to decrease the incidence and mortality rates of HIV by 50% because of this multidimensional approach.

Another promising example of a country who has used a multidimensional approach to tackle the HIV epidemic is Uganda (Slutkin et al., 2006). Uganda implemented numerous HIV prevention programs and activities during its critical HIV epidemic between 1987 and 1994. These interventions were multifaceted, encompassing multiple levels to strategically curb the epidemic. At the societal level, extensive financial support was provided by the government to develop an AIDS control program in the country. Concurrently, a mass health education campaign, consisting of trainers and extensive public education informational materials, was launched. At the community level, HIV sentinel surveillance was tested in a clinic and other settings and eventually expanded to six sites and then to the whole country (Slutkin et al., 2006; Slutkin, Chin, Tarantola, & Mann, 1990). By changing the social and physical environment, these multipronged interventions ultimately trickled down to the individual level. Changes were reported in a whole range of sexual behavior, including decreased age of first intercourse, decreased frequency of multiple partners, fewer irregular partners, increased condom use, and a decreased gap between girls and their male partner behaviors (Asiimwe-Okiror et al., 1997; Atkinson, 1989; Singh, Darroch, & Bankole, 2003; Stoneburner & Carballo, 1997; UNAIDS, 1998; USAID, 2003). By utilizing a multilevel approach, Uganda was able to successfully reverse the direction of its HIV epidemic.

As seen in the example of Brazil and Uganda, multidimensional intervention approaches represent a promising way to tackle the HIV epidemic, since it encourages program developers to consider all levels of influences on an individual’s behavior. By doing this, public health professionals are able to design a more comprehensive risk-reduction program.


In summary, this chapter focused on the global HIV epidemic. The socio-ecological model was used as a guiding framework to organize interventions in the individual, relational, community, and societal domains. While public health as a field has made successful strides in developing and implementing interventions at each of these levels, much work remains to be done in using a multipronged approach. Many HIV-prevention programs developed in specific levels have failed to integrate other levels. This presents a problem, since there is a complex interaction between each of the levels. Therefore, designing intervention strategies that incorporate multiple levels and complement each other is the key to addressing the HIV epidemic.

Biomedical approaches have been an emerging advancement in the field of HIV prevention that could complement a multipronged approach. These approaches directly target biological systems by using medical and public health approaches to block infection, decrease susceptibility, and decrease the amount of infectiousness. Two examples of biomedical intervention include Treatment-as-Prevention (TasP) for HIV-positive individuals and chemoprophylaxis (preexposure prophylaxis, or PrEP). PrEP consists of people who are not HIV-positive but are taking medication daily to reduce their risk of contracting HIV. Studies have found that PrEP significantly reduces the risk of HIV acquisition in heterosexual men, women, MSM, and injection drug users (Choopanya et al., 2013; Grant et al., 2010; Paltiel et al., 2009; Thigpen et al., 2012). A study found that when discordant couples took a pill containing tenofovir plus emtricitabine consistently, they were 75% less likely to acquire HIV in comparison to the control group that was given a placebo (Baeten et al., 2012). Furthermore, their risk of infection was reduced up to 90%. Treatment as prevention (TasP) is another promising avenue in HIV prevention, which includes a focus on adhering to treatment, scaling up HIV treatment and screening, and strengthening retention in care. Specifically, treatment adherence is particularly important, as findings have shown combined antiretroviral (ARV) therapy decreases morbidity and mortality rates for HIV-infected individuals (Ray et al., 2010). Strategic Timing of AntiRetroviral Treatment (START), a randomized controlled trial done in multiple countries, found that HIV-infected individuals significantly lowered their risk of developing AIDS or other illness if they began ARV treatment when their CD4+ T-cell count was higher (Babiker et al., 2013). Given the advances in biomedical interventions, the field of HIV prevention can benefit from employing these strategies synergistically with the multiple levels of the socio-ecological framework.

Multipronged intervention strategies provide an efficacious route to tackling the HIV epidemic. It is also important that these prevention programs are adequately developed, conducted, investigated, and reported. While change may not be rapid, comprehensive and sustained efforts will be crucial in effectively reinforcing HIV-prevention messages and skills, while concurrently creating an environment supportive of behavior change. The field of HIV prevention presents an exciting opportunity as researchers and program developers navigate ways to move beyond singular-level interventions and embrace a more comprehensive approach to tackling the HIV epidemic globally.

Suggested Reading

Auerbach, J. D., Parkhurst, J. O., & Caceres, C. F. (2011). Addressing social drivers of HIV/AIDS for the long-term response: Conceptual and methodological considerations. Global Public Health, 6(Suppl 3), S293–S309.Find this resource:

Baral, S., Logie, C. H., Grosso, A., Wirtz, A. L., & Beyrer, C. (2013). Modified social ecological model: A tool to guide the assessment of the risks and risk contexts of HIV epidemics. BMC Public Health, 13(1), 482.Find this resource:

Chang, L. W., Serwadda, D., Quinn, T. C., Wawer, M. J., Gray, R. H., & Reynolds, S. J. (2013). Combination implementation for HIV prevention: moving from clinical trial evidence to population-level effects. The Lancet Infectious Diseases, 13(1), 65–76.Find this resource:

Dehne, K. L., Dallabetta, G., Wilson, D., Garnett, G. P., Laga, M., Benomar, E., . . . Bermejo, A. (2016). HIV Prevention 2020: A framework for delivery and a call for action. The Lancet HIV, 3(7), e323–e332.Find this resource:

DiClemente, R. J., & Crosby, R. A. (2009). Preventing HIV among adolescents in sub-Saharan Africa. Journal of Adolescent Health, 44(2), 101–102.Find this resource:

Jones, A., Cremin, I., Abdullah, F., Idoko, J., Cherutich, P., Kilonzo, N., . . . Schwartlander, B. (2014). Transformation of HIV from pandemic to low-endemic levels: A public health approach to combination prevention. The Lancet, 384(9939), 272–279.Find this resource:

Peterson, J. L., & DiClemente, R. J. (Eds.). (2000). Handbook of HIV prevention. London, UK: Taylor & Francis.Find this resource:

Pope, C., White, R. T., & Malow, R. (2014). HIV/AIDS: Global frontiers in prevention/intervention. Abingdon, UK: Routledge.Find this resource:

Sallis, J. F., Owen, N., & Fisher, E. (2015). Ecological models of health behavior. In K. Glanz, B. K. Rimer, & K. Viswanath (Eds.), Health behavior: Theory, research, and practice (5th ed., pp. 43–64). San Francisco, CA: Jossey-Bass.Find this resource:

Zimmerman, R. S., DiClemente, R. J., Andrus, J. K., & Hosein, E. N. (Eds.). (2016). Introduction to global health promotion. Chichester, UK: John Wiley.Find this resource:


Abu-Raddad, L., Akala, F. A., Semini, I., Riedner, G., Wilson, D., & Ousama, T. (2010). Characterizing the HIV/AIDS epidemic in the Middle East and North Africa: Time for strategic action. Washington, DC: World Bank.Find this resource:

Agate, L. L., Cato-Watson, D., Mullins, J. M., Scott, G. S., Rolle, V., Markland, D., . . . Roach, D. L. (2005). Churches United to Stop HIV (CUSH): A faith-based HIV prevention initiative. Journal of the National Medical Association, 97(7 Suppl), 60S–63S.Find this resource:

Aidala, A., Cross, J. E., Stall, R., Harre, D., & Sumartojo, E. (2005). Housing status and HIV risk behaviors: Implications for prevention and policy. AIDS and Behavior, 9, 251–265.Find this resource:

Asiimwe-Okiror, G., Opio, A. A., Musinguzi, J., Madraa, E., Tembo, G., & Carael, M. (1997). Change in sexual behavior and decline in HIV infection among young pregnant women in urban Uganda. AIDS, 11, 1757–1763.Find this resource:

Atkinson, B. (1989). Uganda: Contraceptive supply status review. FPLM Project, August 25–September 18, 1989.Find this resource:

Babiker, A. G., Emery, S., Fätkenheuer, G., Gordin, F. M., Grund, B., Lundgren, J. D., . . . Vjechaj, M. J. (2013). Considerations in the rationale, design and methods of the Strategic Timing of AntiRetroviral Treatment (START) study. Clinical Trials, 10(1 Suppl), S5–S36.Find this resource:

Baeten, J. M., Donnell, D., Ndase, P., Mugo, N. R., Campbell, J. D., Wangisi, J., . . . Partners PrEP Study Team. (2012). Antiretroviral prophylaxis for HIV prevention in heterosexual men and women. New England Journal of Medicine, 367(5), 399–410.Find this resource:

Berkman, A., Garcia, J., Muñoz-Laboy, M., Paiva, V., & Parker, R. (2005). A critical analysis of the Brazilian response to HIV/AIDS: lessons learned for controlling and mitigating the epidemic in developing countries. American Journal of Public Health, 95(7), 1162–1172.Find this resource:

Bertrand, J. T., & Anhang, R. (2006). The effectiveness of mass media in changing HIV/AIDS-related behaviour among young people in developing countries. Technical Report Series-World Health Organization, 938, 205.Find this resource:

Bickmore, T., & Giorgino, T. (2006). Health dialog systems for patients and consumers. Journal of Biomedical Informatics, 39(5), 556–571.Find this resource:

Brahmam, G. N. V., Kodavallaa, V., Rajkumar, H., Rachakulla, H. K., Kallam, S., Myakala, S. P., . . . & IBBA Study Team. (2008). Sexual practices, HIV and sexually transmitted infections among self-identified men who have sex with men in four high HIV prevalence states of India. AIDS, 22, S45–S57.Find this resource:

Bronfenbrenner, U. (1979). The ecology of human development: Experiments by design and nature. Cambridge, MA: Harvard University Press.Find this resource:

Bu, W., & Liu, X. (2004). Zhongguo dazhong meijie zhong de aizibing baodao yanjiu.Find this resource:

Burton, J., Darbes, L. A., & Operario, D. (2010). Couples-focused behavioral interventions for prevention of HIV: Systematic review of the state of evidence. AIDS and Behavior, 14(1), 1–10.Find this resource:

Cassel, M. M., Jackson, C., & Cheuvront, B. (1998). Health communication on the Internet: An effective channel for health behavior change? Journal of Health Communication, 3(1), 71–79.Find this resource:

CDC. (2017). HIV in the United States: At a glance.

Choopanya, K., Martin, M., Suntharasamai, P., Sangkum, U., Mock, P. A., Leethochawalit, M., . . . Bangkok Tenofovir Study Group. (2013). Antiretroviral prophylaxis for HIV infection in injecting drug users in Bangkok, Thailand (the Bangkok Tenofovir Study): A randomised, double-blind, placebo-controlled phase 3 trial. Lancet, 381, 2083–2090.Find this resource:

Coates, T. J., Richter, L., & Caceres, C. (2008). Behavioural strategies to reduce HIV transmission: How to make them work better. Lancet, 372(9639), 669–684.Find this resource:

Coyne-Beasley, T., & Schoenbach, V. J. (2000). The African-American church: A potential forum for adolescent comprehensive sexuality education. Journal of Adolescent Health, 26(4), 289–294.Find this resource:

DeHovitz, J., Uuskula, A., & El-Bassel, N. (2014). The HIV epidemic in Eastern Europe and central Asia. Current HIV/AIDS Reports, 11(2), 168–176.Find this resource:

DiClemente, R. J., Crosby, R., & Kegler, M. (2002). Emerging theories in health promotion research and practice: Strategies for enhancing public health. San Francisco, CA: Jossey Bass.Find this resource:

DiClemente, R. J., Salazar, L. F., Crosby, R. A., & Rosenthal, S. L. (2005). Prevention and control of sexually transmitted infections among adolescents: The importance of a socio-ecological perspective. Public Health, 119(9), 825–836.Find this resource:

DiClemente, R. J., & Wingood, G. M. (2000). Expanding the scope of HIV prevention for adolescents: Beyond individual-level interventions. Journal of Adolescent Health, 26(6), 377–378.Find this resource:

Earl, A., & Albarracín, D. (2007). Nature, decay, and spiraling of the effects of fear-inducing arguments and HIV counseling and testing: A meta-analysis of the short-and long-term outcomes of HIV-prevention interventions. Health Psychology, 26(4), 496.Find this resource:

Fishbein, M., Higgins, D. L., Rietmeijer, C., & Wolitski, R. J. (1999). Community-level HIV intervention in 5 cities: Final outcome data from the CDC AIDS Community Demonstration Projects. American Journal of Public Health, 89(3), 336–345.Find this resource:

Fisher, J. D., Cornman, D. H., Shuper, P. A., Christie, S., Pillay, S., Macdonald, S., . . . Fisher, W. A. (2014). HIV prevention counseling intervention delivered during routine clinical care reduces HIV risk behavior in HIV-infected South Africans receiving antiretroviral therapy: The Izindlela Zokuphila/Options for Health randomized trial. Journal of Acquired Immune Deficiency Syndromes, 67(5), 499.Find this resource:

Fisher, J. D., Cornman, D. H., Shuper, P. A., Christie, S., Pillay, S., Macdonald, S., . . . SA Options Team. (2014). HIV prevention counseling intervention delivered during routine clinical care reduces HIV risk behavior in HIV-infected South Africans receiving antiretroviral therapy: The Izindlela Zokuphila/options for health randomized trial. Journal of Acquired Immune Deficiency Syndromes, 67(5), 499–507.Find this resource:

Fisher, J. D., Fisher, W. A., Bryan, A. D., & Misovich, S. J. (2002). Information-motivation-behavioral skills model-based HIV risk behavior change intervention for inner-city high school youth. Health Psychology, 21(2), 177.Find this resource:

Frieden, T. R. (2010). A framework for public health action: The health impact pyramid. American Journal of Public Health, 100(4), 590–595.Find this resource:

Grant, R. M., Lama, J. R., Anderson, P. L., McMahan, V., Liu, A. Y., Vargas, L., . . . iPrEx Study Team. (2010). Preexposure chemoprophylaxis for HIV prevention in men who have sex with men. New England Journal of Medicine, 363, 2587–2599.Find this resource:

Gupta, G. R., Parkhurst, J. O., Ogden, J. A., Aggleton, P., & Mahal, A. (2008). Structural approaches to HIV prevention. The Lancet, 372(9640), 764–775.Find this resource:

Hanenberg, R. S., Sokal, D. C., Rojanapithayakorn, W., & Kunasol, P. (1994). Impact of Thailand’s HIV-control programme as indicated by the decline of sexually transmitted diseases. The Lancet, 344(8917), 243–245.Find this resource:

Herbst, J. H., Beeker, C., Mathew, A., McNally, T., Passin, W. F., Kay, L. S., . . . Johnson, R. L. (2007). The effectiveness of individual-, group-, and community-level HIV behavioral risk-reduction interventions for adult men who have sex with men: A systematic review. American Journal of Preventive Medicine, 32(4), 38–67.Find this resource:

Jiwatram-Negrón, T., & El-Bassel, N. (2014). Systematic review of couple-based HIV intervention and prevention studies: advantages, gaps, and future directions. AIDS and Behavior, 18(10), 1864–1887.Find this resource:

Khumalo-Sakutukwa, G., Morin, S. F., Fritz, K., Charlebois, E. D., van Rooyen, H., Chingono, A., . . . Sweat, M. (2008). Project Accept (HPTN 043): a community-based intervention to reduce HIV incidence in populations at risk for HIV in sub-Saharan Africa and Thailand. Journal of acquired immune deficiency syndromes, 49(4), 422.Find this resource:

Kim, J. C., Watts, C. H., Hargreaves, J. R., Ndhlovu, L. X., Phetla, G., Morison, L. A., . . . Pronyk, P. (2007). Understanding the impact of a microfinance-based intervention on women’s empowerment and the reduction of intimate partner violence in South Africa. American Journal of Public Health, 97, 1794–1802.Find this resource:

Kinsler, J., Sneed, C. D., Morisky, D. E., & Ang, A. (2004). Evaluation of a school-based intervention for HIV/AIDS prevention among Belizean adolescents. Health Education Research, 19(6), 730–738.Find this resource:

Li, L., Rotheram-Borus, M. J., Lu, Y., Wu, Z., Lin, C., & Guan, J. (2009). Mass media and HIV/AIDS in China. Journal of Health Communication, 14(5), 424–438.Find this resource:

MacDonald, M., Law, M., Kaldor, J., Hales, J., & Dore, G. J. (2003). Effectiveness of needle and syringe programmes for preventing HIV transmission. International Journal of Drug Policy, 14(5), 353–357.Find this resource:

Mahajan, A. P., Sayles, J. N., Patel, V. A., Remien, R. H., Ortiz, D., Szekeres, G., & Coates, T. J. (2008). Stigma in the HIV/AIDS epidemic: A review of the literature and recommendations for the way forward. AIDS, 22, S67–S79.Find this resource:

Morineau, G., Nugrahini, N., Riono, P., Nurhayati, Girault, P., Mustikawati, D. E., . . . Magnani, R. (2011). Sexual risk taking, STI and HIV prevalence among men who have sex with men in six Indonesian cities. AIDS and Behavior, 15, 1033–1044.Find this resource:

Noar, S. M., Black, H. G., & Pierce, L. B. (2009). Efficacy of computer technology-based HIV prevention interventions: A meta-analysis. AIDS, 23(1), 107–115.Find this resource:

Paltiel, A. D., Freedberg, K. A., Scott, C. A., Schackman, B. R., Losina, E., Wang, B. X., . . . Walensky, R. P. (2009). HIV preexposure prophylaxis in the United States: Impact on lifetime infection risk, clinical outcomes, and cost-effectiveness. Clinical Infectious Diseases, 48, 806–815.Find this resource:

Ray, M., Logan, R., Sterne, J. A. C., Hernandez-Diaz, S., Robins, J. M., Sabin, C., . . .Collaboration, H.-C. (2010). The effect of combined antiretroviral therapy on the overall mortality of HIV-infected individuals. AIDS, 24, 123–137.Find this resource:

Rou, K., Wu, Z., Sullivan, S. G., Li, F., Guan, J., Xu, C., . . . Yin, Y. (2007). A five-city trial of a behavioural intervention to reduce sexually transmitted disease/HIV risk among sex workers in China. AIDS, 21, S95–S101.Find this resource:

Rotheram-Borus, M. J., Flannery, D., Lester, P., & Rice, E. (2004). Prevention for HIV-positive families. JAIDS Journal of Acquired Immune Deficiency Syndromes, 37, S133–S134.Find this resource:

Rotheram-Borus, M. J., Swendeman, D., & Chovnick, G. (2009). The past, present and future of HIV prevention: Integrating behavioral, biomedical, structural intervention strategies for the next generation of HIV prevention. Annual Review of Clinical Psychology, 5, 143–167.Find this resource:

Rotheram-Borus, M. J., Swendeman, D., & Flannery, D. (2009). Family wellness, not HIV prevention. AIDS and Behavior, 13(3), 409–413.Find this resource:

Rotheram-Borus, M., Ingram, B., Swendeman, D., & Flannery, D. (2009). Common principles embedded in effective adolescent HIV prevention programs. AIDS and Behavior, 13(3), 387–398.Find this resource:

Rotheram-Borus, M. J., Swendeman, D., Flannery, D., Rice, E., Adamson, D. M., & Ingram, B. (2009). Common factors in effective HIV prevention programs. AIDS and Behavior, 13(3), 399–408.Find this resource:

Rotheram-Borus, M. J., Swendeman, D., Lee, S.-J., Li, L., Amani, B., & Nartey, M. (2011). Interventions for families affected by HIV. Translational Behavioral Medicine, 1(2), 313–326.Find this resource:

Shriver, M. D., Everett, C., & Morin, S. F. (2000). Structural interventions to encourage primary HIV prevention among people living with HIV. AIDS, 14, S57–S62.Find this resource:

Singh, S., Darroch, J. E., & Bankole, A. (2003). ABC in Uganda: The role of abstinence, monogamy and condom use in HIV decline. Occasional Report No. 9. Washington, DC: The Allan Guttmacher Institute.Find this resource:

Slutkin, G., Chin, J., Tarantola, D., & Mann, J. (1988). Sentinel surveillance for HIV: A method to monitor HIV infection trends in population groups. WHO/GPA/DIR/88.8. Geneva, Switzerland: World Health Organization.Find this resource:

Slutkin, G., Chin, J., Tarantola, D., & Mann, J. (1990). Use of HIV surveillance data in national AIDS programmes. WHO/GPA/SFI/90.1. Geneva, Switzerland: World Health Organization.Find this resource:

Slutkin, G., Okware, S., Naamara, W., Sutherland, D., Flanagan, D., Carael, M., . . . Tarantola, D. (2006). How Uganda reversed its HIV epidemic. AIDS and Behavior, 10(4), 351–360.Find this resource:

Stimson, G. V. (1989). Syringe-exchange programmes for injecting drug users. AIDS, 3(5), 253–260.Find this resource:

Stoneburner, R., Low-beer, D., Barnett, T., & Whiteside, A. (2002). Enhancing HIV prevention in Africa: Investigating the role of social cohesion on knowledge diffusion and behavior change in Uganda. Presentation to USAID. Washington DC.Find this resource:

Stoneburner, R. L., & Carballo, A. (1997). An assessment of emerging patterns of HIV incidence in Uganda and other east African countries. Final Report of Consultation. Family Health International AIDS Control and Prevention Programme. International Centre for Migration and Health.Find this resource:

Tesoriero, J. M., Parisi, D. M., Sampson, S., Foster, J., Klein, S., & Ellemberg, C. (2000). Faith communities and HIV/AIDS prevention in New York State: Results of a statewide survey. Public Health Reports, 115(6), 544.Find this resource:

Thigpen, M. C., Kebaabetswe, P. M., Paxton, L. A., Smith, D. K., Rose, C. E., Segolodi, T. M., . . . Grp, T. S. (2012). Antiretroviral preexposure prophylaxis for heterosexual HIV transmission in Botswana. New England Journal of Medicine, 367, 423–434.Find this resource:

Tomlinson, R. (2010). Resolving to save lives: HIV/AIDS prevalence among MSM in the anglophone Caribbean and OAS Resolutions 2435 and 2504. Paper presented at the AIDS 2010XVIII International AIDS Conference, Vienna, Austria.Find this resource:

UNAIDS. (1998). A measure of success in Uganda: The value of monitoring both HIV prevalence and sexual behavior.

UNAIDS. (2011). Global HIV/AIDS response: Epidemic update and health sector progress towards universal access.

UNAIDS. (2013). Fact sheet.

UNAIDS. (2016). Prevention gap report.

UNAIDS. (2017). Fact sheet.

USAID. (2003). Sexual behavior, HIV and fertility trends: A comparative analysis of six countries; Phase I of the ABC Study.

Ybarra, M. L., & Bull, S. S. (2007). Current trends in Internet-and cell phone-based HIV prevention and intervention programs. Current HIV/AIDS Reports, 4(4), 201–207.Find this resource: