Prevention from the hearth

And, unfortunately,
The pain grows in the world at each instant,
It grows at thirty minutes a second, step by step,
,…………..
How can I not tell you, human brothers,
That I cannot take any more
I just cannot take any more
Of so many drawers,
So many minutes,
So much a lizard,
And so much investment
So far and so much ambition!
Mr Health Minister; What to do?
Ah! Unfortunately, human men,
There is, brothers, a lot to be done.
Cesar Vallejo (The Nine Monsters)

The Casares ideological dictionary links the word “prevent” to “having a feeling, feeling the onset of something, suspecting, seeing, listening to one’s heart”… The word “prevention” is associated with the term “preparation which is also attempt, provision, making ready, priming, taking measures, field reconnaissance”… My heart tells me that we haven’t prepared ourselves for this epidemic, that our provisions have been insufficient, and that adequate measures have neither been taken nor are being taken even after having made a reconnaissance of the field, seen the consequences of this epidemic and of having felt its effects.

After 20 years of the epidemic and numerous strategies directed towards prevention, the current number of new infections is 14,000 people per day (let’s take the example of, because sometimes we visualise better from a known reality, a country of some 40 million inhabitants, like our own; within nine months the whole population would be infected).
But let’s go back to the world reality of 14,000 cases of new infections on a daily basis: 2,000 are under 15 years of age and 12,000 are adults (ranging from 15 to 49 years of age), of which 50% are women and close to 50% are between 15 and 24 years of age. Of whom 95% would live in lower income bracket countries. If the figures continue at this rate it is calculated that by the year 2050 there will have been 500 million AIDS deaths. It would seem that we know very little as to how to go about things so as to prevent the epidemiological prognoses from turning into prophecies, when it only really depends on money and that is what is most lamentable.

The HIV/AIDS epidemic is a global crisis; it not only affects public health but also global development and even, currently much-mentioned, world safety. The epidemic leads to greater family and social impoverishment, a cut in nations’ life expectancy, tremendous and progressive economic costs in order to alleviate the effects of the infection, a heavy reduction in the working population and as such a hindrance to the economy and consequently political and social instability. The effects of the epidemic on the nations and the people seem clear. What are we doing to reduce them? Who complies with the UNGASS agreements? The commitments adopted by the United Nations to contribute a certain sum to the global fund have not been carried out in spite of the urgent necessity to promote the strategies directed towards preventing the spread of the HIV/AIDS epidemic and to palliate the effect of it on those populations with greater prevalence and incidence of the infection. For example, current annual expenditure on prevention is 3.8 thousand million dollars below what is necessary as predicted for 2005 (UNAIDS data). The prevention of HIV/AIDS depends on a real commitment and interest on the part of society as a whole: governments, private international bodies and civil society, so that the resolution of this crisis turns into a political priority and one of action.

The effects of the epidemic have been considered, prevention aims to anticipate what is believed to be possibly approaching and to take measures in order to prevent it happening or to reduce its impact. It is necessary to be prepared for the change, to change that which could determine the continuance or increment of the epidemic and its effects. The factors which are determining vulnerability in facing HIV, those which place people at risk of exposure in the face of HIV, have everything to do with inequality in all its spheres and contexts; inequality in the application of rights which impedes free decision making, social inequality which makes access to information difficult, economic inequality which impedes the use of resources… Prevention has everything to do with human rights; the real application of these rights would suppose one of the true preventive policies, which would reach all citizens equally and globally.

Nonetheless, preventive programmes, despite their proven effectiveness in the reduction of the prevalence rate of the infection, those which are emphasised with a special insistence, are those which are directed towards enabling people to choose safer life strategies. One of these strategies is that known as ABC (abstinence, be faithful and condom) which directs programmes towards a change in sexual behaviour, included in which are efforts to spread the incentive to people at risk so that they delay the initiation of sexual activity, reduce the number of sexual partners and use condoms in sexual intercourse. In short, this type of strategy centres responsibility on personal behaviour; it would seem as if having the information about and being capable of using the condom were the only things necessary to being able to respond in the face of risk situations. These are indispensable elements but they are by no way sufficient given that not only do they not take into consideration social phenomena that have a bearing on people not taking preventive measures, despite being aware of the information, or on empowering them, or which prevent them from accessing said information, or which make them not feel vulnerable in the face of the epidemic, i.e. that have a bearing on the perception of risk, but also that the underlying message to this strategy assimilates healthy lifestyles with behaviour which (in another era?) was considered to be morally acceptable. The establishment of these programmes without the community as a whole assuming its responsibility in the transformation and necessary social change in order to diminish vulnerability factors, will entail the continuance of the prevalence of the epidemic; greater stigma attached to infected people and to their blame; the exposure of women to the infection with their regular partners; the communication of the fact that for between 20% and 48% of all girls their first sexual relations were forced; rape and sexual violence will continue to constitute a weapon of war and women will continue to be subject to violence because of gender which increases their vulnerability to HIV amongst other diseases.

This calls for the revision of any social and economic policies that entail inequality, discrimination and social exclusion. The economic, cultural and social conditions in which people live shape their options and their behaviour, changing these conditions can enable people to build their lives around safer alternatives. This is the duty of the community: to put on the pressure so that human rights are applied equally in any context, in any country and in any situation…; to foster policies that promote access to strategies and tools that allow people to decide how they want to live and to be able to feel protected in all areas of their lives and not only as regards their sexual practices; to implicate all social agents with the aim to globally tackling this world crisis.

UNAIDS is well aware of this need and has drawn up a series of recommendations for the establishment of plans of action which mitigate the differences in access to prevention and curb the spread of the HIV epidemic. These recommendations are:
- Financing: World spending allocated to prevention should be multiplied by three by the year 2005. Donating governments would have to increase their endowment by 0.02% annual GDP.
- The amplification of programmes and the prioritisation of such.
- The integration of prevention and treatment programmes. Understanding that prevention programmes cannot be separated from those programmes directed towards HIV infected people is important.
- The development of the means of action: the long-term economic provision for the creation of the infrastructure and for human resources.
- Political and social reforms in order to deal with the conditions which increase vulnerability to HIV/AIDS and which facilitate its rapid spread, like sexual inequalities, stigma and poverty.
- To significantly speed up the process of research into the new strategies and technologies. Special mention should be given to the development of the new technologies of prevention in which are included pre and post exposure treatment, microbicides and vaccines.

As regards microbicides, to which I would like to devote a few lines, these have a special importance as an instrument of protection for women, in so far as the other methods of prevention depending on the collaboration of the male, microbicides place the power of prevention directly into the hands of the woman.
Microbicides are substances which, when applied directly to the vagina (it is also possible to the anus), reduce the transmission of HIV and other STI. Current research contemplates its presentation in gel or cream form with an applicator, but this does not rule out other forms of presentation in the future such as the slow-release vaginal rings and lubricating sponges etc. The research is a long and complex process given that apart from aspects relating to the safety of the substance it is also important to bear in mind factors relating to its social acceptability.

Up to the present day 11 of these products are in the safety trial stage and 4 in more advanced stages of research. The importance of these microbicides is the impact that they would suppose on the epidemic. It has been calculated that if a product with an efficiency of 60% were to be introduced into the 73 lower income bracket countries and were to be used by 20% of the women who are already in contact with the health services, in three years 2.5 million new infections of women, men and children could be avoided. Political will and sufficient investment could mean that within the term of five years the first generation of microbicides could be ready for their distribution.
The goal of the Global Campaign for Microbicides initiative is the mobilising of people from all over the world so that they work in their own communities with the aim to finding support from politicians, opinion leaders and the public in general so as to accelerate the development of microbicides, facilitate their accessibility and use and to protect the interests of the users.
This campaign is a model of activism to be borne in mind by the community. The work carried out for years has managed to make the research into microbicides enter into the political agenda of governments as much as of NGOs and of international agencies. And, stemming from this point, an attempt is being made to mobilise the necessary economic resources for its future development given that private investment does not, at least for the moment, seem to be very much interested in its financing. (For more information: www.ifh.org.uk or www.creacionpositiva.net)


Although these initiatives open the doors to hope… “There is, brothers, lots to be done”

Mª Luisa García Berrocal

Mª Luisa García Berrocal graduated in psychology from the UAM (Madrid University) in 1988.

As part of her career choice she is currently co-ordinating the care services for people affected by HIV/AIDS in the association Creación Positiva (Positive Creation). Likewise she has provided various workshops for seropositive gays organised by the association Gais positius (Positive Gays) of the Coordinadora gai-lesbiana (CGL - Gay-Lesbian Co-ordinating Committee). Since 2002 she has been collaborating in the Psychological Consultancy of the Coordinadora de Gai-Lesbiana (Barcelona) (Gay-Lesbian Co-ordinating Committee) which was set up in June 2001. Along similar lines, she has been providing voluntary work courses for the CGL since 2003. She has also carried out workshops for primary health care specialists.

She previously co-ordinated the individual and group care programme in ACTUA (1999 to 2001), co-ordinated the programme for the prevention of sexual abuse to minors for the Save the Children Fund (October 1996 to July 1999). She also co-ordinated the European project Gays Aids Prevention (GAP) (the creation and maintenance of a European network for the Prevention of HIV/AIDS in the sector of the population of men who have sexual relations with other men) co-financed by the European Union, from 1997 to December 2000, while at the same time co-ordinating the Health Commission (HIV/AIDS) of COGAM (Madrid Collective of Gays and Lesbians), from 1995 to 1999, in which prevention and sensitisation programmes surrounding HIV/AIDS were carried out and also safe sex workshops for women, men and the young. She also worked in the Real Fundación Victoria Eugenia (Victoria Eugenia Royal Foundation) devoted to the care of people affected by HIV/AIDS in the haemophiliac sector of the population, in which she carried out 22 workshops aimed at parents, the young, couples and adults affected by HIV/AIDS. She has been an official tutor within the Faculty of Psychology at the Universidad Autónoma de Madrid (UAM – Madrid University) in the academic year 1998-1999.

She has participated in the AMAS, a multidisciplinary approach to dealing with AIDS, project, co-ordinated by the E.U.E. Santa Madrona de la Fundación "la Caixa" (Santa Madrona University School of Nursing of “la Caixa” Foundation), 2001-2002, and in the research “The Analysis of Risky Sexual Conduct and the Prevalence of HIV Infection in Homo/Bi-sexual Men of the Community of Madrid”, directed by the National Centre of Epidemiology, financed by the Fondo de Investigación Sanitaria (Health Research Fund), dossier number 98/0309.


She has attended and participated in numerous courses, lectures and congresses related to HIV/AIDS and participates in various community networks in the field of HIV like, for example, Red2002 (Network2002).

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