Just days before researchers and activists around the world marked the 25th year of battling the HIV epidemic, the United Nations General Assembly Special Session (UNGASS) on HIV/AIDS convened in New York City to revise the "declaration of commitment" on AIDS, which was created at the first meeting of this kind held five years ago. This high-level event, which took place from May 31 to June 2, was attended by more than 10 heads of state and leaders from more than 140 UN member states, as well as over 1000 representatives from activist groups and other civil society organizations.

Although few of the goals laid out in the 2001 declaration adopted by the General Assembly were achieved, the total expenditure on AIDS in developing countries, which reached $8.3 billion last year, did fall within the target range set in the initial document. This money has in part provided treatment for the 1.3 million people now receiving antiretrovirals (ARVs), up from just 240,000 in 2001, and helped to quadruple the number of people accessing voluntary HIV counseling and testing services.

But now the Joint United Nations Programme on HIV/AIDS (UNAIDS) estimates that $20-23 billion will be needed each year until 2010 to control the spread of AIDS and provide ARV treatment, care, and prevention services. The record number of civil society groups involved in the meeting pushed for the assembly to endorse a new target of providing ARVs to 80% of HIV-infected individuals in need and to an equal number of HIV-infected pregnant women to prevent them from transmitting the virus to their infants. However, after extensive negotiations many of the organizations involved, including the International AIDS Society and the International Council of AIDS Service Organizations, were disappointed with the final declaration.

Many said that it failed to set concrete goals for the future by which progress could be measured. Prior to the meeting IAVI and its partners worked to ensure that the UN leaders recognized how research into new prevention technologies, like vaccines and microbicides, could play an important role in combating the epidemic in the future. In the final declaration AIDS vaccines were acknowledged as crucial to global public health.

Just before UNGASS took place, UNAIDS also released the 2006 Report on the global AIDS epidemic. This report cited a slowdown in the global epidemic for the first time, highlighted by a decline in HIV prevalence in Kenya, Zimbabwe, Burkina Faso, Haiti, and other countries in the Caribbean. But even as infection rates are dropping in some areas, the overall number of people dying from AIDS or AIDS-related illnesses continues to rise. Increasing HIV prevalence was reported in several countries, including China, Indonesia, Papua New Guinea, and Vietnam, and there is evidence of possible "HIV outbreaks" in Bangladesh and Pakistan, according to UNAIDS.

This report also declared India as the nation with the highest number of HIV-infected individuals at 5.7 million, surpassing South Africa, which still has the greatest prevalence owing to its much smaller population. While HIV prevalence is declining in four Indian states the epidemic in South Africa shows no evidence of decline.

The first vaccine capable of preventing cervical cancer recently received approval and licensure by the US Food and Drug Administration (FDA) for use in females ages 9-26. Gardasil, the quadrivalent vaccine manufactured by Merck, also prevents the development of precancerous genital lesions and genital warts caused by four types of the human papillomavirus (HPV), which is one of the most common sexually-transmitted infections in the world (see February 2006 Spotlight article, Cervical cancer vaccines).

The efficacy of the vaccine, administered through 3 immunizations over a period of 6 months, was illustrated in 4 Phase III trials conducted in 21,000 women in several countries. The greatest need for the vaccines lies in developing countries, where the majority of the 250,000 deaths from cervical cancer occur each year. On June 5, the Bill " Melinda Gates Foundation awarded the Seattle-based not-for-profit organization Program for Appropriate Technology in Health (PATH) a US$27.8 million grant to conduct a five-year effort to ensure that this vaccine is made available to women and girls in developing countries. PATH is collaborating with Merck and GlaxoSmithKline, which also manufactures a cervical cancer vaccine that is expected to receive a license for use in the European Union, as well as officials in Peru, India, Uganda, and Vietnam to establish mechanisms for financing purchase of these vaccines and to ease introduction efforts.

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All articles written by Kristen Jill Kresge

How can home-based or mobile services for HIV counseling and testing improve community responses?

Voluntary counseling and testing (VCT) services are a key component of HIV prevention, treatment, and care programs. Individuals learn about behaviors that put them at risk of HIV infection and how they can reduce this risk through the counseling process, and this information can be a catalyst for people to alter their behaviors.

Individuals who undergo VCT also find out whether or not they are HIV infected (see November 2005 Primer onUnderstanding HIV Testing). VCT services, therefore, are often the primary entry point for infected individuals into treatment and care programs. These important outcomes make VCT programs a critical part of the community's response to HIV/AIDS.

There are various types of VCT services, including those given before enrollment in a vaccine trial or research study or sessions specifically tailored for couples (see April 2005 Primer on Understanding Research Voluntary Counseling and Testing and October 2005 Primer on Understanding Couples Voluntary Counseling and Testing). These almost always occur at community health clinics or clinical trial sites, but the stigma associated with HIV in many communities, as well as the distance people are required to travel to clinics in rural areas, can prevent people from seeking these services on their own. Since VCT is such a powerful tool in getting people information on HIV and access to treatment if needed, researchers have looked for ways to maximize the number of people utilizing these services. One of these approaches is taking VCT services directly to people in their homes or neighborhoods. Such home-based or mobile VCT services, while limited, have been successful in getting more people to be tested for HIV infection.

The process

The VCT services administered in people's homes are conducted similarly to those in clinics. Community healthcare workers are trained to provide HIV counseling and testing and must obtain consent from all individuals before administering VCT. The only difference is that these healthcare workers go door-to-door offering these services.

Some organizations, such as The AIDS Support Organization (TASO) in Mbale, Uganda, couple their home-based VCT services with at-home care programs. So when field officers deliver antiretrovirals (ARVs) directly to the homes of infected individuals they also offer VCT services to other family members in the household.

Others, like the AIDS Information Centre (AIC) in Uganda, have implemented a stand alone home-based VCT program in an effort to increase the number of people being tested for HIV. National surveys in the country reported that although 70% of people want to be tested for HIV infection, only about 10% have actually participated in VCT.

A pilot project, funded by the US Centers for Disease Control and Prevention (CDC) was started by AIC in 2004 in the districts of Tororo and Busia in Uganda in an attempt to reach as many people as possible in these districts and offer them home-based VCT services. Trained outreach teams visited each home and offered all family members information so they could decide if they wished to participate. Adults in the household were given the choice to receive these services individually, or as couples. Anyone who was found to be HIV infected during this process received referrals to treatment and care programs in their community.

Judging success

Many organizations have found that offering home-based VCT programs is an effective way to increase access to treatment and prevention services. The AIC program lasted for one year and during this time over 5000 individuals received VCT services in their homes, which was more than double the study's target. The outreach teams visited more than 2000 homes in these two districts of Uganda and in 65% of them at least one household member agreed to participate in VCT.

The results of this program were presented at the International AIDS Society meeting on HIV Pathogenesis and Treatment, which took place last year in Rio de Janeiro, Brazil, and the CDC plans to use this program to create guidelines that will allow additional home-based VCT programs to be started in Uganda.

The AIC concluded that stigma seemed to be much less of an influence on a person's decision to undergo HIV testing when VCT services are administered in the home, instead of in clinics. Home-based VCT services could also be a promising strategy for reaching disempowered individuals, especially women.

Another option is providing just the test results and post-test counseling at home. In settings where rapid tests are unavailable, people sometimes do not return to the clinic to find out the results of their HIV test. In a study conducted by the Medical Research Council in Entebbe, Uganda, researchers found that offering test results in a person's home was an effective way to ensure that people received them.

Mobile units

Another method for bringing VCT services directly to communities is to utilize mobile VCT units. The Foundation Agency for Rural Development, a non-governmental organization in Nairobi, Kenya, uses bicycles to bring VCT to local communities. Four mobile sites are set up in different areas throughout the city and each week several individuals undergo VCT. Like home-based services, these mobile units can reach people who may be unable to travel to a clinic to receive VCT.

From community to country

The most ambitious home-based VCT program is currently taking place in Lesotho, where on World AIDS Day last year the president announced plans to take VCT services door-to-door in an effort to reach every household in the country by 2007. To meet this challenge the government trained 6500 healthcare workers to provide VCT services. Prior to this universal HIV testing initiative, it was estimated that only 1% of the population had accessed VCT.