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umerous world leaders recently gathered at the UN General Assembly High Level Meeting in New York City discussing several key issues on HIV/AIDS recently.

The meeting among heads of state and other leaders from the government, scientific community, private sector and civil society provided a valuable opportunity to reflect the future course of the global responses and strategies to combat the epidemic.

Prof. Françoise Barré-Sinoussi, a Nobel laureate and co-chairman of the UNAIDS High Level Commission on HIV Prevention, in her recent essay in The Jakarta Post maintained that the meeting took place at a critical time in which after three decades into the epidemic we have achieved several key things.

Barre-Sinoussi cited the recent report of the UN secretary-general indicated that by the end of 2010 there were more than 6 million people with access to the lifesaving antiretroviral treatments in developing countries compared to just 400,000 in 2003.

Over the last decade, the number of newly infected HIV cases decreased by nearly 20 percent. Additionally, in 2009 more than 50 percent of women living with HIV were able to assure their babies were with being infected by HIV.

It is also worthy to note that there have been significant achievements in the Asia-Pacific region. The estimated figure of new infections is 20 percent lower than in 2001 and in the past five years the number of people living with HIV appears to have remained stable.

However, Barre-Sinoussi reminded us that these gains are fragile. The fragile nature of these achievements can be seen through the fact that the HIV epidemic continues to outpace the response.

It was estimated that there are two new HIV infections for every individual initiating treatment.

Moreover, in Asia-Pacific, the most vulnerable groups to HIV infection such as sex workers, drug users, men who have sex with men and transgender people are not sufficiently reached for prevention and treatment.

The fact that 90 percent of the countries in the region have laws or practices that impede access to HIV prevention and treatment services for people living with HIV and/or people from key affected populations make the situation more fragile.

In addition, it should be noted that most current prevention programs are highly individualized or tend to overlook the crucial role of the social, cultural and economic context of the epidemic.

The limitations of the individualized programs have been shown by a synthesis of worldwide evidence that HIV prevention programs among drug injectors, which emphasize only individual behavioral changes are likely to result in only a minor reduction of susceptibility to HIV infection.

It is in this context that structural interventions to combat the HIV epidemic are highly needed.

Structural interventions focus on changing the context or environment within which individuals act for the purpose of persuading them to apply healthier and safer behaviors.

In other words, structural interventions attempt to create an enabling environment, an environment that enables or empowers people to make positive preferences by providing them a supportive context and sufficient opportunities to make healthier choices.

Structural interventions seek to affect risk environments by altering the context in which ill-health occurs.

It should also be noted that structural interventions are consistent with the principles of the “new public health” as presented in the Ottawa Charter for Health Promotion, that explicitly advocates the need to address social and environmental determinants of health and advocate the need to develop effective responses to public health issues both at the individual and community level.

In addition, numerous studies have revealed the relevance of and the need for structural interventions in the field of drug use and HIV prevention. Structural interventions on HIV prevention and drug use should focus on three areas of change i.e. first, by addressing social change.

This approach focuses on factors affecting multiple groups (e.g. a region or country as a whole), such as legal reform, socio-economic empowerment and stigma reduction for marginalised groups, and efforts to cultivate strong leadership on HIV and drug use prevention programs.

Second, by promoting changes within a specific group. This approach addresses social structures that create vulnerability among specific populations, such as problematic drug users, drug injectors, sex workers, men who have sex with men and low-income young people.

Examples include efforts to organize and empower problematic drug users, drug injectors, sex workers, including microfinance programs for poor people as well as interventions to change harmful local norms.

Third, harm reduction and health-seeking behavior changes. This approach focuses on ensuring harm reduction programs are available to those in need, and helps to change rules, services and attitudes that impede access to these programs. Examples include efforts to provide employment and safe housing for drug users and 100-percent condom use campaigns.

Numerous studies suggested that multiple and concerted programs addressing social conditions that generate HIV-related harms could more significantly lower susceptibility to HIV particularly among the most vulnerable groups such as sex workers, problematic and injecting drug users, prisoners, men who have sex with men and transgender people.

The current achievements in combating HIV epidemics will be strengthened if we take into consideration and combat the social, cultural and economic context that produces HIV-related risks.

The writer is a lecturer and researcher at the Faculty of Public Health at Hasanuddin University, Makassar.