Human immunodeficiency virus risk: is it possible to dissuade people from having unsafe sex?

Summary. The cumulative number of human immunodeficiency virus (HIV) infections worldwide has reached 60 million in little over 30 years. HIV continues to spread despite a detailed understanding of the manner in which it spreads and measures which can prevent spread. Some governments have been highly successful in containing the spread of HIV through blood products and from mother to child and among injecting drug users. Lack of political will, lack of resources or challenges to widely accepted scientific evidence have held back similar interventions in other countries. It has proved much more difficult to reduce the sexual transmission of HIV in both high and low income countries. A wide range of strategies has been identified but it remains unclear which strategies deserve priority and what methods of promoting them have the greatest effect. There is ample evidence that awareness of HIV and changes in sexual behaviour have occurred widely but the penetration of information remains poor in some vulnerable groups especially adolescents and women in poorer countries. Further obstacles face those who have information about the risk. The subordinate position of women and a desire for large families are important obstacles to condom negotiation and use. Urbanization, poverty, conflict and declining public services all exacerbate unsafe sexual behaviour. We argue that so-called 'structural' interventions directed at these wider contexts of unsafe behaviour merit greater attention. Such approaches have the added benefit of being less susceptible to 'risk compensation' which has the potential to undermine strategies directed at reducing the transmission efficiency of HIV.