KAMPALA, 4 June 2008 (IRIN) - "One-size-fits-all" HIV programmes are leaving huge gaps in the global response, and a better understanding of each country's unique epidemic is central to successful management of the pandemic.

"Emerging information shows varied epidemics between countries, and varied epidemics within countries," said Susan Kasedde, of the UNAIDS regional support team for East and Southern Africa. "Poor analysis of evolving epidemics leads to poor strategic focus and continued misallocation of resources."

Delegates learnt of this possible new approach to tackling the pandemic at the fourth HIV Implementer's Meeting in the Ugandan capital, Kampala.

In Ghana, for example, prevalence in the general population is two percent, but is well over 70 percent among commercial sex workers; about three-quarters of HIV-positive Ghanaian men contracted the virus from a commercial sex worker, but less than one percent of HIV funding is dedicated to addressing sex work.

Kasedde said it was important to examine trends in both the general population and specific groups within the general population, in order to gauge where the next infections were most likely to come from and correctly address gaps in existing programming. "We need to ask what should be done, versus what is being done."

According to the Great Lakes Initiative on HIV/AIDS (GLIA), which is funded by the World Bank, the six countries in the Great Lakes Region – Burundi, Democratic Republic of Congo, Kenya, Rwanda, Tanzania and Uganda – have fallen short in protecting some of the groups most at risk from the pandemic.

Some of the vulnerable populations glaringly absent from most national AIDS programmes in the region are: long-distance truck drivers, fishermen and fisherwomen, the military, female sex workers, refugees and internally displaced people, women and girls affected by sexual violence, and prisoners.

"Some sub-populations display higher-risk sexual behaviour, are in mobile occupations, are in contact with persons in mobile populations, or are exposed to violence and conflict, and as a result have higher median HIV prevalence than the general population in the Great Lakes Region," noted a January 2008 GLIA rapid analysis of HIV epidemiological data on vulnerable populations.

In some countries that have identified specific groups as the key drivers of a concentrated epidemic, more focus is needed on the general population, and more analysis of possible bridging between the most at-risk groups and the general population.

"In the Ukraine, we know that intravenous drug use, commercial sex work and men who have sex with men are the main drivers of the epidemic, but big pockets of the unknown remain," said Ana Shakarishvili, from UNAIDS in the Ukraine. "There is a lack of research into overall sexual behaviour in the general population, and while we know that heterosexual transmission is on the rise, there are few incidence studies."

As national epidemics evolve, so must the programmes created to deal with them. In eastern and southern Africa, for instance, it has become increasingly clear that male circumcision contributes to HIV risk reduction, but rolling out male circumcision has been sluggish in many countries in the region.

"In Uganda we now know that most new HIV infections are occurring in stable relationships, in marriages, so more focus is needed on prevention within those relationships," said Flavia Kyomukama, of the National Forum for People Living with HIV/AIDS in Uganda.

The implementers were also urged to "put the missing face of children" in their HIV programmes, because data showed that children's programmes were still woefully under-funded: globally, fewer than five percent of children in need of life-prolonging antiretroviral medication are receiving it.

The conference was organised by the US President's Emergency Plan for AIDS Relief (PEPFAR), the Global Fund to fight HIV/AIDS, Tuberculosis and Malaria, the World Bank and UN agencies, so that HIV programme implementers could exchange ideas, share best practices and analyse trends in the global HIV/AIDS epidemic and response.

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