To accelerate the scale-up of HIV prevention, national governments should use inclusive, broad-based processes to develop comprehensive, evidence-based, target-driven national prevention strategies.

• Inclusive National Planning Process. An inclusive national process, bringing together multiple sectors and ensuring strong participation by civil society, affected communities, and people living with HIV, should develop a comprehensive strategy for the HIV response, with a simultaneous and integrated scaling-up of HIV prevention and treatment strategies. Available data should help guide national decision-making on allocating prevention resources among different program components.

• Establishing Prevention Targets. National HIV authorities should establish and disseminate concrete goals for coverage, intensity, and impact of HIV prevention efforts.

• HIV Information Systems. Each national HIV authority should develop and implement plans for strengthening HIV surveillance and other HIV-related information systems. Through collection and analysis of reliable and up-to-date data, countries should fully understand their epidemic, including HIV prevalence and incidence, the relative sources of HIV infection, the size and characteristics of groups most at risk, important sources of HIV-related vulnerability (e.g., social, economic, legal, etc.), and key gaps in the HIV response.

• Addressing Factors That Increase Vulnerability. National governments should complement programmatic HIV prevention initiatives with broader social and structural actions to reduce vulnerability. (For a discussion of relevant policy actions, see box above on “the Factors That Increase Vulnerability to HIV.”)

• Adapting HIV Prevention Strategies. Working with international technical agencies, national HIV authorities should assess HIV prevention scale-up on an ongoing basis and identify factors that impede program expansion. Joint reviews of the HIV response should be regularly undertaken by national stakeholders. National strategies should be revised as needed, based on epidemiologic trends, evaluation findings, and the emergence of new prevention tools.

• Integrating HIV Treatment and Prevention. National governments should investigate incentives, training programs, and other policy actions to encourage field-level integration of HIV treatment and prevention, including the delivery of HIV prevention services in treatment settings. Similar incentives should be explored to encourage integration of HIV prevention in service settings for TB, sexual and reproductive health, and STI treatment.

• Accountability. With assistance from technical agencies and donors, where needed, each national HIV authority should establish a comprehensive HIV monitoring and evaluation system that encompasses regular reporting by all relevant national and sub-national stakeholders, including international NGOs, bilateral donors, UN agencies, workplaces, and faith-based groups. Each national HIV authority (or designated agency) should submit accurate, comprehensive, and timely reports to UNAIDS on national HIV progress. National HIV authorities should also work with UNAIDS to undertake National AIDS Spending Assessments.

• Stigma and Discrimination. All countries should have in place laws that prohibit discrimination on the basis of real or perceived HIV status or of membership in a vulnerable population at elevated risk of HIV infection. Such national laws should adhere to the 2006 consolidated version of the International Guidelines on HIV/AIDS and Human Rights, jointly issued by UNAIDS and the Office of the United Nations High Commissioner for Human Rights.

• HIV Prevention Research. National governments should welcome, facilitate, and build community support for clinical trials and other research projects associated with the development of new HIV prevention strategies.

International donors must assume primary responsibility for closing the HIV prevention resource gap.

• Doubling HIV Assistance, Including for Prevention. International donors and domestic governments should take immediate steps to dramatically increase financing for HIV prevention, with the aim of making US $22 billion available in 2008 for HIV prevention, treatment, care, and support. Dramatically increasing resources to reach the needed funding levels, donors should aim to ensure that 52% of available HIV funding in 2008 is allocated toward HIV prevention efforts, as recommended by UNAIDS. The balance of funding between HIV prevention, treatment, and other needs will vary, based on regional and national needs. Donors should ensure that the HIV prevention efforts they support are based on sound scientific evidence.

• Coordination, Harmonization, and Alignment. Bilateral donors should work with each other and with the Global Fund, World Bank, UNAIDS regional teams, and international NGOs to develop coordinated, multiyear plans for external HIV assistance. Such efforts should be undertaken in close consultation with national governments and HIV authorities and should align with nationally determined HIV priorities, strategies, and targets.

• Building Civil Society Capacity. Donors should prioritize capacity-building assistance to civil society organizations, with particular emphasis on support to networks for people living with HIV for anti-stigma initiatives and “positive prevention” programs.
  
  
• Endorsing Universal Access for HIV Prevention. Building on their endorsement of treatment scale-up in 2006, the Group of 8 industrialized countries should formally endorse universal access to HIV prevention and make firm commitments for increased resources to support prevention scale-up.

The technical resources available to countries to support HIV prevention scale-up should be stronger and better coordinated.

• Coordinated technical support for national HIV prevention planning. A coordinated system of technical support is needed to assist countries in developing comprehensive national HIV plans that include well-targeted, evidence-based, and scaled-up prevention programming. Ongoing technical support services should be made available, as opposed to traditional time-limited technical assistance. Technical support must be designed to meet the needs of national planners and should utilize and build in-country technical capacity.
  
  
• Independent Assessment of National Strategies. Through coordinated technical mechanisms, such as the UNAIDS AIDS Strategy and Action Plan service, housed at the World Bank, technical experts should provide independent feedback on national HIV prevention plans. This effort should assess the degree to which national programmatic actions are evidence-based, the alignment of prevention allocations with available epidemiological data and documented national needs, and whether needed programmatic actions are supported by social or structural policy actions that address nationally relevant factors that increase vulnerability. Such independent assessments would not serve as an official “imprimatur” for donors but would rather solely focus on assisting countries in adapting national strategies to maximize their public health impact.
  
  
• Improving National HIV Information Systems. WHO, UNAIDS, CDC and other technical agencies should continue and enhance technical support to countries in building and strengthening national HIV-related data systems.
  
  
• Monitoring Resource Flows. UNAIDS and its research partners should improve their capacity to differentiate available funding by category of intervention, comparing expenditures with global and regional projections of resource needs for specific kinds of programs. UNAIDS should also build on the experience of prior National AIDS Spending Assessments to improve estimates of HIV spending in countries, including better understanding of the magnitude, nature, and targeting of HIV prevention efforts.

Scaling-up HIV prevention requires action by not only national governments but also by health clinics and systems in localities and districts. Health care workers should be trained to maximize their capacity to function as partners in HIV prevention efforts.

• Integrating HIV Prevention in Larger Service Systems. HIV services should be closely integrated with key service systems, such as TB clinics, STI clinics, and sexual and reproductive health settings. Health systems and providers should incorporate detection of active syphilis and the routine offer of HIV testing in antenatal care.

• Accountability and Transparency. All prevention service providers, including those supported or administered by external sources, should regularly report data on utilization and impact of services to the designated national agency for monitoring and evaluation.

• Infection Control. All health care settings should educate and actively encourage health care workers to adopt sound infection-control practices. Such initiatives should extend beyond provision of education materials and include opportunities for audit and feedback. With the support of national governments, international donors and multilateral agencies, all health care settings should make safer technologies readily available to workers, including auto-disable syringes and up-to-date kits for antiretroviral prophylaxis.
  
  
• Training in Sexual Health. Health care workers should be trained on sexual health to increase their facility in discussing sexual practices and risk exposure with patients and to reduce workers’ prejudicial attitudes toward vulnerable populations.

In addition to the continuing urgency of the search for new HIV prevention technologies, social and operational research is also imperative in the effort to bring prevention to scale.

• Social Research. Public-sector research agencies, academic researchers, and leading foundations should prioritize relevant social research in countries to improve understanding of factors that increase vulnerability, identify and characterize programs and specific policy actions to address such factors, and inform the development and adaptation of national HIV prevention strategies.

• Operational and Implementation Research. Public-sector research agencies, academic researchers, and leading foundations should increase investment in research on optimal, cost-effective strategies to accelerate scale-up, ensure sustainability, and maximize the impact of HIV prevention strategies. Focused research should investigate strategies to integrate new HIV prevention technologies and approaches in the broader HIV prevention and service continuum. WHO and UNAIDS should actively work to coordinate integration of new approaches in countries.
  
  
• New HIV Prevention Approaches. Continued and sustained efforts should focus on the development of new prevention technologies and approaches and on improving those that already exist.

The active involvement of civil society is essential to effective HIV prevention advocacy and to efforts to hold key stakeholders accountable for their commitments.

• HIV Prevention Advocacy by Treatment Activists. At national and global levels, HIV advocates should actively support a comprehensive response to the epidemic that simultaneously brings HIV prevention and treatment to scale.

• Monitoring HIV Prevention Progress. With support from donors and multilateral agencies, civil society networks should assist in monitoring national HIV prevention efforts and work to hold governments, donors, and other actors accountable for agreed targets.
  
  
• Participation in National Prevention Planning and Monitoring. Civil society should be integrally involved in national bodies that develop and/or monitor national efforts to bring HIV prevention to scale, including National AIDS Councils and Country Coordinating Mechanisms for the Global Fund. Countries should define civil society broadly to encompass community-based organizations, faith-based groups, business and labor, and people living with HIV.