Combining structural, biomedical, behavioral responses to HIV can make difference for those at highest risks, and least access to services

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PathfindercombprevhivCarlos Laudari had a splinter.

He got it on his way to a lunch meeting at Pathfinder International’s Washington, DC office, and although he was looking forward to the talk over lunch, he told the group there, the splinter distracted him. Laudari uses a cane, is not a young man, and can surely put so small a distraction as a splinter into perspective, but, he said, holding up the injured hand, for a while, the splinter was all he could think about. “I have it still!” he said.

Laudari had come to discuss the organization’s publication on Combination Prevention of HIV: A Technical Working Guide to Working with Key Affected Populations, so, as it happened, the splinter also reminded him of the issue at hand.


Carlos Laudari

“Sometimes,” he told the audience, “structural issues are like splinters.”

Those  are the issues which, for men who have sex with men, make the fear of being arrested and beaten up by police larger than the need to get condoms, testing and treatment for HIV. Those are the issues that make even carrying condoms an arrestable offense for a sex worker. Those issues are why, Laudari told a group Thursday, efforts to confront HIV must combine structural, biomedical and behavioral strategies, preferably, he said, in that order.

To often, he said, it is done the other way around. “Starting with behavior is still pointing,” he said. “Let’s start with your behavior. Then we’ll give you the medicine. Then we’ll look at the structure.”


“But why?” Laudari says. “Who are we to say?”

Laudari, a physician who is Pathfinder’s senior technical advisor in HIV prevention, showed a poster, that he assured his audience, “you will never see from Pathfinder.”

“Commercial SEX work is not the OPTION,” the poster says. “Choose a Better Future.”

“But why?” Laudari said. “Who are we to say?”

Rather, example activities in the guide include:

  • training police on issues related to human and sexual rights,
  • promoting use of internet platforms to share information about abuse and abusers,
  • promoting meaningful participation of sex worker organizations and facilitate their participation in World AIDS Day, International Women’s Day, Human Rights Day, and others.

Pathfinder, which along with Allliance for Open Society International and Interaction, successfully sued the United States Agency for International Development to throw out the requirement that organizations getting funding through the President’s Emergency Plan For AIDS Relief  take an “anti-prostitution pledge,”  put together the guide to assist work in the field and in forming policies.

The guide looks at the web of interacting factors that influence the effectiveness of HIV interventions among sex workers, men who have sex with men, people who use injecting drugs, and other “key affected populations.” It provides examples of activities to strengthen individual and collective abilities to access  treatment, prevention measures, and economic strengthening pulled from actions that the organization has employed in work in India, Kenya, Mozambique and Brazil.

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