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Lancet. 2014 Jul 19;384(9939):272-9. doi: 10.1016/S0140-6736(13)62230-8. Epub 2014 Apr 14.

Transformation of HIV from pandemic to low-endemic levels: a public health approach to combination prevention.

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O'Neill Institute for National and Global Health Law, Georgetown University Law Center, Washington, DC, USA.
School of Public Health, Imperial College London, London, UK.
South Africa National AIDS Council (SANAC), Pretoria, South Africa.
National Agency for the Control of AIDS, Abuja, Nigeria.
National AIDS/STD Control Programme (NASCOP), Nairobi, Kenya.
Liverpool Voluntary Counselling and Testing, Care and Treatment, Nairobi, Kenya.
Wits Reproductive Health and HIV Institute, University of Witwatersrand, Witwatersrand, South Africa.
Department of HIV/AIDS, World Health Organization, Geneva, Switzerland.
Department of Evidence, Strategy and Results, UNAIDS, Geneva, Switzerland.
Office of the Deputy Executive Director for Programme, UNAIDS, Geneva, Switzerland.
Director's Office, London School of Hygiene and Tropical Medicine, London, UK.
O'Neill Institute for National and Global Health Law, Georgetown University Law Center, Washington, DC, USA; The Global Fund to Fight AIDS, Tuberculosis and Malaria, Geneva, Switzerland. Electronic address:


Large declines in HIV incidence have been reported since 2001, and scientific advances in HIV prevention provide strong hope to reduce incidence further. Now is the time to replace the quest for so-called silver bullets with a public health approach to combination prevention that understands that risk is not evenly distributed and that effective interventions can vary by risk profile. Different countries have different microepidemics, with very different levels of transmission and risk groups, changing over time. Therefore, focus should be on high-transmission geographies, people at highest risk for HIV, and the package of interventions that are most likely to have the largest effect in each different microepidemic. Building on the backbone of behaviour change, condom use, and medical male circumcision, as well as expanded use of antiretroviral drugs for infected people and pre-exposure prophylaxis for uninfected people at high risk of infection, it is now possible to consider the prospect of what would be one of the most remarkable achievements in the history of public health: reduction of HIV transmission from a pandemic to low-level endemicity.

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