Tuberculosis, malaria, malnutrition, alcohol abuse, depression, suicide, and trauma destroy as many lives as HIV, often in a shorter time frame. There is ample evidence that these and other health challenges intersect with HIV and exacerbate each other, rooted in their common biological causes or co-infection, and shared distal or structural factors, such as poor health care infrastructure, poverty, warfare, and societal upheavals or transformations (Singer and Clair 2003
). Yet, prevention for each disease is often embedded in health care systems via separate, vertically integrated units. With total health budgets in Sub-Saharan Africa averaging about $80 per person across the region (World Health Organization 2006
), it is impossible to build parallel health systems to prevent and treat multiple diseases. There must be horizontal integration of services for HIV, TB, malaria, alcohol abuse, nutrition, and mental health problems, for example, especially in rural environments with few resources.
Furthermore, prevention is best delivered to families (Rotheram-Borus et al. 2005
), rather than to individuals in age and gender segregated groups, which is the typical organization in HIV services. In several countries, the health system integrates care locally by having a generalist responsible for a geographic area: for example, in China, the village doctor addresses all local health problems and difficult problems are referred to more specialized services serving a larger geographic area. Such generalists are needed in prevention.
However, the healthcare sector is not likely to be the optimal site for prevention. Systems for delivering healthcare are stressed and not consumer-friendly. One billion people do not have access to healthcare globally (Shah 2008
). If available, clinic waiting lines are long, difficult to access, and often expensive. Consumers often struggle to know whether a problem is severe enough to require treatment; the responsibility and choice for seeking care is with the consumer. Deciding to seek care, families often face a complex process that involves getting referrals to the right clinic, long waiting times for appointments, taking time off from work or taking children out of school to accommodate available appointment times, paying high rates that are frequently not covered by insurance, and uncertainties around the duration of appointments and whether specific concerns will be addressed successfully. These are difficult challenges to overcome.
It is noteworthy that countries with the greatest turnarounds in the HIV epidemic have local health planning committees and health advocates that are not based in the healthcare system. For example, rather than the ABC (abstinence-be faithful-use condoms) Campaign, Kirby (2003)
has argued that local community planning groups in Uganda, following Adi Amin’s exit, were responsible for decreasing HIV seroincidence in the mid 1990s. In Thailand, there is a hierarchical community surveillance system that goes down to the level of one health monitor for every ten persons (Jiraphongsa 2007
). China, a country without a generalized HIV epidemic, despite high rates of sexually transmitted diseases (STD), has hierarchically-linked leadership structures: village leaders, women caucus representatives, and village doctors. When these leaders are placed in charge of HIV prevention planning, initiation of drug use decreases (Wu et al. 2002
). There may be substantial benefits to charging local leaders with the responsibility for addressing HIV and other diseases in their community. Local leaders can target and be responsible for their community’s specific health risks, whether the problem is malaria, tuberculosis, alcoholism, or HIV.
Promoting a family’s healthy routines from cradle to maturity is the best strategy for protecting family’s health. While linkage to healthcare is needed, prevention is likely to be more accessible and less stigmatizing, if not nested within the healthcare system.
There are many vehicles that can deliver the evidence-based prevention programs (EBPP) necessary to establish healthy daily routines. Family wellness centers in communities are one vehicle, staffed by the community members whose families are thriving (Marsh et al. 2004
), and supported by culturally adapted programs for experiential workshops and exhibits, prevention programs, and recreational and vocational programs that engage the community. An alternative strategy is home visiting programs by Mentor Mothers, similar to the nurse home visiting program of Olds (2002)
. The proliferation of the internet and mobile phones is creating new opportunities and vehicles to promote wellness, even in the most remote, rural areas. Soon, expert information, consultation, and support will be available worldwide “virtually”, revolutionizing daily lives (Sorensen et al. 2008