HIV prevention at the population level depends on synergistic behavioral and biologic strategies. Safer sex includes limiting the number of sexual partners, use of male latex condoms, and structural interventions to reduce exposure, and these interventions appear to have led to reduced HIV incidence in many countries. Biological strategies have proven catalytic: these include treatment of inflammatory cofactors, voluntary male circumcision and use of antiviral agents either for infected people (who can be rendered remarkably less contagious) or as pre- and post-exposure prophylaxis (PrEP and PEP). Suppressive antiviral treatment virtually eliminates HIV transmission in HIV discordant couples, when combined with safer sex counseling. Ecologic evidence suggests that broader, earlier antiviral treatment of HIV may already be reducing HIV incidence in some (but not all) populations. However, maximal benefit of HIV "treatment for prevention" will require a program of universal "test and treat", where many more infected patients are identified, linked to care, and treated very early in disease and for life. Community randomized trials designed to support this approach are underway in Africa. The "test and treat" prevention strategy is cost effective, but also very resource intensive. The broader treatment of HIV for prevention must be viewed as a bridge to other simpler forms of HIV treatment and prevention which will surely evolve in the coming years.
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