Principles of Positive Prevention

After 2 decades of the death and devastation of AIDS, ever-increasing numbers of HIV-infected persons are able to live longer and healthier lives, chiefly as a result of effective antiretroviral treatment (ART). At the same time, there are larger pools of HIV-infected persons in many populations than before, which could result in increased HIV transmission if prevention efforts are not expanded. Thus, current efforts to develop more effective HIV prevention strategies for persons living with HIV/AIDS are timely and appropriate. As we focus more on “prevention for positives,” it may be useful to articulate some principles that reflect lessons learned to date—chiefly from prevention efforts aimed at “negatives”—and suggest future directions. HIV IS TRANSMITTED THROUGH HUMAN RELATIONSHIPS AND THUS SHOULD BE APPROACHED FUNDAMENTALLY AS A RELATIONAL PHENOMENON Whether transmission occurs through sexual intercourse, from mother to child during birth, by sharing injecting equipment, or by transfusing blood from 1 person to another, it virtually always involves 2 people in some sort of social relationship to each other. Yet, historically, most HIV prevention efforts, particularly in the developed world, have focused on reducing risk among individuals rather than dyads. Although some small-group and community interventions have been developed, tested, and implemented, individual-level psychosocial interventions have been the mainstay of HIV prevention research and practice. What is missing is a focus on the dynamics of the relationship in which transmission occurs. Relational dynamics are important and explain such fundamental things as why condom use is often inconsistent or lacking, even though people know it is an effective HIV prevention strategy. Negotiating over condom use and disclosure of HIV infection status require interpersonal and communication skills and a level of comfort that are not possessed by all. In many contexts, the social construction of sexual relationships renders those kinds of conversations moot or impossible. For example, women and men engaged in commercial or transactional sex cannot demand condom use by their partners if to do so jeopardizes their ability to earn payment (of whatever sort), and thus to survive. In more intimate relationships, conversing about condom use and infection status suggests a lack of love, fidelity, and trust, and for many people, the emotional risks of having this conversation are thought to be much greater than the potential risks of acquiring or transmitting HIV. Conversely, for those who do possess the necessary skills and comfort to discuss sexual intercourse before it happens, decisions can be made at the couple level to avoid HIV transmission, whether this means using condoms or engaging in “strategic positioning” during sex so as to reduce the risk of transmission (eg, among men who have sex with men MSM, the HIV-infected partner in a serodiscordant couple may take the “receptive” position instead of the “insertive” position).1 Little research has investigated the nature of relational dynamics and the translation of findings about those dynamics into effective HIV prevention interventions. Thus, we need to focus much more attention on dyads in developing effective HIV prevention strategies for HIV-positive persons, whether in concordant or discordant relationships and whether those relationships are short term or long term. BECAUSE HIV TRANSMISSION IS RELATIONAL, PREVENTION EFFORTS MUST ADDRESS TRANSMISSION AND ACQUISITION Historically, most HIV prevention research and practice have focused on HIV-negative persons and the goal of averting acquisition of HIV infection. For many good reasons, HIV prevention scientists, program directors, and policy makers have been ambivalent about targeting HIV-positive people, chiefly because of the social stigma and blame that still exists around the disease. Before the advent of effective ART, there also were fewer reasons to discuss the individual benefits to the HIV-positive person of protecting himself or herself from reinfection as well as protecting others from initial infection. All this has changed over the past 8 years, however, because ART has provided many HIV-positive people the opportunity to live a more normal and healthy lifespan. This situation offers the possibility of promoting more rigorously a dual message for HIV-positive individuals with respect to HIV prevention: (1) the need to protect oneself from disease progression, coinfection, and superinfection and (2) the need to accept some social responsibility to not transmit HIV to others. Even with the benefits of ART, much of the social stigma and discrimination associated with being HIV-positive remains—not just in developing countries but in the developed world as well. Thus, it is essential to find ways to provide social support and nonstigmatizing services to people already infected with HIV and to get the general public and policy makers to adopt a greater sense of “collective responsibility” in the epidemic.2 This means not only developing clinician-driven interventions to deliver HIV prevention messages to HIV-positive patients but social marketing and institutional interventions targeted to HIV-positive persons as well as to the general population to develop the personal and collective sense of responsibility we all should share in advancing HIV prevention efforts related to transmission and acquisition. Also, as new HIV prevention technologies are developed, their applicability for HIV-positive as well as HIV-negative people must be considered. Currently, most vaccine and microbicide trials, for example, are targeted only to HIV-negative individuals, because the defined clinical outcome of the trials is the prevention of HIV acquisition. So far, only limited attention has been paid to a therapeutic vaccine that could prevent HIV infection from progressing once it already has occurred or to a microbicide that might prevent reinfection among individuals who already have HIV. Such technologies are important for providing a full range of prevention tools to HIV-positive people. RELATIONSHIPS WITHIN WHICH HIV IS TRANSMITTED MUST BE VIEWED IN THEIR SOCIAL, CULTURAL, AND PHYSICAL CONTEXTS Although those of us committed to HIV/AIDS work tend to think of the disease as the most salient thing in affected people’s lives, in many cases, we are wrong. For many people, whether infected or not, HIV is a concern low on their list relative to other things, including other health challenges that may seem to be more proximate or more prevalent. Globally, HIV/AIDS affects some of the most vulnerable and socially marginalized people in a society—particularly those who are poor, geographically mobile, and dependent on others for economic support, for whom having food to eat for themselves and their families, being employed, and securing an education for their children may be of much greater concern than worrying about HIV. Moreover, many of the messages about risk reduction for HIV prevention assume that protective behaviors are a matter of personal choice and control when, in reality, they often are not. For example, in many societies with prevalent HIV epidemics, such as South Africa, the cultural imperative to bear children is profound. Indeed, in some South African communities, a young woman is expected to prove her fertility before a man will marry her. This expectation conflicts with the public health imperative for sexually active people to use condoms consistently to prevent HIV transmission, because, of course, condom use generally prevents pregnancy. Young women in this society—who are 77% of the young people infected with HIV3—have virtually no control over condom use, and their ability to protect themselves from HIV infection is a minor consideration in the larger social context that places a premium on parenthood for social acceptance. All this suggests that HIV prevention for infected and uninfected individuals must be embedded in larger and more comprehensive efforts to promote positive physical and emotional development, life skills and chances, poverty alleviation, and gender equity. NO SINGLE HIV PREVENTION STRATEGY IS 100% EFFECTIVE In research and practice, there is a tendency to focus on a single approach to prevention as the ultimate solution, whether that is behavioral change interventions or vaccine development. Data from a wealth of behavioral intervention studies suggest that risk reduction (eg, increased condom use, decreased number of sex partners, decreased needle sharing) can be achieved at a level between 10% and 40%. Current vaccine trial designs assume somewhere around 50% efficacy for candidate products. Given such imperfect methods, we must accept that a combination approach to HIV prevention is as necessary as a combination approach to HIV treatment has been (ie, where no single drug can effect the health outcomes that combinations of drugs can). Moreover, this combination should be comprehensive in the sense of including biomedical, psychologic, and social interventions, such as HIV testing, counseling, behavioral change, harm reduction, postexposure prophylaxis, ART for preventing mother-to-child transmission, and, once proven effective, vaccines and microbicides. The recent policy shift of the Centers for Disease Control and Prevention (CDC) toward diagnosing HIV infection rather than promoting behavioral change interventions is problematic in this regard. Although voluntary counseling and testing (VCT) are necessary elements of any HIV prevention strategy, they are not sufficient. Evidence suggests that VCT programs have not significantly reduced sexual risk behaviors among persons with HIV.4,5 Furthermore, experience from Botswana illustrates the limitations of singularly focusing on scale up of VCT, even where ART is available, theoretically making it desirable to know one’s HIV status. In that country, uptake of testing services has been extremely low, because the prevailing social stigma around HIV infection has not been addressed. Even though services are widely available and easily accessible, people do not avail themselves of them for fear of being identified as HIV-positive and suffering social disgrace. This experience underscores the importance of undertaking social interventions (eg, to reduce stigma and discrimination) in conjunction with and simultaneous to biomedical (eg, testing) and behavioral (eg, counseling) interventions. HIV PREVENTION AND TREATMENT ARE INTERTWINED AND SHOULD NOT BE COUNTERPOISED Throughout the first 2-plus decades of HIV/AIDS, there has been an unfortunate divide between prevention and treatment. This has historical reasons, including the fact that effective HIV treatment did not really exist until the late 1990s and still is not widely available in most places with high HIV and AIDS prevalence. In this situation, HIV prevention was singularly emphasized in program and policy efforts. Meanwhile, in relatively rich societies, people with HIV and AIDS and their advocates lobbied hard for treatment research to help keep those people already infected alive. At the same time, a cultural sentiment prevailed that those already infected were somehow less “innocent” than those not yet infected, especially in places such as the United States, where the epidemic first hit gay men and injecting drug users, who were socially marginalized groups. So, on a political level, prevention and treatment were cast as competing interests. Additionally, as the US government response to the epidemic increased, its efforts were channeled into existing agencies, programs, and funding streams, which had the effect of establishing a tripartite approach to HIV that remains today: treatment (Health Resources and Services Administration HRSA), prevention (CDC), and research (National Institutes of Health NIH). The advent of ART has changed the landscape and made evident the fact that prevention and treatment (and research for that matter) are inextricably linked. First, ART has become an effective prevention strategy itself for preventing transmission from mother to child and in postexposure prophylaxis. Currently, clinical trials are underway to see if the administration of ART to HIV-uninfected individuals at high risk will reduce HIV acquisition among them—a sort of “pre-exposure” prophylaxis. Second, the availability of ART makes it more desirable to know one’s HIV status, which should encourage people to get tested for HIV infection. Diagnosis is an important step toward directing people to more comprehensive HIV prevention and care services. Clearly, HIV treatment and prevention must go hand in hand and cease to be viewed as competing agendas. SCIENCE RATHER THAN POLITICS OR IDEOLOGY SHOULD DRIVE THE DEVELOPMENT OF HIV PREVENTION STRATEGIES To the extent possible, evidence-based approaches should be the approaches promoted and implemented by governmental and nongovernmental bodies. This is the unchallenged expectation in HIV medical care, and it should be so in HIV prevention. Currently, political and sectarian interests have overtaken scientific consensus in official US policy governing HIV prevention programs. In particular, the current US policy emphasizing an “abstinence until marriage” approach to HIV prevention has no scientific grounding. On the contrary, systematic reviews have demonstrated that comprehensive sex education programs that include abstinence as well as risk reduction information are more effective in reducing risk behaviors, unintended pregnancy, and sexually transmitted infections (STIs) among young people than are abstinence-only programs.6 Yet, the federal government has recently doubled funding to the states for domestic abstinence-only programs and is mandating an abstinence-only agenda for potential recipients of international HIV prevention funds under the President’s Plan for Emergency AIDS Relief (PEPFAR). The determination to take this approach stems from an ideologic conviction that people should not engage in sexual intercourse outside of a legally sanctioned, monogamous, heterosexual marriage. It does not flow from a review of evidence about effective HIV prevention interventions. The trumping of science by political and ideologic concerns is a dangerous precedent. At the least, it undermines the validity and credibility of certain public health strategies, and at the worst, it can jeopardize lives. HIV prevention researchers, programmers, and policy makers should resist political pressure to sully public health science with ideologic agendas. In sum, it is imperative that HIV prevention—for HIV-positive and HIV-negative persons alike—be addressed more holistically than it has been to date. This means recognizing that HIV is an infectious agent transmitted by people in human relations that take place in and are affected by social, political, and cultural contexts. Attending to the principles outlined previously should help to move us toward this more holistic approach and improve our overall effort to stem HIV transmission domestically and globally.