In-depth: Beyond ABC: The challenge of Prevention
Playing safe is not really what you want to do as a young man
JOHANNESBURG, 14 November 2005 (IRIN) - In theory, preventing HIV/AIDS seems simple enough: give people information on how the disease is spread, and the desire for self-preservation will, naturally, make them adopt safer sexual behaviour.
The reality has proved much more complex. Almost 30 years after it was first diagnosed, ignorance about HIV/AIDS still persists. Even more challenging is the realisation that some of those who are aware of the message are ignoring it, or are powerless to negotiate safer sex.
According to the UNAIDS Epidemic Update for 2005, [www.unaids.org
] "there is new evidence that prevention programmes initiated some time ago are currently helping to bring down HIV prevalence in Kenya and Zimbabwe" but, overall, prevention efforts have a poor track record, particularly in sub-Saharan Africa, which is home to two-thirds of all people living with HIV.
Much of the continent has initiated treatment programmes, but experts warn that unless the incidence of HIV/AIDS is sharply reduced, treatment will not be able to keep pace with the number of people needing therapy.
HIV prevention opens a Pandora's box of issues, such as sex and sexuality, and forces people to re-evaluate societal and individual factors that may be contributing to the epidemic.
The cost of failure is clear. The Global HIV Prevention Working Group [www.gatesfoundation.org
] estimates that if existing prevention interventions were brought to scale, nearly two-thirds of the 45 million new infections projected to occur between 2002 and 2010 could be averted.
Barriers to HIV prevention
Some AIDS researchers maintain that the inability to induce long-term behavioural change lies in the nature of the messages: top-down, fear-inducing lectures on safe sex by national AIDS bodies do not acknowledge that sex is about desire, love, the irrational and the illicit; cultural contexts, gender roles, and the influence of peers confound a "one size fits all" approach to awareness and motivating people to take change their ways.
'Facing the Future Together', a study by the UN Secretary-General's Task Force on Women, Girls and HIV/AIDS in Southern Africa, [www.unicef.org
] called for a departure from the orthodox prevention approach, pointing out that the ABC strategy - abstain, be faithful and use a condom - did not fit the needs of women and girls.
"The messages have been missing the mark," the report observed. One reason was the "not only widespread, but widely accepted and endorsed" prevalence of rape and sexual violence against women and girls.
In a context where men grow up believing masculinity means having plenty of sexual partners, being faithful to your husband does not prevent infection: using a condom requires a willing partner, and in a region where one in five women is physically abused, fear can undermine insistence on protection.
If prevention activities were to succeed, the task force said, they needed to be coupled with efforts, such as legal reform and the promotion of women's rights, to address and reduce violence against them.
Men have to play a role - societal norms about masculinity also make them vulnerable to HIV infection, as they are encouraged to engage in risk-taking behaviour.
Amy Kaler, a sociologist who conducted research into men and behaviour change in Malawi, found that "skin-to-skin ejaculation is the marker of a real man - one who uses condoms is being cheated out of his right to a high-grade sexual experience, or may even be the subject of gossip or ridicule".
Prevention messages emphasising safe behaviour and not taking chances did not resonate with masculine sub-cultures, she pointed out. "Playing safe is not really what you want to do as a young man", which needed to be taken on board when designing interventions.
Culture was another barrier, and UNAIDS admitted in its policy position paper on HIV prevention that "while culture can function as a vehicle for promoting HIV infection, it must be recognised that it can also constitute a barrier against HIV prevention".
Moving beyond ABC
The success of Uganda's fight against AIDS has been largely attributed to its president, Yoweri Museveni, who took the bold decision to speak out publicly about what was considered a shameful disease and tell people how to combat it. Prevention strategies, including the promotion of condoms, were central to the achievement.
But in recent years the Ugandan and US governments have shown increasing interest in promoting abstinence and fidelity in marriage, with condoms given only to those who cannot manage either.
Activists argue that while abstinence until marriage and fidelity inside marriage are admirable, human weakness, transactional sex, existing gender roles and the difficulty of changing behaviour dictate that condom use must be at least as well promoted, and condoms must be easily available.
In an article in the British Medical Journal, Daniel Halperin, a prevention expert with the US Agency for International Development (USAID), and his colleagues pointed out that behaviour change programmes to prevent HIV transmission have mainly promoted condom use or abstinence, while the 'be faithful', or partner reduction, component of ABC had been neglected.
"We have a public health responsibility to help people understand the strengths and limitations of each component, and not promote one to the detriment of another. For example, although abstinence may be a viable option for many young people, for others it may be an unrealistic expectation. Likewise, even though prospective studies have shown that condoms reduce risk by about 80 to 90 percent when always used, in real life they are often used incorrectly or inconsistently," the article commented.
Changing human behaviour is not an overnight process. In the meantime, technologies old and new, from diaphragms to vaccines, are being investigated, in the hope that science will succeed where attempts to alter human behaviour have not done as well as anticipated.
A recent study in South Africa found that circumcised men were at least 60 percent less likely to become infected than those who were uncircumcised. Two similar trials are underway in Uganda and Kenya, with results expected later this year. If they support the Johannesburg study, male circumcision is likely to be added to the cocktail of prevention mechanisms.
Professor Alan Whiteside, director of the Health Economics and HIV/AIDS Research Division at the University of KwaZulu-Natal, observed that strategies had neglected to address the distinct prevention needs of people living with HIV/AIDS, and warned that this not only posed a threat to people living with AIDS, but also to future generations.
"We have to consider the dangers of re-infection among HIV-positive people, as well as the possible emergence of new strains of HIV. This would also raise huge concerns about the ability of current treatments to fight a new and possibly stronger version of the HI virus," he noted.
"The issue of prevention, however, should not rest solely on the shoulders of government," Whiteside said, "as it has a great deal to do with individual choice."