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ABC - The challenge of prevention
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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
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
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
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
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
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 [http://bmj.bmjjournals.com/],
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
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."
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