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HIV Prevention Strategies

A roadside sign in Botswana promoting the ABC approach

Preventing HIV transmission is an essential part of addressing the global HIV/AIDS epidemic. As epidemics change, so do the prevention methods used to prevent new HIV infections. Around the world, there are many different types of HIV epidemic, each with its individual prevention needs.

At the beginning of the AIDS epidemic, HIV prevention methods focused primarily on preventing HIV transmission through sex. However, overtime, the complex nature of HIV epidemics has been recognised, and global HIV prevention strategies have changed.

Replacing the once leading HIV prevention strategy, 'Abstinence, Be Faithful, Condomise' (ABC), the 'combination prevention' approach has come to inform HIV prevention strategies around the world. Combination prevention advocates for a holistic prevention approach, where HIV prevention is not a single intervention – such as distributing condoms - but the implementation of many different HIV prevention interventions at once; each intervention designed with its target epidemic in mind – considering: location, available resources, and most affected populations.

HIV prevention approaches transformed

As the global HIV epidemic has evolved, so have the ways that individuals, organisations and governments address the spread of HIV. When HIV first emerged, it quickly became associated with marginalised groups, sex, AIDS and death; consequently becoming shrouded with stigma and denial. 1 In the USA, the first people known to be affected were gay men, a group that already faced prejudice and discrimination. Across sub-Saharan Africa, images emerged of people dying of an unknown disease that had no cure, creating a climate of fear. In the early years of the epidemic, some governments denied the existence of HIV or the high-risk behaviours that spread the infection, leading many people to take HIV prevention into their own hands.

Evolving epidemic, evolving responses

Silence = Mort badges produced by ACT UP 1989In the first decade of the epidemic, community organisations with close ties to those directly affected by the disease largely led the HIV response. In the USA, the first ‘safer sex’ information emerged from community groups working to help people protect themselves from this new infection. Over the course of the 1980s, these groups evolved to become more formal organisations delivering HIV and AIDS services; such as the Terrence Higgins Trust, in the UK, and Gay Men’s Health Crisis, in the USA. 2 It was these community-led groups that became increasingly unhappy with the inaction of governments, physicians and scientists; calling for action to develop a coordinated response to a growing epidemic.

It was not until the late 1980s, that the World Health Organisation (WHO) launched the Global Programme on AIDS (GPA), the first global organisation to focus on HIV and AIDS. 3 Between 1987 and 1995, the GPA worked closely with global community organisations, supporting a wide range of HIV prevention initiatives. These included condom promotion, syringe exchanges, sex education for young people, and blood safety measures. In 1995 the GPA was replaced by the Joint United Nations Programme on HIV and AIDS (UNAIDS), a lengthy process during which momentum for the global HIV response was lost and international assistance diminished. 4 The development of highly-active antiretroviral therapy (HAART) in 1996, meant that efforts to curb the epidemic were largely focused on scaling-up treatment access, with lesser attention on HIV prevention strategies.

However in the 2000s, HIV epidemics began to emerge in countries beyond sub-Saharan Africa, such as Russia, India, and China. This resulted in widespread concerns that HIV would destabilise global development and security, and a growing political interest in the global HIV response emerged. 5 It was this association that spurred renewed funding for HIV prevention. The creation of huge funding bodies, such as the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, Tuberculosis and Malaria, marked the start of HIV prevention strategies delivered on a global scale.

ABC prevention approach

In the early stages of the epidemic, it was known that HIV was transmitted sexually, thus the first HIV prevention programmes attempted to promote behavioural change. The ABC approach to preventing sexual transmission of HIV has been defined and adopted by a variety of organisations, governments and non-governmental organisations over the course of the epidemic’s history. Before the term ‘ABC’ was first coined in 1992, programmes and materials contained information on how abstinence, being faithful and condom use could prevent the sexual transmission of HIV. 6 These include:

  • AIDSCOM (1987-1993): USAID programme promoting either abstinence, fidelity or condom use depending on the targeted group. 7
  • Botswana (1990s): poster awareness campaign containing ABC message
  • Senegal poster (1991): “stick to one partner; should you have more than one partner, be sure to use condoms correctly and dispose of them after one use” 8 9
  • GPA (1992): promoted delaying sex, marital fidelity and condoms, but did not mention ABC specifically 10

However it was not until 1992 that the Filipino Secretary of Health, Dr. Juan Flavier, brought together abstinence, fidelity and condom use to create the ABC slogan: 11

  • Abstain from sex
  • Be faithful if you do not abstain 
  • Use a condom if you are not faithful

At the time, Dr. Flavier’s ABC approach angered members of the Catholic Church, prominent in the Philippines, who believed the promotion of condoms would encourage promiscuity. Careful to avoid arguments centred on morality, he cited scientific evidence, and began promoting it widely within the Philippines and abroad at international conferences.

  • PEPFAR and ABC

In 2003, PEPFAR, the United States of America’s initiative to combat the global HIV/AIDS epidemic, adopted the ABC method as its primary prevention strategy against the sexual transmission of HIV, emphasising: 12

  • Abstinence for youth, including the delay of sexual debut and abstinence until marriage
  • Being tested for HIV and being faithful in marriage and monogamous relationships 
  • Correct and consistent use of condoms for those who practice high-risk behaviours

President George W Bush signs PEPFAR initiativePEPFAR’s use of the ABC method has garnered much criticism and controversy. Notably, its policy not to promote condoms to young people, and only to those groups among the general population who practice “high-risk behaviours”. 13 14 15 16 Under the original 2003 directive, one-third of PEPFAR funds were required to be spent on abstinence and fidelity programmes. Funds may be used to support programmes that deliver age-appropriate “ABC information” for certain high-risk young people; provided they are informed about failure rates of condoms. HIV/AIDS organisations and experts voiced concerns that PEPFAR put too much emphasis on abstinence until marriage, and was not doing enough to make young people aware of the benefits of condoms. 17 18 19 20 PEPFAR is also obliged to notify Congress if less than 50 percent of funds towards preventing sexual transmission of HIV are spent on abstinence and fidelity programmes.

However, 2008 welcomed a new PEPFAR law which removed the abstinence directive, and embraced a more comprehensive and evidence-informed HIV prevention strategy. 21 Also, in June 2013, the U.S Supreme Court rejected PEPFAR's refusal of funding for organisations that do not actively denounce sex work. This was on the grounds that the pledge was violating free speech and creating barriers between sex workers HIV prevention workers. It is hoped that more organisations will now benefit from PEPFAR funding. 22

PEPFAR claims that its ABC approach was validated by 'what worked in Uganda'. However, on closer examination marked differences can be seen between PEPFAR's approach to ABC prevention and that of Uganda's in the 1990s. Most notable, is that whilst PEPFAR focused primarily on abstinence, Uganda adopted a more comprehensive approach, giving equal weight to A, B and C.

  • Uganda and ABC

In the late 1980s, the Ugandan government took swift action on an escalating epidemic. Through an aggressive media campaign, they began educating the public about sexual transmission, but focused on abstinence for youth and 'zero grazing', or partner fidelity. Then in the early 1990s, condom promotion in Uganda became more accepted by the government and condom use increased. The most important element of the Ugandan response was the mobilisation of community leaders, churches and indeed the public in general; meaning the response was led from the bottom, as well as the top. 23

What appears to have worked in Uganda was a combination of strategies focusing on abstinence and delaying sex, in addition to the widespread promotion and distribution of condoms. 24 During the 1990s, schemes funded by USAID and other donors increased condom use. 25 This combination approach resulted in a fall in the annual number of new infections between the late 1980s and mid 1990s, which in turn led to a reduction in HIV prevalence.

In recent years, however, Uganda’s HIV prevention response has lost momentum. Some experts have attributed this to when PEPFAR, under the directive of the administration of former US President, George W. Bush, started working with the Ugandan government. 26 27 Under PEPFAR, Uganda adopted a narrower approach to ABC, which emphasised abstinence and limited the promotion of condoms; it was reported that in the first two years of youth abstinence focus, rates of new HIV infections nearly doubled. 28

In 2011, a senior official at the Ugandan Ministry of Health commented that... "We have concentrated so much on treatment and care yet more Ugandans are getting infected each year and the number of those who need ARVs is increasing. It is time we reviewed the old-fashioned prevention because it has flopped...Few people in Uganda are using the “ABC”- abstain, be faithful and use condoms strategy". 29

Limitations of the ABC approach

Although Uganda and PEPFAR support the ABC approach, some countries that have also promoted it as a core part of their national strategy on HIV and AIDS have expressed doubt about its effectiveness. In the mid-2000s, many African countries reported ‘mix experiences’ with the ABC prevention method. 30 In those countries where the majority of new infections are heterosexually transmitted, the ABC approach has been sidelined in national strategies by more comprehensive prevention approaches.

For example:

  • Swaziland announced in 2010 that it was going to scrap its ABC prevention strategy because it had not been effective in reducing HIV infection rates. According to the Director of the National Emergency Response Council on HIV/AIDS... “If you look at the increase of HIV in the country while we've been applying the ABC concept all these years, then it is evident that ABC is not the answer”. 31
  • In Namibia, women's groups have criticised the ABC approach, claiming that it does not taken into consideration cultural context, where women's inequality often means that they cannot remain abstinent, practice marital fidelity or demand the use of condoms. 32

By the mid-2000s, it was evident that to prevent HIV more was needed than simply ‘ABC’. Whilst ABC can be a viable prevention strategy, critics of PEPFAR’s use of ABC said that it was driven too strongly by religious and conservative ideology in the U.S., and failed to take into account the diverse contexts within which programmes were implemented. 33

Ultimately, it became clear that HIV prevention programmes needed to take social and economic factors into account. 34

Combination prevention

Combination prevention programmes combine many different HIV prevention interventions into a single, all-inclusive programme. Prevention interventions may include condom promotion, blood screening, and legal reform. Tailored to address each individual epidemic, combination prevention programmes consider factors specific to each setting; levels of infrastructure, local culture and traditions, and the populations most affected by HIV. 35 36 Combination prevention programmes can be tailored for implementation at both individual level, community level, and population level.

UNAIDS have called for combined approaches to HIV prevention to be scaled-up, to reinvigorate the global response, and make a sustained impact on global HIV incidence rates. 37 38 UNAIDS defines combination prevention as: 39

"…rights-based, evidence-informed, and community-owned programmes that use a mix of biomedical, behavioural, and structural interventions, prioritised to meet the current HIV prevention needs of particular individuals and communities, so as to have the greatest sustained impact on reducing new infections."

Emergence of combination prevention

In the mid-2000’s, it became clear that despite vast improvements in the efficacy and access to HIV treatment, the impact of existing HIV prevention efforts were comparatively lagging. 40 At one point, it was suggested that 'DEF' should be added to 'ABC' to represent: 'Defending against gender-based violence', ' Education: improving girls education' and 'Fix property and inheritance laws'. Yet increasingly, the need to abandon one-size-fit-all approaches, like ABC, became apparent. Instead, the need to tailor prevention approaches to the local context gained support, and a consensus emerged that HIV prevention approaches should be based on the key drivers of the local epidemic. 41

The concept of combination prevention was first conceived in 2003, by the Global HIV Prevention Working Group. 42 They investigated shortfalls of existing HIV prevention programmes, and identified two key issues: inadequate funding and limited access to HIV prevention services. 43 As part of their investigations, it became clear that all of the countries that had selected specific interventions based on the characteristics of their epidemics, were considered as HIV prevention success stories – Thailand, Brazil and Uganda. 44

Throughout the mid-2000’s, UNAIDS worked towards ‘intensifying’ HIV prevention so that it became comprehensive, evidence informed and human rights focused. 45 46 The shift towards re-focusing the HIV response on prevention was further emphasised at the 2008 International AIDS Society Conference in Mexico; with ‘Combination Prevention’ becoming the buzzword of the conference. 47 48 Here, stigma, discrimination and human rights violations were identified as seriously impeding efforts to address the HIV epidemic, with calls to prioritise the response around these issues.

Know your epidemic, know your response

Developing a clear and evidence-informed picture of a specific HIV epidemic is needed before deciding on a package of HIV prevention interventions. The ‘know your epidemic, know your response’ approach is the starting point for combination prevention programming, and is comprised of a series of exercises to help categorise an epidemic (i.e. generalised, concentrated). This involves looking at: the modes of transmission, populations most at risk, and key epidemiological trends, for example, the number of new HIV infections among young people. 49 50

The planning process that programmers and policy makers should follow is described below: 51 

Know your epidemic, know your response: Planning process

Upon completion of the ‘know your epidemic, know your response’ planning process, a package of coordinated biomedical, behavioural and structural HIV prevention interventions can be developed.

  • Behavioural Interventions

Behavioural interventions seek to reduce the risk of HIV infection by addressing risky behaviours or activities. A behavioural intervention may aim to do this by reducing the number of sexual partners people have, by improving adherence among people taking antiretroviral treatment, by increasing the use of clean needles when injecting drugs, or increasing the consistent and correct use of condoms during sex. To date, these types of interventions have been the most successful. 52

Behavioural interventions:

Biomedical interventions use a mix of clinical and medical approaches to try to reduce the physical risk of a person contracting HIV. A key example of a biomedical intervention is male circumcision, a relatively simple medical procedure that has been shown to reduce the risk of HIV transmission by up to 60 percent, during heterosexual sex. 54 It is important to point out that in effective combination prevention programmes, biomedical interventions are rarely implemented on their own, instead they are often used in conjunction with a range of behavioural interventions. For example, when a man decides to be circumcised, he will be tested for HIV and receive counselling and education about continuing condom use and safer sex. 55

Biomedical Interventions:

Structural interventions seek to address underlying factors that make individuals or groups vulnerable to HIV infection; these may be social, economic, political, or environmental. 58

“For many people, the simple fact that 90% of the world's HIV infections occur in developing countries is evidence that social, economic and political structures drive risk behaviours and shape vulnerability.”  59

Structural interventions have been hard to implement, generally because they deal with deeply rooted socio-economic issues, that can take a long time to change; such as poverty, gender inequality and social marginalisation. 60 They can also be reliant on the cooperation of governments, to achieve law or policy reforms. For example, laws that criminalise same-sex relationships often hinder men who have sex with men from accessing condoms, a woman’s subordinate status can affect her ability to negotiate condom use, and a lack of infrastructure, such as transport, prevents people from accessing health clinics. By successfully addressing these structural barriers, individuals are empowered and able to access HIV prevention services.

Structural Interventions:

  • Decriminalise sex work
  • Decriminalise homosexuality
  • Decriminalise drug use
  • Law reform to protect people living with HIV
  • Law reform to address gender inequalities
  • Interventions that address poverty: e.g. microfinance programmes; programmes for gender based violence
  • Addressing stigma and discrimination towards key populations 61 62

A public health approach to combination prevention

More recently, some people have advocated for a public health approach to combination prevention.

This involves using a combination of biomedical, behavioural and structural strategies to target currently available resources at high transmission regions or 'hot spots', and high risk groups.

The idea is that even a partially effective HIV vaccine targeted in the right way, has the potential to provide a cost-effective way of containing the global HIV epidemic. 63

Combination prevention case study: IMAGE

Intimate partner violence and HIV/AIDS have been identified as major and interlinked public health concerns in South Africa. The continued power-imbalance among men and women in South Africa means that, in many cases, intimate partner violence is directed at women. Violence against women impacts both directly and indirectly on a woman’s vulnerability to HIV infection; a woman may be placed at risk of HIV infection as a result of a forced sexual act, or she may avoid attempting to negotiate condom use due to fear of violence. It is estimated that 1 in 7 new HIV infections among women could have been averted if they were not subjected to intimate partner violence. 64

Unfortunately, violence against women remains common throughout South Africa. Surveys show that 40 percent of men reported physical violence towards an intimate partner in the past; whilst over a quarter of men reported raping a woman in their lifetime. 65 Of the men surveyed, there was no substantial difference in socio-economic background or race. 66 Furthermore, studies in South Africa show that women who are subject to intimate partner violence are at a higher risk of HIV infection. 67 Thus is it vital that HIV prevention and healthcare services address gender imbalance, and challenge social norms around masculinity and sexual entitlement. 68 

Previously, government approaches to HIV prevention in South Africa had focused largely on individual risk to HIV infection, and thus on behavioural change prevention programmes. 69 However, a rapidly growing epidemic led researchers to review some of the wider, environmental factors that shaped the epidemic. They identified three structural factors that accelerated HIV transmission in South Africa: poverty, gender inequality, and mobility (i.e. migration, etc.). 

Based on this evidence, between 2001-2005, the ‘Intervention with Microfinance for AIDS and Gender Equality’ (IMAGE) project was launched. This sought to reduce a woman’s risk of contracting HIV, by addressing gender-based vulnerabilities to HIV infection. 70 These included violence against women, economic dependency on men, and lack of knowledge about HIV and transmission. IMAGE integrated itself into microfinance initiatives already working with local communities, by implementing gender and HIV education workshops, and identifying peer educators to pass on information to the rest of the community. Microfinance initiatives are those that provide small loans to cooperatives, often women, so that people who might not otherwise have access to money, can start their own business.

IMAGE worked by empowering women by making them less dependent on others and, for example, in a position to insist on condom use. Over 2 years, it was estimated that levels of intimate partner violence were reduced by 55 percent. Overall the study found that there was significant evidence to support the provision of health services and education through microfinance programmes. 71

Global strategies for HIV prevention going forward

Over the course of more than three decades the global approach to HIV prevention has moved from a fragmented one, initiated by different communities affected by HIV, to a unified approach led by international and national organisations and governments. As a result of past experiences and lessons learnt, global HIV prevention has evolved from a ‘one-size-fits-all’ approach, to an all-incorporating and combined approach that provides people with both the right environment and the tools they need to prevent HIV.

Expansion of the combination prevention approach is essential to avoid future HIV infections and for the health and well-being of people living with HIV. Currently, less than 10 percent of people in the world who are at risk of HIV infection are reached with prevention services. 72 The global HIV response must continue to find ways of working with and empowering communities who are affected by HIV to deliver the prevention techniques that work for them.



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