Meanwhile, the hitherto sharp focus on the prevention needs of the uninfected population, as well as those who do not know that they are infected, is being lost. We feel it is incumbent on all actors involved in fighting the AIDS epidemic in Africa to remember that while all due attention must of course be given to those already suffering from HIV related disease, the great majority of the population of every African country remains uninfected and therefore theoretically at risk. To ensure that they remain free of HIV, our efforts must be redoubled to identify and evaluate appropriate messages for this majority.
Otherwise we face the calamitous prospect of increasing HIV prevalence because of a decrease in AIDS related mortality because of ART , alongside an increase in HIV incidence because of behavioural dis-inhibition within the general population. The long term burden to society of such a scenario would be intolerable.
Several reviews have concluded that each of A, B, and C have played a critical part in curbing the Ugandan AIDS epidemic to date, 17, 23, 24 with each of the three focusing on specific groups and behaviours, as identified in this piece; and it is evident that they should each continue to do so during the era of ART.
A will continue to be an essential message for young people who have not yet become sexually active. B is imperative for all those persons who have established long term and life long relationships. Finally, C will remain vital for people living with HIV and for all those people who for one reason or another are not able to abstain or to be faithful to their partners.
Search for this keyword. Log in via Institution. HIV prevention in Uganda in the era of antiretroviral therapy. Revisiting the ABC strategy: Abstinence The term abstinence can refer either to a situation in which a young person who has never had sex delays starting sexual activity primary abstinence , or to a person who decides to stop sexual activity after initiation secondary abstinence.
Being faithful In its purest sense, the B of ABC entails practising sex with just one partner, in a long term or lifelong relationship such as marriage and only after determining that both partners are not infected with HIV. Condoms When used consistently and correctly, the male condom is effective for the reduction of sexual transmission of HIV and of other sexually transmitted infections.
Acknowledgments We thank Professor Jimmy Whitworth as well as the two anonymous referees for their valuable comments on the paper. Declining HIV rates in Uganda: Let it be sexual: Transmission of HIV-1 infection in sub-Saharan Africa and effect of elimination of unsafe injections. Lancet ; Declining HIV-1 incidence and associated prevalence over 10 years in a rural population in south-west Uganda: Uganda Bureau of Statistics.
Uganda Bureau of Statistics, Ministry of Health, Impact of highly active antiretroviral treatment on HIV seroincidence among men who have sex with men: Am J Public Health ; Gremy I , Beltzer N. HIV risk and condom use in the adult heterosexual population in France between and AIDS ; Effect of highly active antiretroviral therapy on diagnoses of sexually transmitted diseases in people with AIDS.
Changes in the transmission dynamics of the HIV epidemic after the wide-scale use of antiretroviral therapy could explain increases in sexually transmitted infections: Sex Transm Dis ; Straight Talk ; Ministry of Education and Sports. Ministry of Education and Sport, Population-level HIV declines and behavioural risk avoidance in Uganda. Science ; Demographic and Health Surveys. A, B and C in Uganda: The Alan Guttmacher Institute, Position statement on condoms and HIV prevention. Effectiveness of condoms in preventing sexually transmitted infections. Bull WHO ; However, what is less well understood is how to bring about A, B, and C.
The related programmatic interventions have focused on mass education, with related mass condom distribution, in the process creating the impression that nations are responding and, as such, any demonstrable impacts on new infections must be due to risky behaviour or inflexible cultural norms. The reality, however, is a little more complex and suggest a fundamental misalignment of prevention approaches to the needs of not only countries, but communities of populations within countries.
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Improved HIV surveillance shows that concentrated epidemics are more widespread than generally believed. Yet, the focus in programmatic interventions remains at the level of the general population, with limited or no knowledge in most countries about the key populations driving the epidemic. This reflects a disconnect between the epidemic and the response, one reason for which is the reliance on behavioural survey data, which may indicate a lack of protected sexual contact, without adequate episurveillance data, which would indicate that this may not matter for the general population. This implies that countries urgently need good surveillance data and better monitoring of interactions among groups such as sex workers and clients, injecting drug users and their partners.
The lack of adequate data gathering and monitoring means the epidemic is taking off in several countries. This, along with similar scenarios in other countries in the region, suggests that primary prevention focused on the uninfected matters for southern Africa and probably eastern Africa, but secondary prevention focused on the infected groups in concentrated epidemics is needed elsewhere.
Rethinking Aids Prevention: Learning From Successes in Developing Countries
Based on this argument, two parallel and interconnected approaches will improve the efficacy of prevention programmes. The first is to better target prevention interventions to specific groups in ways that take into account their risk factors. The second is to expand prevention services to reach groups in underserved areas.
The problem with the ABC approach is that the neat alphabetic label confuses the outcomes of successful HIV programmes with the message needed to achieve effective results.
Edward C. Green
It also ignores the strong possibility that each of these components may be more or less effective or relevant depending on cultural, political and economic circumstances, and the stage of the epidemic - early or late. The experience of Uganda is instructive.
BBC News Online God and the fight against AIDS. New York Rev Books ; 52 7: Uganda was remarkable in the extent to which it achieved diversity in prevention messages, but this was done by establishing a political environment that encouraged many actors with many messages [ 24 Stoneburner RL, Low-Beer D. Population-level HIV declines and behavioral risk avoidance in Uganda. Science ; Behaviour and communication change in reducing HIV: Recent regressions are arguably attributable to the focus on treatment at the expense of the traditional method of multi sectoral prevention.
The second ideological obsession is the focus on condom use as an indication of efficacy of prevention interventions. It is obvious that a barrier method prevents transfer of the virus. Condoms have been very important in reducing transmission in heterosexual and homosexual epidemics in the rich countries.
Yet it was not to do with condoms alone. In this highly motivated group, where sex was largely recreational, condoms were a key component of an effective response. Men who have sex with men were familiar with the technology, they had few moral or ideological scruples about using condoms, and if they wished to continue with the bath house culture of the s, then condoms were a necessity. In contrast, the explosive nature of the African epidemics shows that despite the resources devoted to condom distribution over the past two decades, there has never been sufficient availability of condoms, and where available, people have been very reluctant to use them.
Until recently, religious opposition has also been a significant adverse factor. In sub-Saharan Africa, this translates into eight condoms per man per year and one condom per every 10 women per year. Reviewing the role of condoms in the fourth decade of HIV. While some of the largest countries Brazil, China and India are self sufficient in providing condoms, for many poor countries, the gap between condom needs and donor support means paying for imported condoms with funds diverted from purchases of much needed food, medicine and other necessities.
Though condom promotion looked like a sensible response, it has been singularly ineffective; a point recently made by President Yoweri Museveni of Uganda: We managed to bring down the rates of infection through prevention messages until other people brought in condom use and circumcision. People became complacent… for a young person to get AIDS is to betray their parents who have invested so much in them. Uganda to fight AIDS with or without aid. So, why have condoms been the preferred strategy? Prevention, and especially the behaviour changes needed to ensure prevention, occur in social and economic contexts, yet they depend on individual decisions.
Behaviour change requires far more than having basic knowledge about AIDS, or even being disturbed or concerned about it. It is in this sense that the author Pisani is wrong to suggest HIV prevention is not essentially a development issue: There are obvious and less obvious answers to this question, with the obvious answer being that a virus passes between one person and another, most often during sex, but also via inadequately cleaned medical instruments, injection syringes, blood transfusion, or from an infected mother to her child during birth.
The less obvious answer and it is one that takes us directly onto development is that wider social, economic and cultural conditions affect the likelihood of somebody becoming infected. In essence we need to examine two major factors: The means to change depends on the physical means, the social status to do be able so, some control over relationships and actions, and certain choices.
In the presence of choices and physical means, the motivation or propensity to change becomes a factor. Propensity is dependent on sufficient motivation to never engage in risky behaviour, motivations to shift from a mode of risky behaviour to less risky behaviour, and sufficient motivation to maintain less risky behaviour once in that state. This propensity to engage in less risky behaviour is dependent upon social norms, perceptions of what such behaviour implies about the individual and others, and the perceived reward that this will bring.
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Taking cognizance of the context or environment in which individual behaviour changes occur will help to precipitate and maintain the changes. We know that social and economic inequality, including gender inequality, can and does lead to men exercising sexual power over women. What happens in the market, what happens in the public arena, the public examples set by rich and powerful men, terms of trade between producers and purchasers of commodities all of these may affect sexual choices and situations. The fact that women fish sellers may have to facilitate their purchases from fishermen and their sales to dealers by providing sex as well as cash or fish, may seem surprising but it happens, and it happens because men expect it and women feel they have no choice.
At another level, wage rate systems that habitually pay women less than men, property laws that give men precedence over women in ownership and inheritance, laws against rape that are not treated seriously by the courts all of these are ways in which broad social conditions provide a breeding ground for HIV. The social scorn and even violence that afflict sex workers, men who have sex with men, and injecting drug users in many settings, now often exacerbated by HIV stigma, can be an almost insuperable barrier to reaching these vulnerable populations with prevention services, even when resources are available.
Many governments refuse to acknowledge the existence of these populations or their right to prevention services, setting inappropriate prevention priorities that endanger those at risk and squander the opportunity to bring the epidemic under control at an early stage. Moreover, many governments continue to pursue failed punitive policies toward sex work and drug use, driving those at risk of HIV infection further underground and enhancing the spread of the virus through incarceration or forced and ineffective drug treatment.
Although effective prevention interventions for sex workers, injecting drug users, and men who have sex with men are well known, scaling them up will depend fundamentally on protecting the rights of these vulnerable populations, reversing harmful government policies, and setting appropriate priorities.
So where do we go to from here with prevention? Conventional wisdom argues that the problem is one of scale of bringing a set of proven interventions to those who need them, of moving from projects to national programmes and that the primary obstacle is lack of resources. Indeed, most people in the developing world still do not have access to basic prevention services, and rapid scale up of coverage remains a central priority. There is no doubt, moreover, that the gap between what comprehensive coverage would cost and the resources currently available to developing countries remains large.
For some prevention services, notably prevention of mother to child transmission and treatment of sexually transmitted infections, the challenge is indeed primarily that of scaling up, and of strengthening health systems to make this possible. However, for other critical aspects of prevention, other challenges are at least as important.
In the high prevalence, generalised epidemics of eastern and southern Africa, successful prevention will require broad based changes in behaviour. At an individual level, we know that using condoms consistently and having fewer sexual partners can prevent most new infections, but, at a population level, patterns of sexual behaviour have often proved resistant to change. Part of the answer is greater coverage of standard prevention services and provision of basic information and motivation for change through the media, schools, and other channels.
This will require more resources, but the experience of 30 years has taught that success will require greater attention to two additional factors, outlined below. First is that we now understand that the capacity of individuals to change their behaviour and to protect themselves is often very constrained by economic circumstances, by gender inequities, often reinforced by both cultural forms and economic circumstances. Thus, greater efforts should be focused on addressing these broader obstacles to behaviour change, especially the rigid gender roles and inequalities that put both women and men at greater risk.
Currently, we are seeing differential vulnerability to HIV - with young women showing the highest incidence. As a result, we are seeing differential impacts of HIV, with women more likely to be stigmatised and left without care; more likely to face financial difficulties in accessing treatment or care; more likely to be engaged in a form of income generation which offers no legal protection and no medical aid.
Second, one of the greatest lessons of the few relatively large scale HIV prevention success stories is that the impetus for lasting change, and much of the difficult work of addressing deeply rooted cultural norms, must come from communities themselves. Community involvement is essential in reaching key marginalised and vulnerable populations at greatest risk of infection and at risk of infecting others.
Donors and national governments can do much to stimulate, support, and expand this local response, but must do so in ways that respect and enhance the leading role of communities and local civil society. An approach which is centred around community mobilization does not pre empt the possibility of setting priorities; rather it does so with the assistance of communities.
The foci of assistance need to be complemented by a more general mobilization and sustained by appropriate forms of assistance, by the availability, accessibility and affordability of the required goods and services and by appropriate legal, ethical and human rights policies and practices.
The progress made against HIV and AIDS in the last fifteen years has rightly been hailed as an unprecedented, extended expression of global solidarity; as a first order organizational and political achievement; and as a unique programme combining biomedical and behavioural interventions; sustained, in country innovations in prevention; an astonishing marshalling of financial resources; and feats of consensus building and coordination against all manner of national, organizational and cultural divides.
With 15 million human beings now on life saving antiretrovirals it is perhaps difficult to appreciate the intimidating odds against meeting that target at the outset. On the fast track to end AIDS. The momentum achieved during the course of the MDGs is of invaluable political and normative importance, but it is likely to be an unhelpful guide to the next fifteen years in respect of either the disease dynamics or the world of fiscal and political possibilities.
Rethinking AIDS prevention : learning from successes in developing countries
In any event, the normative force of sustained effort and the early achievement of the ART enrolment target will diminish rapidly; and all the more swiftly if the world ceases to perceive HIV and AIDS as a continuing global health emergency. The encompassing, strategic challenge for the next fifteen years is this: The strengthening and enlargement of programmatic activities at the heart of the campaign must be newly enabled, on the basis of reconfigured donor recipient and other key relationships.
The challenges this will generate will reach all levels and nearly every particular of the global AIDS response. Revitalising prevention initiatives is an urgent priority. Without renewed, effective prevention programmes, we run the risk of losing ground to HIV, even as we prepare to extend treatment coverage to millions more people. Linked to the full panoply of tailored interventions and education, there are several other issues related to the quality of the current ART regime: The triumph over the past decade or so is more a reprieve than a victory one that requires consolidation through renewed effort.
The key to not losing ground is in the prevention of new infections. AIDS, poverty, and human development. PLoS Med ; 4 The balance between prevention, treatment and impact mitigation will be specific to each country.
The specific local cultural, political and material circumstances will influence the content of any particular programme. Furthermore, countries will need to break down the epidemics into their geographic, social and economic components, in order to frame and target national prevention programmes in ways that increase their efficacy. This must take place in an environment that promotes the possibility of open and honest discussion of sexuality and dying by confronting some uncomfortable cultural and societal truths.
For three decades it has been the position of many observers of this grotesquely pervasive epidemic that politics, not medicine, has been its dominant feature.
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Consequently, it is in the political arena in which a solution has to be conceived and enacted to enable a revolution in HIV prevention, as much as in medical terms. The challenge for all governments is to understand just how little we have in the armoury, how cunning is the enemy, and how important it is to seek solutions in the diversity of responses which have been shown to be possible, from within the richness of their particular circumstances.
The time has come for common ground on preventing sexual transmission of HIV.