Beyond ABC: Newer Approaches to Preventing HIV/AIDS

Hi, my name is [PRESENTER NAME]. I’m [PRESENTER ROLE]. Welcome to “Beyond ABC: Newer Approaches to Preventing HIV/AIDS.”

For many years, governments and non-governmental organizations have promoted an “ABC” approach to preventing HIV/AIDS. “ABC” stands for Abstain from sex until marriage, Be faithful to a single partner, and use a Condom every time you have sex. That’s all certainly good advice, and if we can get more people to follow it, we will reduce the spread of HIV, the virus that causes AIDS.

But is ABC the whole story? Is it the best we can do? ABC has some known limitations. This video discusses those limitations and additional things we can do to prevent the spread of HIV.

One problem with ABC is that it assumes that a person has control over their own body and the ability to get help if their rights are violated. Obviously, if a person is in a culture where they do not have equal rights, they may not be able to follow the ABC guidelines. This often happens to women in cultures where gender inequality is the norm. For example, women may contract HIV through rape, marital rape, or their husband’s infidelity. Women may be unable to flee an abusive marriage for fear of poverty and starvation or of losing their children. These problems are discussed in more detail in our video called “Ending Gender Inequality: A Key to Stopping HIV.” 

Because of these realities, a broader acronym was recently developed called S.A.V.E. This means Safer practices, Access to antiretroviral medications, Voluntary counseling and testing, and Empowerment/Education. Let’s talk about what each one of these things mean.

“Safer practices” includes some parts of the ABC message. For example, choosing abstinence until marriage, being faithful to a single partner, and using a condom every time you have sex are all examples of safer practices that are better than alternatives like unprotected sexual activity. However, SAVE recognizes that ABC isn’t a message that is helpful to women and girls who aren’t able to control whether they have sex, who they have sex with, under what conditions they have sex, whether condoms are used, and whether their partner is honest with them about their fidelity.

“Access to AIDS medications” recognizes that for people who are already HIV positive or for risk reduction of the HIV negative partner of those already positive, it’s crucial that AIDS medications (known as antiretroviral medications, or ARVs for short) be made readily available to all who need them.  Making AIDS medications readily available is critical to stopping the spread of HIV. People treated with AIDS medications have lower viral loads, are less infectious, and are therefore only one twenty-fifth as likely to transmit HIV to others.

Voluntary counseling and testing recognizes that all people in every country must have access to counseling and be encouraged to get counseled in the modes of transmission of HIV.  Additionally, it recognizes that all people must have access to testing.  If everyone were aware and educated about how HIV is transmitted, with additional focus on stigma reduction and testing with universal access to AIDS medication and nutrition, it would be a great step forward for HIV prevention. 
 
Reducing HIV stigma will in turn make individuals more willing to be tested. When testing is available but treatment is not, people are unlikely to seek testing because they see possible negative consequences such as stigma, discrimination, and domestic violence if they receive a test result of "HIV positive" but no benefits. When people know that if they are HIV positive they can get treatment that will prolong their life, they are more likely to seek testing. 

“Education/Empowerment” recognizes that awareness and knowledge, combined with the ability to act on it, reduces the spread of HIV/AIDS. People need education about HIV so they understand how it is transmitted, how to reduce their risk, how and why to get tested, and that there is treatment. Broad-based education is also necessary to reduce cultural stigma about HIV. But education alone is not enough.  Education won’t help you if you don’t have control over whether you have sex, with whom, and on what terms.

Education/Empowerment is also part of another “Beyond ABC” approach known as “DEF” for Disclosure in safety, Education/empowerment, and Female-controlled prevention methods.

Let’s discuss Disclosure and Female-controlled prevention methods in detail.

Disclosure in Safety

Women in particular often fear that if they disclose their HIV-positive status to their partner or husband, they may suffer harm as a result. They fear consequences like domestic abuse, being ejected from the household, losing their children, being ostracized in their community, losing their job, and loss of family support—even if they were faithful to their husband and infected by him! Steps like training police and law enforcement officials on the links between HIV/AIDS and domestic violence, ensuring that there is a functioning legal system people have confidence in, and providing shelters for women who fear domestic violence can all help create an environment that enables disclosure in safety.

Female-Controlled Prevention Methods

The condom is the most effective tool we have for preventing HIV transmission during sexual activity such as vaginal, oral, and anal sex. Unfortunately, a condom can’t be used without the man’s knowledge and cooperation. This means that a woman who is in a sexual relationship with a man who refuses to use a condom is unable to use the most effective barrier method to protect herself from infection.  It would be a great step forward if there were proven female-controlled methods for reducing the risk of HIV transmission. Scientists are currently studying whether technologies such as microbicides are effective for preventing HIV transmission.

Medically Performed Male Circumcision (With Counseling)

Tests in 2005 and 2006 showed that medically performed male circumcision with counseling is a safe and effective way of reducing a man’s risk of contracting HIV through heterosexual intercourse. Tests in Uganda, Kenya, and South Africa showed that medically performed male circumcision with counseling reduced a man's risk of contracting HIV by half or more. It is important to note that these tests only proved that men would be at lower risk of contracting HIV through heterosexual sex. It has not been proven whether there is a risk reduction for a man’s female partner and if so, how much. It is also unknown whether circumcision reduces the risk of HIV transmission during anal sex between men. Circumcision is definitely no guarantee against HIV infection and is no substitute for safer practices like using a condom. Circumcised men must continue to use condoms just like uncircumcised men for their own protection and for the protection of their partner. However, medically performed male circumcision, accompanied by appropriate counseling about the need for continued safer sex practices, is clearly one more tool we can use to slow the spread of HIV, particularly in areas such as Africa where there is a heterosexual epidemic of HIV and access to condoms can be limited.

Significantly slowing the spread of HIV will require not only the ABC approach, but also additional methods such as the ones we have discussed in this video. By focusing on testing and access to AIDS medications, education and empowerment to those at risk, and the use of newer methods and techniques to reduce transmission, we will help prevent the further spread of HIV/AIDS. This is [PRESENTER NAME].

This script was reviewed for accuracy and approved by Becky Kuhn, M.D. on July 30, 2011.

References:

"Christian Aid’s HIV unit replaces ABC with SAVE in its comprehensive HIV programmes." 21 March 2006 news release from Christian-Aid.org.uk. http://www.christian-aid.org.uk/news/media/pressrel/060321p.htm

Fleishman, Janet. “Beyond ‘ABC’: Helping Women Fight AIDS.” Commentary. 29 June 2004 Washington Post p. A23. http://www.washingtonpost.com/wp-dyn/articles/A13501-2004Jun28.html

Jha, Alok. "Taking prevention of AIDS beyond ABC: British doctors lead European search for microbicides to stop transmission of HIV." 22 March 2004 Guardian. http://www.guardian.co.uk/uk_news/story/0,3604,1174871,00.html

McNeil, Donald G., Jr. "Early H.I.V. Therapy Sharply Curbs Transmission." 12 May 2011 New York Times. http://www.nytimes.com/2011/05/13/health/research/13hiv.html. Accessed 25 July 2011.

National Institute of Allergy and Infectious Diseases. "Adult Male Circumcision Significantly Reduces Risk of Acquiring HIV." 31 December 2006 news release. http://www.nih.gov/news/pr/dec2006/niaid-13.htm