On World AIDS Day (1 December), the Joint United Nations Programme on HIV/AIDS (UNAIDS) called for a revival of HIV prevention efforts. They launched a global campaign entitled ‘Hands Up for HIV Prevention’ in which famous and less famous people were asked to write a prevention message on the palm of their hand and have their photo taken. It was a clever communications strategy, but it reminded me of how UNAIDS and other organizations tend to simplify the complexity of HIV prevention into short slogans. In this blog, I argue that we should stop simplifying HIV prevention and move from one-size-fits-all-approaches to ‘Prevention 2.0’, making individual clients and their individual contexts and needs central to the messages and prevention options we provide in acknowledgement of the diversity and complexity of HIV transmission and prevention.
In the past decades, I have worked on promoting HIV prevention in Cambodia, Lao PDR, Mongolia, the Philippines and many other Asian countries. Often I found that HIV prevention was conducted using simple slogans such as ‘No Condoms No Sex’ or ‘Stop AIDS, Use a Condom’ (see illustrations), without adapting such messages to the context of individual clients. I learned that HIV outreach workers often do not have the skills needed to seriously discuss behavioural change with clients and motivate them to change their sexual behaviours or the challenges that come with such change. Local HIV practitioners often have limited knowledge about HIV; for example, they are often not aware how difficult it is to transmit HIV or about the different transmission probabilities of HIV via different sexual behaviours. And most importantly, most HIV prevention efforts are not truly ‘client-centered’—meaning that they do not take the situation of each individual client as the starting point for a trajectory towards gradual HIV risk reduction.
No wonder that many prevention programs have been found to have little effect; in many countries, prevention programs have been scaled down. Instead, main donors, including USAID and the Global Fund on AIDS, Tuberculosis and Malaria, have now started focussing their efforts entirely on biomedical prevention, especially ‘Treatment as Prevention’. The focus of HIV prevention programming has shifted to ‘case finding’; i.e., finding undiagnosed HIV cases in a population and putting them on treatment, resulting in a reduction of onward HIV transmission.
This has worked well in heterosexual populations, where transmission between sero-discordant couples occurs gradually, over longer periods of time. However, in populations of men who have sex with men (MSM) and transgender women (TGW), the situation is very different. It has been estimated that up to 60% of all HIV transmission among MSM and TGW takes place during the phase of acute HIV infection; i.e.; in ‘bursts’ or ‘chains’ of new infections that occur between 4-12 weeks after exposure. As soon as an undiagnosed MSM or TGW is reached as part of an HIV case-finding program, it is likely that he/she has already passed on his/her infection to one or more other people during the acute infection phase. Thus, no matter how good case finding is, it will be impossible to prevent continued and significant HIV transmission in MSM and TGW by relying only on Treatment for Prevention.
For this reason, UNAIDS is completely correct in calling for a renewed push for HIV prevention. But let’s move beyond the “same-old, same-old”. We need to do a better job this time around by upgrading our HIV prevention programs. I am calling for ‘HIV Prevention 2.0’, a better version of our previous HIV prevention approaches. HIV Prevention 2.0 aims to make HIV prevention more complicated, less simple and, above all, less simplified – in other words, messier. Overly simplifying HIV and its transmission in our prevention messages implies that we, as HIV practitioners, think that people at risk for HIV infection are somehow not intelligent enough to deal with the complexity that surrounds the transmission and prevention of HIV. Educational messages about HIV and about HIV prevention need to be more diverse and better tailored to individual clients’ needs, and most importantly, each client should be given a more diverse set of options to reduce his/her personal risk for HIV. HIV Prevention 2.0 is based on the principle that people at risk for HIV should be given the detailed and complex knowledge they need to make up their own minds when it comes to exposing themselves to – and preventing infection by -- HIV.
First and foremost, this means that we have to start promoting detailed knowledge about the different HIV transmission probabilities involved in anal insertive sex, anal receptive sex, oral sex, vaginal sex and other forms of sex (see Table 1 below). In most countries where I have worked, MSM and TGW, even those working as HIV outreach workers, strongly overestimate the chance of HIV transmission if an HIV negative person has sex with a positive person. Many people think the transmission probability when having any kind of sex with an HIV positive person is 90-100% per sexual act, whereas in reality it is closer to 1-2% or even lower (see Table 1 below). Most people I asked also thought all sexual behaviours had the same transmission probability; they had no idea that unprotected insertive anal sex was 12 times ‘safer’ than unprotected receptive anal sex, and they did not know that there was virtually no HIV transmission risk involved in unprotected oral sex as compared to unprotected anal sex.
Why is this important? If people do not understand these details, a person who receives a blowjob from another person without using a condom (which has a virtually zero % HIV risk) may then proceed to have unprotected anal sex with that person, erroneously believing that he was already ‘exposed’ while having the blowjob; i.e., he may not use protection thinking that ‘it doesn’t matter anymore…’
HIV Prevention 2.0 therefore calls for outreach and other HIV service staff to understand the details of HIV transmission and transmission probabilities. This will allow them to reassure clients if they had a condom break or if they had unsafe sex for other reasons, thus preventing fatalistic/self-destructive reactions. Understanding the different transmission probabilities of different sexual behaviours will ultimately help clients switch from receptive anal sex to insertive anal sex only, or, much better, from anal to oral sex and to other safer sexual behaviours.
A second component of HIV Prevention 2.0 is related to the supply of condoms. Public health authorities in most countries where I have worked provide only one size of condom across its HIV prevention programs, as if every man has exactly the same size and shape of penis. Having condoms at your disposal that are either too large or too small is an important reason for inconsistent condom use and condom-slippage or breakage. Under Prevention 2.0, at least three different sizes of condoms must be made available to clients of HIV prevention services. Outreach and information campaigns need to focus on providing detailed knowledge to their clients about the different sizes, shapes and even tastes of condoms that are available and, if they are not available for free, where these can be bought. In addition, lubricants also exist in many types; MSM and TGW clients need detailed knowledge about differences among them so they can find the lubricant that they like most.
The third component of HIV Prevention 2.0 is Pre-Exposure Prophylaxis (PrEP). It’s more than 10 years since the effectiveness of PrEP in preventing HIV infection among MSM was discovered. It has been found to be even more effective as an HIV prevention strategy than the use of condoms. The World Health Organization is now recommending PrEP as a complementary HIV prevention strategy besides condoms. So why are we still not seeing widespread implementation of PrEP policies and programs among MSM and TGW in Asian cities? HIV Prevention 2.0 proposes to give PrEP the prominent position it deserves and calls for a swift roll-out, making PrEP available to every person who needs/wants it.
The fourth component of HIV Prevention 2.0 is for outreach workers and other HIV prevention workers to be trained to talk about HIV risk reduction options that do not rely on using condoms. These are much less safe than using condoms or PrEP consistently, but they can also help reduce HIV risk significantly. There are three strategies that have been found to have some positive preventative effect:
Negotiated Safety means that two men who are confirmed HIV negative and who are in a committed relationship stop using condoms while promising to be safe at all times if they have other sexual partners.
Strategic Positioning aims to reduce the chance a positive partner who has unprotected sex transmits HIV to an uninfected partner. Making use of the fact that unprotected insertive anal sex by a positive person is 12 times more ‘efficient’ in transmitting HIV than receptive anal sex (see Table 1), strategic position means that the HIV positive partner is advised to avoid being the insertive partner in anal sex while having condomless sex. In short: the positive partner should only be a ‘bottom’.
Sero-sorting is if men ask about each other’s sero-status before engaging in anal sex without condoms, making sure they do this only with people who have tested recently and who have the same HIV sero-status. This can result in a false sense of security if people are a) not testing often enough or b) are not or cannot be honest about their HIV status. Another concern is that the practice of sero-sorting might reinforce stigma against people living with HIV as long as they are a small minority, as the negative majority will actively look for sero-negative partners. Despite these drawbacks, practicing ‘sero-sorting’ has been found to reduce the risk of HIV transmission significantly as compared to having unprotected anal sex indiscriminately, without asking about each other’s sero-status.
These strategies are not as safe as using condoms consistently, but they do make a difference in reducing HIV risk so they are better than having unsafe anal sex indiscriminately. Importantly, these non-condom risk-reduction strategies work only if sexual partners have a fairly accurate knowledge of their HIV status, which means only for people who test for HIV regularly. Promoting these prevention strategies can therefore make regular HIV testing both more relevant and more attractive for MSM and TGW.
In conclusion, the practice of over-simplifying HIV prevention has systematically deprived people at risk for HIV of the skills and knowledge they need to make their own decisions when it comes to reducing their risk for HIV infection. I believe the lack of complexity in our prevention messages has led to increased risk and higher HIV exposure. It is therefore not surprising that many of these simplified programs have been unsuccessful and are being closed down in favour of biomedical HIV prevention strategies (PrEP, Treatment as Prevention). I have argued that that part of the failure of previous prevention efforts lies in the way they have kept crucial detailed information from people at risk, relying instead on broad, simplified messages. Rather than over-simplifying messages around HIV prevention as has been the case in the past, I call for ‘HIV prevention 2.0’ consisting of four equally important components: (1) promoting detailed knowledge about HIV and its transmission probabilities; (2) diversifying condom- and lubricant supplies; (3) introducing and promoting Pre-Exposure Prophylaxis, and (4) promoting the understanding of non-condom-risk reduction strategies. Although Prevention 2.0 might ultimately be “messier” than Prevention 1.0, its aim of informing and educating people at risk for HIV about the complexity of HIV transmission and about the multiple options that exist to gradually reduce HIV risk is worth the effort.