From bloggers Neil M. Orr and David R. Patient, June 3 2014 - The Failure of the ABC Approach
For close to 25 years the standard HIV prevention strategy was the ABC sexual behaviour change strategy: Abstain, be Faithful, and use Condoms. Today, this ‘old’ strategy has all but faded into the background, with only condoms remaining on the tick-list of ‘to do’s’. The evidence was clear: New infections continued to rise steadily year after year, regardless of ABC. The 2012 South African Department of Health Antenatal Study confirms this.
Re-focusing upon the Facts and Rules of Transmission
One of the failings of the old ABC approach was to make the exceptions the rule, and to focus upon these exceptions to deal with preventing HIV transmission in the general population: Multiple partners, infidelity, high frequency of sex, and early age of commencement of sexual activity, to name a few assumptions.
Research during the past decade revealed that people are not (by and large) overly sexually active: The average South African is literally average in terms of sexual activity, compared to the rest of the world. The same was found for the age of first sexual activity. It also turned out that multiple partners - although a high risk for HIV transmission - is not as widespread as previously thought, and cannot explain rapid increases in overall HIV transmission within a community. The ‘AB’ (abstain and be faithful) strategy failed because people were (by and large) already pretty conservative in this regard.
Condoms, although a logical and ideal solution, did not have the impact that was expected. At first, the reason for this failure was blamed on lack of education and availability. However when these were corrected not much changed, except for youth and sex workers (recreational sex). Other people resisted condoms for relationship reasons (trust issues; proof of love and commitment) and because it simply prevented having babies (procreational sex). The desire to have babies beats the risk of death, for many people. Count the number of pregnant peer educators if you question the mismatch between the ABC message and what people are really doing.
Focusing upon the general rules, not the exceptions
There has always been - and always will be - people, behaviours, resources and circumstances that are beyond the range of what is considered average or normal. These would require target-specific methods. However, for the great majority of people and circumstances, the A-3B-4C-T approach is pretty straightforward and (mostly) within the current government health guidelines and protocols.
It’s time to catch up, refocus, and spend our energies and resources with a higher level of efficiency and impact.
The A-3B-4C-T Approach
Fortunately, a completely different prevention strategy has emerged over the past few years, which we term – for the lack of a better acronym - the A-3B-4C-T approach. These are the 9 primary HIV transmission risk-reduction strategies that can reduce HIV transmission as stand-alone interventions:
- A: Antiretrovirals (ARVs) as prevention, with emphasis upon access and adherence
- B1: Barriers (physical barriers - condoms and microbicides when approved released, - and behavioural barriers - abstinence, delayed sexual debut, multiple partner reduction),B2: Blood precautions (issues concerning breaches of skin and membranes)
- B3: Babies (PMTCT)
- C1: Circumcision (VMMC) - Voluntary Male Medical Circumcision
- C2: Co-infection reduction (TB, gastrointestinal, malaria, STIs, and others)
- C3: Couples HIV testing and counseling and testing (CHTC)
- C4: Community Viral Load Management (CVLM) - group-focused; primary health and occupational health issues
- T: Testing (HCT)
We have intentionally deleted Be Faithful from the list of primary prevention methods because many people - especially women - have been faithful to their partners and have become infected because they did not consider the fidelity (or lack thereof) of their partner. It takes more than one person to be faithful, in terms of reducing the risk of HIV transmission. To retain Be Faithful, this strategy needs to be considered a secondary strategy, and included as part of Couples’ HIV Testing and Counseling (C3), not as a primary stand-alone strategy.
The nature of the required behaviour changes is different to ABC, and are more closely linked to economics, gender equity, and mental health issues, including motivation towards a better future, communication within relationships, stress and depression, and substance use (especially alcohol).
The results of the A-3B-4C-T approach are dramatic. A selection of results illustrates the impact of some of these primary prevention methods:
- For couples where one person has HIV and is taking ARVs, and the other is HIV-negative, the probability of transmitting HIV to the uninfected partner is close to zero (99.9%) after the treated partner achieves an undetectable viral load;
- With the new PMTCT (Prevention of Mother-to-Child Transmission) protocols - when applied as intended - mother-to-child transmission rates can be reduced from 20 to 25% levels to close to 1%. This is a 95%+ reduction in transmission;
- Voluntary Male Medical Circumcision (VMMC) reduces the chances of a male becoming infected with HIV by about 50%, and the probability of him later infecting his regular partner by about 50% (WHO).
Condoms have re-emerged as an effective - but more targeted - prevention method. For example, advocating condoms as a short-term protective measure while a couple waits for the infected partner’s viral load to drop to safer levels, so that conception of babies can occur without risk of transmission from one partner to another. Condoms are also much more effective in specific groups, such as those engaging in sexual behaviour for recreational or economic reasons, as opposed to those having sex for procreational purposes.
New opportunities require new understanding
The new A-3B-4C-T is largely based upon biology: The nature of HIV and how the viral load is the key to understanding risk of transmission within any given situation. Three biological terms need to be thoroughly understood: Viral Load (VL), Co-infections, and Langerhans Cells. When these terms are understood and logically applied, a wide range of prevention methods become obvious, including individual, couples, and community interventions.
Understanding the general course of HIV viral load is essential in developing effective prevention strategies. Many medical experts state that the viral load is more important that the CD4 count in determining the health and wellbeing of a person.
Sexual behaviour has not been eliminated as a primary factor in HIV transmission. In the A-3B-4C-T approach, sexual behaviour may be viewed (metaphorically) as the vehicle, while HIV is the passenger. To date, little attention (from a prevention perspective) has been paid to the activity of the passenger (HIV), and its’ peculiarities. Sometimes – such as when the viral load is undetectable – the passenger (HIV) has great difficulty escaping the vehicle it is in to enter another vehicle.
Naturally, this shift in focus has resulted in a range of new issues, such as ensuring adherence to treatment, early pregnancy detection, and facing traditional and religious beliefs regarding male circumcision, to name a few of the emerging challenges. Also, the fact that the viral load is significantly affected by basic issues such as access to primary health care for co-infections as well as the quality and quantity of food, water and sanitation, requires a far more integrated (mainstreaming) approach to HIV prevention and risk-reducing methods.
Other challenges include a change in the nature of stigma. In the ‘old ABC’ era, stigma was based heavily upon the morality of sexuality and fear of death. With large-scale ART implementation, the new A-3B-4C-T approach brings a different kind of stigma based upon judgments of carelessness regarding health behaviour.
Prevention messaging is also changing because the threat of illness and death has been potentially removed. The youth, in particular, are skeptical of the need to reduce the risk of becoming infected: “You get HIV then take the pills. What’s the big deal?”
The following is a brief (incomplete) list of issues to be discussed concerning the new A-3B-4C-T approach:
Viral Load (VL): VL levels vary from infection to AIDS: What does this mean for targeted prevention efforts?
- Window period; Highest VL and thus risk of transmission; Person tests HIV-negative, yet has the highest probability of transmission; ARS (Acute Retroviral Infection): Typical symptoms and practical interventions during HCT and primary health care visits;
- Sero-discordant (HIV+/HIV-) partners: How does this happen?
- AIDS: High VL but low sex drive;
- Pilot studies on PrEP (Pre-exposure Prophylaxis);
- Substance use (drugs): Various effects on VL
- Majority of infection: Low VL, but ‘viral spiking’ during co-infections;
- How co-infections affect the viral load (e.g., TB, STIs [sexually transmitted infections], malaria, common parasites) and the role of primary health interventions (washing hands, kitchen hygiene, cooking methods) and treatment.
Antiretroviral treatment (ART) as prevention:
- It is all about the viral load...
- Treatment adherence: The real challenge
- Non-adherence: Partner infected with drug-resistant strain
- Adherence monitoring: How? Who?
- Reasons for non-adherence: Money (transport cost), distance, depression, alcohol, and side-effects
- Traditional mutis: What are the facts?
Medical Male Circumcision (MMC):
- Langerhans Cells
- The difference between traditional and medical circumcision
- Recuperation time
- Incentivizing / Motivating
Myths and Facts about ‘Cures’:
- The Berlin Patient: The first ‘cure’?
- Babies being ‘cured ‘
- French patients who stopped ART: No viral load
- Faith-healing: HIV-positive to HIV-Negative; What is that about?
- Pre-ART Sex-Death morality and fear-based stigma
- Post-ART patronizing stigma
David Patient & Neil Orr
David Patient has been living with HIV since 1983. He has been on ART since 2006. He has been actively involved in community advocacy since 1986. Neil Orr is a research psychologist. Both have been working in the area of HIV and AIDS in South Africa for more than 20 years. They are currently focusing upon a peer-based programmes and materials designed to integrate new medical developments into risk-reduction interventions.
Organisation: Empowerment Concepts
Office: Nelspruit (Mpumalanga), South Africa