It’s not as simple as ABC
Susan Kippax
HIV is a blood-borne virus transmitted by sexual practice, particularly penetrative intercourse (vaginal or anal) with an HIV-infected person; by the sharing of HIV-contaminated needles and syringes; from an HIV-positive mother to her child during birth and breast feeding; and via the transfusion of HIV-infected blood and blood products. It is estimated that over 25 million people have died of AIDS and 33 million people are living with HIV, with 95 per cent living in low/middle income countries (UNAIDS 2007; Cohen et al. 2008). In 2007 2.5 million people became infected with HIV, while 2.1 million people died of AIDS (UNAIDS 2007). Each year, prevalence has increased as new infections outstrip the number of deaths. So although the global incidence rate is thought to have peaked, the absolute number of HIV infections continues to grow (UNAIDS 2007).
In response to what is a growing global crisis, questions have been raised concerning the efficacy and effectiveness of HIV prevention efforts, particularly those addressing sexual transmission. As sexual transmission accounts for the majority of HIV infections, this chapter focuses on HIV prevention with reference to sexual practice, that is, on the promotion of ‘safe sex’. Why has safe sex been so difficult to achieve?
HIV-prevention ‘failure’ is a function of at least three factors: the promotion of non-efficacious or ineffective HIV-prevention strategies; the ineffective promotion efficacious strategies; and a failure to address the sociocultural and political factors driving/producing sexual risk. The first two factors are to a large extent a function of the third: the failure to address the sociocultural and political contexts in which sexual practice and associated sexual risk is enacted, and HIV-prevention education is positioned. In order to address these questions I focus on the social aspects of HIV prevention and in particular on the difference between sexual ‘behaviour’ and sexual ‘practice’.
First, however, it is necessary to distinguish between efficacy and effectiveness. Many public health researchers appear to confuse or conflate the two (e.g. see Potts et al. 2008). Effectiveness is different from efficacy in important ways. Aral and Peterman (1998) define efficacy as ‘the improvement in health outcome achieved in a research setting, in expert hands, under ideal circumstances’ and they define effectiveness as ‘the impact an intervention achieves in the real world, under resource constraints, in entire populations, or in specified subgroups of a population’ (p. 33). So while effectiveness is the improvement in a health outcome in the real world, efficacy refers to whether, under ideal conditions, a particular prevention tool works. So, for example, condoms when used correctly and consistently under clinical trial conditions prevent HIV transmission in 95 per cent of cases, in real life their effectiveness falls somewhat short of 95 per cent – because in real life they are not always used and, when used, they are sometimes not used properly.
What ‘tools’ or prevention strategies do we have to prevent or, at least, reduce the likelihood of the sexual transmission of HIV? Among those currently advocated, the most common ‘behavioural’ prevention tools are the ABC: abstinence from sex or the delay of sexual initiation/debut, being faithful to one partner/practising monogamy and condom use.
Others although not advocated by many have nonetheless been adopted by some and these include: the practice of serosorting, i.e. engaging in unprotected sex only with those believed to be the same HIV serostatus as oneself; and withdrawal before ejaculation.
More recently there has been a push to promote so-called ‘biomedical’ prevention strategies. They are so named to distinguish them from behavioural strategies such as those just listed, however, with the exception of male circumcision, most biomedical prevention strategies require behavioural change of some sort. Current biomedical strategies include: microbicide use, treatment of sexually transmissible diseases, male circumcision, use of antiretroviral therapy used as pre-exposure prophylaxis and use of antiretroviral therapy to reduce viral load in individuals living with HIV.
Abstinence is 100 per cent efficacious – in the sense that, if practised, HIV cannot be sexually transmitted. Similarly, if lifelong monogamy is practised by both HIVnegative sexual partners, then it, too, is 100 per cent efficacious. Condoms, when properly and consistently used, are around 95 per cent efficacious (Pinkerton and Abramson 1997). However, withdrawal has been shown not to have reliable efficacy and serosorting is efficacious only under certain conditions (see later discussion of ‘negotiated safety’) (Zablotska et al. 2009; Jin et al. 2009). Male circumcision has been shown to be around 50–55 per cent efficacious in preventing HIV transmission from women to men (Nagelkerke et al. 2007), while evidence for the efficacy of treating sexually transmissible infections (STIs) continues to be debated and there is growing evidence that its impact on HIV control appears to be minimal (Potts et al. 2008). While the efficacy of antiretroviral therapy for the prevention of motherto-child transmission is proven (Sperling et al. 1996) the efficacy of pre-exposure prophylaxis with reference to sexual transmission remains uncertain as does the efficacy of microbicides and efficacy trials are ongoing. There is ongoing debate about the efficacy of using antiretroviral therapy to reduce viral load and hence prevent or reduce the likelihood of sexual HIV transmission between serodiscordant partners (Garnett and Gazzard 2008; Vernazza et al. 2008; Wilson et al. 2008).
So at the time of writing, with reference to the sexual transmission of HIV efficacious prevention tools available are abstinence, being faithful, consistent condom use and, to a lesser degree, male circumcision. There is no vaccine and at present the efficacy of microbicides and pre-exposure prophylaxis has not been shown.
Compared with efficacious prevention tools, there are fewer effective prevention tools and the clarity of evidence is diminished. This is because effectiveness cannot be assessed under ideal conditions but rather is concerned with the social, political and economic conditions of people’s everyday lives and the place that sex occupies within individual lives and communities. There is no evidence that abstinence is effective and little evidence that delaying sexual initiation works – at least in the industrialised world (Grunseit et al. 1997; Weaver et al. 2005).
The evidence with regard to the effectiveness of monogamy (being faithful) is very patchy and debate continues. While a range of factors, which include the practice of zero grazing (fidelity) and condom use, appears to have reduced HIV transmission in Uganda (Shelton et al. 2004; Epstein 2007; Potts et al. 2008), fidelity is more a fiction than a fact of adult sexual life (Holtzman and McLeroy 2007). Many men have extramarital sex: sociocultural structures produce the desire for sexual reputation among men exacerbating gender inequality and giving rise to infidelity in married men – in Mexico (Hirsch et al. 2007) and in Papua New Guinea (Wardlow 2007). In the context of no condom use, extramarital sex leaves wives (even if faithful themselves) vulnerable to HIV, for example, married women in some African countries (Smith 2007) and in India (Holtzman and McLeroy 2007). Infidelity in men and women and concurrent sexual partnering is often the outcome of economic need which results in forced migration for work. For example, about 35 per cent of all documented HIV cases in the Philippines are among returning overseas workers, as were 42 per cent of new cases recorded in 2006 (CARAM 2007).
Studies have shown that prevention programmes advocating condom use have been associated with a 50 to 90 per cent effectiveness in both high income as well as low and middle income countries (Auerbach 2006; Noar 2008). For example, there is evidence that condom use is effective in lowering HIV incidence among gay men in Australia (Kippax and Race 2003; Bowtell 2005) and among sex workers in Thailand (Hanenberg et al. 1994) and India (Evans and Lambert 2008). But it is also true to say that in much of the world their use is neither widespread nor consistent (Global HIV Prevention Working Group 2008).
Whether male circumcision is effective or not remains to be seen and some researchers have argued that recent evidence indicates that the protective claims are overstated (Myers and Myers 2007). On the basis of an analysis of a cross-sectional national household-based community survey in South Africa carried out in 2002, Connolly et al. concluded that ‘male circumcision does not appear to be protective against HIV infection among men in South Africa’ (Connolly et al. 2008: 793). Certainly, time is needed to assess the impact of circumcision in the real world and, in particular, to assess whether male circumcision inhibits condom use.
So with reference to effectiveness, we can say that condom use lowers HIV incidence in some countries and contexts, but not in others, and that while reduction in number of partners in general and fidelity in particular have an impact on HIV infection rates at the population level to slow the HIV epidemic, fidelity does not protect all individuals. More evidence is needed with reference to male circumcision.
In general, with regard to behavioural change, according to the available evidence, strategies that prove to be effective are likely to pursue a combination of behaviour change strategies – condom use and reduction in number of partners (Rutherford 2008). Furthermore, as I shall describe later, they are likely to be effective only if these ‘safe’ sex strategies are promoted in such a way as to engage the communities and sub-populations at risk so as to enable normative as well as individual change (Global HIV Prevention Working Group 2008).
The major reason for the unevenness of the effectiveness of HIV prevention strategies and the lack of clarity with regard to evidence of effectiveness when compared with efficacy, is that the practices that comprise the prevention strategies – condom use, ‘being faithful’ – are cultural practices par excellence. Male circumcision, too, albeit in a somewhat different way, is a cultural practice linked in many societies to initiation rites associated with manhood (Aggleton 2007). Furthermore, because effectiveness, unlike efficacy, refers to health improvement in the real world, it is dependent to some degree on how these strategies – fidelity, condom use and male circumcision are promoted and, in turn, understood and taken up by those whose attend to the health promotion messages.
Practices are socially produced: they are behaviours that are organised and patterned by culture. They cannot be sensibly understood as the behaviour of individuals. The forms sexual behaviour takes are, to a large degree, organised by the sociocultural, economic and political structures in which they are situated and produced (Kippax 2003). The practices that give rise to HIV infection/transmission or contribute to the likelihood of transmission are, to some extent, under the control of those individuals who engage in sexual activity. These individuals are thus open to social transformation and change, via education, health promotion and HIV prevention campaigns, where the information contained within is actively appropriated not simply passively imbibed (Stephenson and Kippax 2006; Kippax 2008).
While sexual behaviour may be similar across time and place, sexual practice differs. There are only a small number of sexual behaviours in which two or more people can engage: vaginal and anal intercourse; oral-genital sex (fellatio) and oral-anal sex, a number of more esoteric behaviours, such as sadomasochism, as well as a range of behaviours that involve touching, mutual masturbatory behaviours. Sexual practice, by way of contrast, is more fluid: it takes on a number of forms. It is enacted in marriage or regular relationships, concurrent partnering, sex work, casual sexual encounters; it involves sexual initiation, changes of regular partner, group sex, rape and so on. In real life, people do not engage in sexual behaviours – penis-in-vagina or penis-in-anus – rather they enact sexual practices: they ‘make love’, ‘have a one night stand’, ‘lose their virginity’ or reassert their sexuality. They act for pleasure, for money, for control. In response to sexual desire, they communicate their love to one another and build intimacy and trust.
Practices are socially produced; they are behaviours that are organised and patterned by culture and organised with reference to normative understandings or discourses: they have meaning (Kippax 2003). As many researchers have pointed out, the most powerful influences on human sexuality are social norms – morals, taboos, laws, beliefs – that regulate and govern its expression. The scale of the regional diversity in sexual practice is matched only by the range of cultural constraints on practice (Wellings et al. 2006).
What is in need of modification is sexual practice and in order to do that prevention experts need to engage with the social and cultural forms that give rise to it. They also need to understand that the HIV prevention strategies that are being promoted, such as condom use and fidelity and male circumcision, are themselves practices. How people respond to the promotion of each of these, especially whether they adopt them or not, will vary depending on how the promoted prevention strategies are understood with reference to people’s sexual relationships and sexual practices. For example, the introduction of condoms into the marriage bed is a very different act from suggesting they might be used with a casual sexual partner. What do people understand by ‘faithfulness’? While some clearly understand monogamy as ‘lifelong’, others – particularly those in countries with high income, read ‘fidelity’ as serial monogamy, and for others in stable concurrent relationships, fidelity will have a different understanding.
Prevention information is not passively imbibed by individuals but is actively taken up (appropriated) through talk and collective action within given social and structural contexts in order to acquire meaning. The advice of public health workers, doctors and nurses, is not simply accepted passively. Indeed unless prevention information is actively taken up it is unlikely to be effective. To illustrate: the majority of gay men in high income countries have regulated their sexual practice depending on the interpersonal context – regular, casual encounter; in terms of whether they are HIV positive or HIV negative; and in terms of the prevailing cultural or community norms that are generally responsive to current medical knowledge. This knowledge, however, is not simply accepted but appropriated in ways that can best support intimacy and pleasure, love and desire in gay communities – and as well reduce risk of HIV transmission. Findings from studies of gay men in Australia demonstrate the ways in which gay men have developed a number of risk-reduction strategies over time in response to changing community norms that, in turn, have changed in response to changing medical knowledge (Kippax and Race 2003).
The strategies used by gay men in Australia include condom use and most gay men use condoms consistently – at least with casual sexual partners (Imrie and Frankland 2008). Gay men, however, also fashioned other harm-reduction strategies for themselves; strategies that allowed them to dispense with condoms under certain conditions. These strategies include: negotiated safety (a strategy of dispensing with condoms within HIV seroconcordant-negative regular relationships under certain conditions – one of which includes monogamy) (Kippax et al. 1993; Kippax et al. 1997); positive-positive sex (a strategy of dispensing with condoms when two HIV-positive men engage in sex) (Prestage et al. 2001); strategic positioning (a strategy for discordant couples in which the HIV-positive man takes up the receptive position in anal sex) (Van de Ven et al. 2002); and, to a lesser extent, reliance on undetectable viral load (a strategy of dispensing with condoms when one’s sexual partner has ‘undetectable’ viral load) (Van de Ven et al. 2005). All these strategies carry some risk – but most of them do reduce risk to a greater or lesser extent (Jin et al. 2009).
All these strategies – with the exception of condom use, rely on knowledge of HIV status. Their adoption is dependent on: the interpersonal nature of the relationship (regular/casual) and whether the sexual partnership is seroconcordant (both of the same HIV status) or not; the social and cultural contexts of the sex (‘marital bed’, beat, sauna, sex club, sex party); and the prevailing cultural or community norms associated with HIV prevention, which are informed by HIV-prevention campaigns and programmes as well as current medical knowledge. These strategies came from community, from community members appropriating medical knowledge as well as from ‘folk’ knowledges that emerge as affected community members seek to reduce the likelihood of HIV transmission.
Community members are not isolated individuals but are persons connected through complex webs of social relationships. The strategies, the effective and sustainable strategies, came from within – from the bottom up not the top down. While mass media campaigns, targeted campaigns, peer-based education, school-based sex education and voluntary counselling and testing are all important sources of information and skills, the safe sex messages will not be taken up or if taken up not sustained unless the strategies being promoted and advocated are strategies that make sense to those to whom they are targeted. Political and community support of the prevention strategies are indispensable for an effective and sustained response to HIV (Kippax 2006). Communities (of gay men, of sex workers, of young people) must appropriate the health promotion messages and make them their own.
Effective HIV prevention needs to address the local and specific circumstances of the populations and communities it seeks to engage in ‘safe’ sex. It should also aim to affect multiple determinants of human practice – including individual knowledge, interpersonal relationships, community and societal norms (Global HIV Prevention Working Group 2008). Essential ingredients of HIV-prevention success are political and hence public acknowledgement of people’s sexual lives and a detailed understanding of the ways in which risk is locally produced via social and cultural drivers. Like Australia, Brazil encouraged open discussion of HIV and supported frank public awareness campaigns as well as campaigns and prevention programmes targeting gay men and sex workers, condom promotion and school-based HIV education. As a result, condom use increased by almost 50 per cent among sexually active adults between 1998 and 2005 and HIV prevalence was maintained at a low level among sex workers (Global HIV Prevention Working Group 2008). Other success stories in Thailand and Uganda similarly illustrate the importance of working with communities at risk and engaging and supporting their efforts to reduce their own risk. Global success is dependent on local initiatives: HIV prevention must engage and build on local responses.
Social theorists agree that individual behaviour is always mediated and structured by social relationships, which are, in turn, traversed by important differences in community, social status, class and other structural differences such as sexuality and age. Individual behaviour is always contextual, always socially embedded. HIV prevention that does not engage with the social is likely to fail. Safe sex is not as simple as ABC – but many countries and communities using comprehensive, public and realistic prevention programmes that both take account of the social production of sexual practice and are politically supported have promoted it effectively.
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