In the very early years of the HIV epidemic, as it was becoming clearer that the virus was mostly sexually transmitted, HIV prevention was limited to promoting condom use. For years, that was all that was available to protect oneself whilst politicians were debating the threat and relevance of this new disease, if they were talking about it at all. Then as the disease spread and a new kind of activism was able to draw more attention to what was becoming an epidemic of epic proportion, it became evident that more needed to be done and from limited, HIV prevention became simple as ABC.
ABC soon revealed its limitations. Abstinence never worked for very long, nor did faithfulness, and as for condom, 30 years of the same repetitive message led to a general fatigue. In 2002, behavioural changes – such as the ABC approache, was accepted as key to understanding and combating the sexual transmission of HIV and confirmed as the way forward for HIV prevention. In 2004 a consensus statement by leading public health experts observed that all the elements of the ABC model were essential to reducing HIV infection.
Came 2008, when it was finally recognised that ABC was simplistic and was failing to achieve notable and sustainable results. Then, Richard Horton wrote in a Lancet editorial “We need combined prevention, including a portfolio of biomedical, behavioural, and structural interventions”.
Combination Prevention is the new metaphor that will be pervading the field for years to come. But to have substance and impact the approach needs to figure out what to combine. Structural interventions are quite straightforward to identify thought far less to implement (e.g. MSM have finally been recognised as a “most at risk population” at the Mexico AIDS conference in 2006 but progress in addressing their needs is still very slow. Women’s rights have been on the table since the eary 70s, and we still talk about them). Behavioural changes interventions have been extensively explored and implemented in a broad range of situations but with limited success. To date there are very few successful biomedical interventions and none that can compare with condoms when considering efficacy only. But it is believed that expanding the range of interventions will be key to a successful control of the epidemic
From here there are different ways to work out the role of biomedical interventions in Combination Prevention, and the HIV Prevention Buffet metaphor (a.k.a “fast food” metaphor) is one of them. Though there is not much on the menu of the Prevention Buffet, the story goes like this:
The unabated HIV epidemic is raising the pressure to develop New Prevention Tools. Doing more research will eventually lead to the discovery of New Prevention Technologies (NPTs) that will contribute to building a pool of options. Individuals will be able to choose the prevention they like and want and as a result, increased protection rate will be achieved leading to a reduction in the number of new HIV infections.
Conceived this way, the Prevention Buffet metaphor emphasises developing options and people making choice. It is a consumerist approach which hope to resolve the problem of behaviour change, still very much required by Combination Prevention, by commoditising HIV prevention strategies and by assuming that the offer creates the demand (and vice versa). Preventions tools become a commodity sought and bought by customers whose choices are driven by their preferences rather than the efficacy of the product they buy for the use they intend.
There are numerous problems with the metaphor starting from its rational. To be fair nobody would ever believe that it could be that simple, but the basis, complexity and ramifications of the metaphor are rarely explored and debated. Combination Prevention and its buffet of options are now part of the HIV Prevention Credo.
|This picture or a similar one is often chosen to illustrate the HIV Prevention Buffet metaphor… But we should not forget that it could lead to the picture of another epidemic of epic proportion.|
But there are other way to approach Combination Prevention whose central role in HIV prevention is without question. Other approaches that do not throw all NPTs in a kitchen sink but make use of them as targeted, tailor-made, specific HIV prevention interventions.
There is a need to develop a conceptual framework to understanding how NTPs could work. The following diagram was built using a System Dynamics approach for thinking and simulating complex situations.
In this version, the story goes like this:
As the number of new HIV infection keeps going up with two new persons infected for every person put on treatment, the pressure to develop new HIV Prevention Tools increases. Such effort should be rewarded by the identification of new HIV prevention technology (NPTs).
It is expected that these NPTs would achieved at least three things. First, they would be more acceptable than current strategies (such as condoms). Second, they would increase the individual interest in protecting oneself. Third, they would increase the personal freedom to protect oneself (because they may be less intrusive or invasive than current strategies or more user-friendly, such as vaginal and rectal microbicide).
The combination of interest, acceptability and usability would lead to a better uptake which would in turn contribute to a higher number of protected sex acts and therefore a decrease in the number of new infections. However, at this point in time, the positive aspects of NPTs remains in the realm of assumptions. But it is worth noting that this is where there is room for consumerist approaches and marketing strategies that would make NPTs fun.
This framework also provides opportunities to identify roadblocks, as well as positive and negative feedback loops. Individual interest highly depends on one’s quality of life and prospects in life. In situation where everyday life is a struggle, HIV and AIDS are remote concerns. “Quality of Life” is one of the many black boxes in this framework that would need further exploration. Economic vitality is another. The consequences of the 2008 economic crisis are still being felt and decreased research funding is only one of them.
Gender Inequity and Poor Human Rights are serious roadblocks that negatively affect individual freedom to choose the protection one wants. They are roadblocks that will need to be addressed for NPTs to have a chance to succeed. Of course willingness to use a particular HIV prevention option ultimately depends on its availability. A number of factors affects availability. Evidence-based policy and agendas, be they that of governments, INGOs, funders and researchers are key to the development of options that will not only work but have a sustainable impact on the course of the epidemic.
This Framework also allows for including possible negative effects of the approaches themselves packed under one heading of “Misuse, Disinhibition, and Side effects”. These cover a broad range of issues. For instance, misuse is not limited to a prevention tool not being used as recommended (and for example leading to poor adherence) but of a prevention tool being used in circumstances where it creates more harm than good (e.g. female sex worker no longer protected against other STIs or unwanted pregnancies). Side-effects do not specifically relate to the potential side-effect of the drug used as prevention tools but to how they can impact on individual’s personal life (stigma, discrimination). In some circumstances NPTs could challenge the freedom of an individual to choose the HIV prevention of his/her choice (when it is the dominant sexual partner who impose the prevention) with dramatic consequences, affecting the overall quality of life of its user and thereby negating the potential to prevent HIV.
Finally, in this framework, “choice” is no longer key to the approach, but “uptake” is, supported by “counselling”. This framework departs from the individualistic Buffet approach to prevention by re-introducing specialist medical knowledge and care into the decision to use a particular option. It brings back Prevention into the domain of Public Health.
There is no doubt that Combination Prevention is the future of HIV prevention. Its success will depend on how it is implemented and it is critical to note that at all levels, it hinges on behaviour change, a change that goes far beyond that of the users. It will require governments, NGOs, policy makers, researchers, advocates, activists to re-assess their position, and beliefs and fully appreciate the complexity and challenges hidden behind the metaphor of Combination Prevention.
In this regard, metaphors do matter because they frame an intervention, how it is perceived and as such they can impact dramatically at many levels on its acceptability and ultimately on its success (recent response to PrEP by the AHF is only one exemple). If there is something that 30 years of HIV prevention should have taught us is that perceptions do matter, sometimes more than evidences.
|Notes:This post was triggered by a discussion that started on the IRMA list, one of the most active and thought provoking HIV advocacy list. IRMA is dedicated to the development of one of these new NPTs which could make a dramatic and sustainable difference to the future of the epidemic.The Conceptual Framework above is built using System Dynamics, a branch of Systems Thinking that was developed by Jay Forester in the 1950s , popularised by Donnela Meadows “The Limits to Growth” and Peter Senge “The Fifth Discipline”. It is a work in progress and I would be delighted to develop this framework further.|