Sunday, December 17, 2006

HIV Prevention for MSM and women is not as easy as A.B.C.: A Sociological Research Perspective - Rodney VanDerwarker

Practically since the first documented cases of HIV in the early 1980’s, researchers and policy makers have tried to develop and implement the most cost-efficient and effective HIV prevention strategies. Dramatic declines in infection rates were seen in the late 1980’s among men who have sex with men and other high risk groups in the US in part due to the promotion and adoption of condom use for anal and vaginal sex. Despite a significant amount of effort and funding put into HIV prevention, the Centers for Disease Control and Prevention estimate that there continues to be 40,000 new HIV infections per year in the United States (http://www.cdc.gov/hiv/resources/factsheets/At-A-Glance.htm). Male to male sexual contact continues to be the largest risk category followed by heterosexual transmission and injection drug use. Heterosexual transmission has a disproportional impact on women. There is no doubt that we need to continue to explore new methods of interventions to further reduce the rates of HIV transmission among these populations.

One public health approach to HIV prevention that has received a lot of attention in recent years is called ABC. ABC is an acronym for Abstinence, Be Faithful and Condom use. Abstinence programs focus on encouraging unmarried people to not have sex. This particular piece of ABC is often focused on youth and encourages them to delay sexual debut until marriage. Be Faithful programs encourage people to practice fidelity in marriage and other sexual relationships and to reduce the number of lifetime sexual partners. Condom use programs under ABC are supported as long as the “full and accurate information” about condom use “reducing, but not eliminating, the risk of HIV infection” is presented (Office of the US Global AIDS Coordinator, 2001). Many ABC programs have actually been criticized for being AB programs since C is presented in a manner that makes it seem like condoms are not a good option for preventing HIV infection. PEPFAR funds can only be used for “C” if information about condom use also includes information about abstinence as the only sure way to prevent HIV infection (Office of the US Global AIDS Coordinator, 2001).

In May 2003, Congress approved President Bush’s global HIV/AIDS strategy referred to as PEPFAR (the President’s Emergency Plan for AIDS Relief). This plan was principally created to support projects that would increase access to treatment and primary medical care to people in the hardest hit areas of the world; therefore, 70% of the 15 billion dollar fund was directed to these efforts (http://www.avert.org/pepfar.htm). 20% of the funds were allocated for HIV prevention work that specifically uses the ABC approach as a guiding principle. This requirement has been greatly criticized by those working in global HIV/AIDS programs and it brought to light the administration’s philosophy about HIV prevention. The current administration’s prevention policies, domestically and internationally, have focused on funding abstinence-based programs that don’t address the needs of those most at-risk for HIV.

The ABC approach to HIV prevention assumes that people have control over sexual decision making. Many people do not; this is especially true for women. Amaro (1995) criticizes behavioral approaches to HIV prevention for not taking into account how gender, women’s role and women’s social status affect sexual risk behaviors, sexual decision making and their ability to reduce HIV risks. Abstinence assumes that a woman has the power to decline sex from a partner. Be faithful is something that takes two people to agree upon and in many societies men are given the freedom to have as many sexual relationships as they desire. In India, women must provide children in a relationship or else they are considered a failure in the marriage and could be disowned. They must have sex with their husbands whether he is cheating or even if he is known to be HIV infected. And condoms are not always perceived positively. A study in Brazil found that women feared using condoms because they would be suspected of infidelity, and that men always had the final word in sex (Hebling and Guimaraes, 2004). Financial dependence is an important element in the power relationship between men and women. Without their male partner/husband, the women, and their children, would potentially lose their homes or not have food. So, these women have no choice but to accept his infidelity and/or to give him sex when he desires it.

Another argument against the ABC approach to HIV prevention is that it assumes that all relationships are supported by their culture or society. This is not true for MSM in most parts of the world. Whereas gay people in the United States have gained significant rights over the past two decades, there are still parts of the world where being gay is illegal and in some countries even punishable by death. In the United States, gay rights are inconsistent and dependent on the political climate. Despite the positive feelings many have had about changes that occurred during the November 2006 elections, 7 out of 8 states voted to specifically exclude gay and lesbian couples from marriage rights in their constitutions. This adds to the 20 states that previously adopted these laws. Research tells us that gay men who live with a partner have a higher self concept (Schmitt and Kurdek, 1987). Men who have better gay self-acceptance also have fewer risk behaviors for HIV (Perkins et al, 1993). How does it make sense to include fidelity as part of HIV prevention messages when the societal messages are clearly against the very existence of such relationships? In fact, I believe that promoting an intervention that is so incongruent with the reality of MSM can cause further alienation and possibly lead to more risk for HIV transmission since it works against gay self-acceptance.

ABC has not been rigorously studied to see how effective it is as an approach to HIV prevention. The most information available about ABC is from epidemiological studies in Uganda. There was a sharp decline in HIV prevalence during the 1990s going from about 15% in the early 90’s to 6.5% in 2004 (Office of the US Global AIDS Coordinator, 2003). Research papers reviewed for this blog stated that it was challenging to pinpoint the cause of this decline (Singh et al, 2003; Kurungi et al, 2006). Both papers also showed that there was a decline among younger people in sexual debut, but there was no difference among those over 20. Premarital sex among women declined, but there was no change among men between 1995 and 2000. This, of course, leads me to wonder who the men were having sex with. Did women really stop having premarital sex or were they less likely to report it because of the messages that it was wrong? Earlier statistics reporting casual sex among men at 40% and women at 20% indicate that reporting issues probably were always present in Uganda. There is no mention of male to male sex in any of the ABC research, despite evidence that such behaviors occur. The evidence seems awfully weak to support ABC as an effective intervention and this is concerning since it has been used to form policy for the federal government’s HIV prevention initiatives here and abroad.

This paper has provided me with a good opportunity to understand the ABC approach to HIV prevention better. Despite all of my arguments, I actually think that offering multiple intervention strategies makes sense. However, the interventions need to be appropriate to the population being served by them rather than serving the morals of those creating the intervention. I believe that harm reduction is an important tool in reducing HIV transmission. It cannot be argued that abstinence is the only way to prevent HIV or that two HIV-uninfected partners being monogamous are the most effective ways to avoid HIV acquisition. I think that ABC has some serious problems, as I have argued, but the fatal flaw has been in its implementation. The government contradicts itself when ABC is put forth as an intervention with three good components, but the C part is the only one that must advertise its limitations. It is contradictory to present an intervention with three good components, but the A gets a mandatory cut of the total funding. People don’t need to be graded for their behaviors because an A isn’t possible for everyone and that makes it unfair. We need to eliminate politics and the imposition of values on others and instead develop public health interventions for HIV prevention that consider the context of people’s circumstances. This is the only way we are going to further reduce and someday end this epidemic.

References

Amaro, H. (1995). Love, sex, and power: Considering Women’s Realities in HIV Preveniton. American Psychologis, 50, 437-447.

CDC (April 2006). A Glance at the HIV/AIDS Epidemic. Retrieved November 10, 2006 from http://www.cdc.gov/hiv/resources/factsheets/At-A-Glance.htm.

Hebling, E. M. Guimaraes, I. R. F. (2004). Women and AIDS: gender relations and condom use with steady partners. Cadernos de Saude Publica. 20(5):1211-8, 2004 Sep-Oct.

Kanabus, A. and Noble, R. (2006). President’s Emergency Plan for AIDS Relief. Retrieved November 10, 2006 from http://www.avert.org/pepfar.htm.

Kirungi, W L. Musinguzi, J. Madraa, E. Mulumba, N. Callejja, T. Ghys, P. Bessinger, R. (2006). Trends in antenatal HIV prevalence in urban Uganda associated with uptake of preventive sexual behaviour. Sexually Transmitted Infections. 82 Suppl 1:i36-41.

Office of the US Global AIDS Coordinator (2001). ABC Guidance #1 for United States Government In-Country Staff and Implementing Partners Applying the ABC Apporach to Preventing Sexually Transmitted HIV Infections within the President’s Emergency Plan for AIDS Relief. Washington, DC.

Perkins, D O. Leserman, J. Murphy, C. Evans, D L. (1993). Psychosocial predictors of high-risk sexual behavior among HIV-negative homosexual men. AIDS Education & Prevention. 5(2):141-52.

Schmitt JP. Kurdek L.A. (1987). Personality correlates of positive identity and relationship involvement in gay men. Journal of Homosexuality. 13(4):101-9.

Singh, S. Darroch, J. E. Bankole, A. (2004). A, B and C in Uganda: the roles of abstinence, monogamy and condom use in HIV decline. Reproductive Health Matters. 12(23):129-31.

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