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One step forward, two steps back

By David Patient and Neil Orr

April 8, 2014 - On the 1st April, 2014, The South African National HIV Prevalence, Incidence and Behaviour Survey, 2012 was released. Not only has the incidence of HIV increased in SA since the last survey; the rate at which prevalence is increasing is also going up. So clearly, when it comes to our prevention programs, they are simply not least that is what the evidence suggests.

As part of 'the way forward' in the report, one of the key recommendations is to revive and strengthen the long standing ABC message (Abstain; Be Faithful; Condomize), messaging based in morality, with a strong focus on monogamy, that is confusing, morality based and ignores the science of transmission. It is time to move from a prevention approach to a risk reduction approach. The model we are suggesting, A-3B-4C-T offers up a much wider menu of options and is based around viral load management and the science of transmission. For too long, HIV infection has been seen as the disease of the promiscuous, yet when you understand the science of transmission, this argument fall flat and is largely, baseless. However the long-term damage this kind of morality based messaging or belief has caused more harm than good (read: stigma). The amount of sexual partners you have is irrelevant. Your or their viral load is highly relevant when it comes to transmission. The ABC focuses on Sex while the A-3B-4C-T focuses on viral load, viral spiking, treating of all secondary infections and the science of HIV transmission. The A-3B-4C-T model offers 28 risk reduction strategies, with all but one, as recommendations by our very own Department of Health. Yet they are still taking the moral high ground and focusing on the morality based messaging of ABC. This is a disservice to the people of South Africa and is, for all intent and purpose, against the law. The Health Professional Council of South Africa states in its Guidelines for Good Practice in the healthcare Profession:

6.1 Patients have a right to information about the health care services available to them, presented in a way that is easy to follow and use.

6.3 Patients also have a right to information about any condition or disease from which they are suffering. Such information should be presented in a manner easy to follow and use, and should include information about the diagnosis, prognosis, treatment options, outcomes of treatment, common and serious side-effects of treatment, the likely time- frames of treatment, and the expected costs, where relevant.

The ABC approach does very little in this regard and certainly does not educate people around their illness or treatment options and has made HIV a morality based disease rather than one based in science of transmission. The A-3B-4C-T model is one of risk reduction and its key focus is on working with the biological basics of the HIV virus, including the importance of understanding viral load and HIV transmission. Risk-reduction aims for 100%, but will settle for less risk reduction, knowing that this can be increased step by step. Risk reduction says: Here are the options. What can you do at this point in time? For example, many people are unaware that during the Window Period people are 'hyper-infectious' and thus there is a very high chance that the HIV virus can be transmitted to another body at this time if unprotected sex occurs. In fact, it is scientifically argued that over 40% of new infections happen at this time. Why are we not focusing more of our efforts on those who are testing negative instead of giving them a pat on the back and saying well done? Keep in mind that during the window period, the person will test HIV negative (to standard HIV finger prick tests), yet their viral load will be at its highest level ever. Risk of transmission during the window period is 1/3 sexual acts.

The A-3B-4C-T model, which is accredited by the South African Counsel for Social Service Professions, provides 28 risk reduction techniques that fall under the Department of Health guidelines (one recommendation is not yet recognized and that is needle exchange for those who use recreational drugs).The A-3B-4C-T framework incorporates the "A" and the "C" of ABC, but omits the "B" because scientific evidence indicates that over 60% of new infections occur amongst individuals within relationships. A recent evaluation of the A-3B-4C-T model indicates that educating people about the 28 opportunities to reduce risk is more relevant to them than heavily promoting ABC.

It is time that Government started to educate people around the realities of HIV (science of transmission) and drop the overdone, out dated ABC rhetoric. If it hasn't worked in the past 20 odd years, why will it start working now, just because they have added 'monogamy' to the list? In the 2012 National Prevalence report, in the discussion section, the following issues were raised:

  1. HIV and marital status .
    Many women report being 'Faithful' to their partners, yet upwards of 60% of female infections take place within this 'be faithful' context. They may very well be faithful to their partners; however the same cannot be said for their partners.
  2. Sexual debut before the age of 15 .
    While we do not oppose the notion of delaying early sexual debut, the science of transmission and age have no bearing on the age of sexual debut. If the viral load of the infected individual is undetectable, regardless as to their age, transmission cannot occur. So age is irrelevant when it comes to science and HIV transmission.
  3. Age-disparate relationships .
    Age play no role in transmission. Viral load does. Why are we about to get engaged in yet another morality based conversation that has no bearing on the reality of transmission? Here we go down the morality path again and we've seen the damage that position creates. Stigma.
  4. Multiple sexual partners .
    While we do not advocate multiple sexual partners, the reality is that transmission of HIV is solely dependent on viral load, not the amount of sexual encounters or partners a person has. So condemning or criticizing those who have more than one sexual partner is yet another morality based conversation that has no place in the science of transmission.  Transmission of HIV is solely dependent on the amount of viral load at any given point in a person's infection. An HIV positive person, on ARV's, with an undetectable viral load has a less than 1% chance of viral transmission (some models indicates a less than 1/1000 sexual acts that there could potentially be transmission). Even in a person who is HIV positive, healthy and not on treatment, the risk of transmission is based, once again, on Viral Load and ensuring that all secondary infections are treated as a matter of urgency (primary health care) to stop viral spiking, a time when transmission can take place.

In a time when our pandemic is increasing and not decreasing, why are we going to simply repeat what has been proven not to be effective; namely the ABC message? The report points out that people have basically switched off to the ABC message, as their behaviours and attitudes reflect. They are bored with the same old rhetoric that most can't relate to. We have an opportunity to finally change the conversation along with knowledge around HIV and its realities, but the authors of the report recommend that we keep on doing more of what we have been doing and somehow expect 'improved' sexual behaviour from people.

We would like to suggest that rather than spend time and money on this potentially disastrous cul-de-sac that the Department of Health immediately scours the county for small scale, effective prevention niches; brings those people together and enter into a genuine dialogue about the pragmatic options that are available to us in South Africa. From a small pool of innovations - such as A-3B-4C-T - it is possible that the innovations that the NSP calls for might emerge. Today we have mass roll-out of ART. The government is to be commended for this commitment but we now need prevention strategies that fit this context, rather than the outdate ABC approach alone. The authors or the report have had their say: it is now time we - civil society - have our say



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