Prevention programmes for HIV-positive people

People with HIV form 50% of those present at any HIV-transmission event and yet are a minority of the population. So, it might be argued, programmes targeted at them may have a disproportionate effect.

One 1999 paper¹ comments:

“Preventive interventions with positive individuals are likely to have a greater impact on the epidemic, for an equivalent input of cost, time, resources, than preventative interventions focused on negative individuals. A change in the risky behaviour of an HIV positive person will, on average, and in almost all affected populations, have a much bigger impact on the spread of the virus than an equivalent change in the behaviour of an HIV negative person.”

Yet, throughout the history of the epidemic, far fewer prevention resources have been directed at people living with HIV than at the uninfected. In the draft version of its guide on ‘Positive Prevention’,² the International HIV/AIDS Alliance suggested why:

“Most prevention strategies to date have been targeted at uninfected people to prevent them from becoming infected with HIV. Historically, there has been a reluctance to work on HIV/STI prevention with people with HIV because of perceptions that the concept of prevention for people already infected is inherently contradictory.

“There have also been justifiable concerns about victimising an already stigmatised group. In addition, there has been a reluctance to acknowledge that people with HIV have sex, and also to get to grips with the complex ethical issues surrounding people with HIV’s responsibilities towards others.”

In the final version, it went further:

“It has been common in some settings for counsellors and nurses to tell HIV positive people that they should abstain from sex completely or just have sex with someone else who is HIV positive. This advice may not be helpful to their psychological health on the one hand and on the other hand may expose them to re-infection. It also does not help the majority of HIV positive people who continue to be sexually active, nor those who are in relationships with HIV negative partners and want to continue a safer sexual relationship. The role of health service providers is to ensure that HIV positive people gain the skills they need to negotiate safer sex and maintain healthy sexual relationships.”

‘Positive prevention’ is therefore potentially an effective tool against HIV, but not always one that has a positive effect on people with HIV.

The International HIV/AIDS Alliance proposes a very wide definition of what ‘positive prevention’ is, dividing the activity into 17 different strategies.  This is shown in the graphic below, taken from the 2003 draft.

This grid of 17 strategies does not in any way make any recommendations as to the content or methodology of any of the strategies it recommends. How is voluntary counselling and testing to be promoted and how voluntary is voluntary? How does one encourage beneficial disclosure and reduce stigma? How can peer support promote safer sex practices? What content should focused communication campaigns have? And, if you involve people with HIV in positive prevention, what will they say they want?