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| Positive Prevention: Opportunity or Threat |
2007-08-27 10:10:00 <Accelerating-Prevention> |
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Positive Prevention: Opportunity or Threat
Kevin Moody
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[Mods note: This is a key paper on the positive prevention discussion. It gives an insight into what positive prevention is and also addresses some of the key moderators questions (previously posted) on positive prevention.]
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Positive Prevention has become a popular term, but there is no consensus on what it means. Is it prevention directed at HIV positive people or is it a manner in which HIV positive people can orient themselves towards prevention? One accepted definition of positive prevention does not yet exist.
This article will explore some concepts around Positive Prevention, both from a public health control perspective and a human rights perspective. The discussion around positive prevention must be regarded within the context of the current environment which is, frankly, hostile to people living with HIV.
In 2003 WHOs 3 by 5 initiative created a lot of excitement. There were great hopes that many more people would get access to treatment. And it worked. Sure, the target of 3 million people on treatment by 2005 was not reached, but the momentum of the initiative led to an amazing effort to scale up treatment.
However, since the end of 2005 the emphasis on treatment has diminished and the pendulum has swung over to prevention, as if prevention and treatment could ever be separated.
At the same time, testing has become more prominent, mainly as a way to identify people who are living with HIV. WHO and UNAIDS focus on provider-initiated testing and counselling" (PITC) as a mechanism to get the health sector involved. Their solution is based on an opt-out strategy whereby adults who visit clinics will undergo testing unless they have the capacity and courage to say No.
There is general agreement that testing must be scaled up. But the proposed strategies for testing are not aimed to support people. Why identify people who are living with HIV if they are not given the treatment needed to stay alive?
Another mitigating factor that affects everyone who tests positive for HIV is the increasing criminalization of HIV transmission. More and more, people who know that they are HIV-positive are criminalized for exposure; bodily harm or transmission, after engaging in a normal human activity sex. And this is not just limited to those who know their status. People from marginalized groups who are engaged in risky behaviour should know better and are being held responsible for infections they dont even know about.
Routinizing the process of detecting HIV-positive people and actively prosecuting HIV-positive people who engage in normal sexual relationships are clear signs that the human rights approach to addressing the needs of people living with HIV is eroding.
Instead of participating in the HIV response and determining their own destiny, people living with HIV are subjected to a war on AIDS, where the goal is to hunt, detect, isolate and contain the HIV virus.
Instead of receiving compassion and support, people are judged by the virus they carry and the main objective is to contain HIV within the existing group of carriers.
It takes two to tango
In this context, what does positive prevention mean? For the HIV/AIDS Alliance in their draft background paper, it means concentrating on strategies that prevent onward transmission from people living with HIV through sex.
For HIV-positive people, this cannot be the goal of positive prevention. It is a too simple representation of reality. As NAPWA in the United States asserts:
It takes two to tango, goes the old saying. Well it also takes two to transmit HIV: one positive and one negative.
The role of prevention is a two-way street. HIV-negative people have to take the responsibility to stay negative and HIV-positive people need to keep the virus to themselves.
The recent hype to treat HIV infected persons as pariahs that need to be contained is problematic for many reasons. In the context of positive prevention, the new public health approach is mainly interested in finding those with HIV and making sure they behave so that the virus doesnt get transmitted. This approach favoured by epidemiologists disproportionately affects women due to their increased vulnerability in our communities.
For most HIV-positive people, positive prevention means so much more. It means making every day decisions around safer sex and risk reduction strategies. It means living positively, working to live their lives in a manner that contributes to their physical, psychological and spiritual well-being. People want to ensure that their families are cared for and are safe. People want to contribute to the welfare of their communities. And they want to be able to live their lives free of stigma and discrimination.
A Positive Prevention strategy directing prevention efforts at people living with HIV cannot be expected to halt the epidemic. For people who are conscious of their HIV, preventing the transmission of the virus is a crucial component of living with HIV. Most HIV transmissions occur with people who are not familiar with their HIV status.
People living with HIV are the key
Even if the incidence of HIV is reduced through strict public health control measures, communities will still need to deal with the high levels of prevalence that exist. People with HIV cannot be locked away and segregated from the communities to which they belong and contribute as mothers, fathers, teachers, farmers, clergy, etc.
For positive prevention to work, women and men living with HIV must be considered valuable and important members of the community. Put even more strongly, people living with HIV must be seen as key to the solution of HIV. Involving HIV-positive women and men in the development of policy and programming is critical to the success of community-based programmes.
Positive prevention will mean different things to different people depending on where they live and what their needs are. It will include caring for themselves and caring for their family and children. It will include engaging in safer sex practices with their partners. It will include being informed and engaging in risk reducing strategies. It will include adhering to treatment to keep viral loads low, thereby reducing transmission chances. It will include staying healthy and finding comfortable places to disclose ones status. It will include starting families and engaging in pleasurable and satisfying sexual relationships. This is what positive prevention should be about.
If the current trend continues, positive prevention will be seen solely as a mechanism to keep the virus contained within the vessels that carry them. People living with HIV, then will become infected persons represented by numbers on an epidemiologists PowerPoint presentation.
Positive prevention can and should be a concept that inspires HIV-positive people to stay healthy and to experience respectful and productive lives with others in their community. Which world do you want? One that isolates and blames or one where mutual responsibility leads to productive relationships?
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Author:
Kevin Moody
International Coordinator
Global Network of People living with HIV/AIDS (GNP+)
Email: kmoody@gnpplus.net
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References
Positive Prevention: Prevention Strategies for People with HIV/AIDS
Draft Background Paper, HIV/AIDS Alliance (July 2003). Available: http://www.aidsalliance.org/graphics/secretariat/publications/ppr0703_positive_prevention.pdf
Positive prevention, Positive Living, Allan, B (1 June 2003).
Available: http://www.napwa.org.au/?q=node/364
Positive Prevention, John Kaldor, (January 2007). Available: http://www.hivnat.org/Download/06%20Bangkok%20Symposium%20Jan%2007.ppt
Expanding the boundaries of Positive Prevention Programmes, Terje Anderson (April 2004). Available: http://hivinsite.ucsf.edu/InSite?page=cfcaps2004-01-sl
Positive prevention in men who have sex with men, HDN Key Correspondent at 7th ICAAP (July 2005). Available: http://www.healthdev.org/eforums/cms/individual.asp?sid=145&sname=ICAAP-18
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Accelerating Prevention is a time-limited eForum for the discussion on the process of accelerating prevention initiatives in southern Africa.
Accelerating Prevention is managed by the Southern Africa HIV and AIDS Information Dissemination Service (SAfAIDS, www.safaids.org.zw), with support from Health and Development Networks (HDN, www.hdnet.org) and UNAIDS (www.unaids.org).
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