The failure of the ABC approach
For nearly 25 years, the standard HIV prevention strategy was the ABC sexual behavior change strategy: abstain, be faithful, and use condoms. Today, this strategy has all but faded into the background, with only condoms remaining on the ‘to do’ checklist. The evidence was clear: New infections continued to rise steadily year over year, regardless of ABC.
Refocus on facts and streaming rules
One of the failures of the old ABC approach was to make the exceptions the rule and to focus on these exceptions to address prevention of HIV transmission in the general population: multiple partners, infidelity, high frequency of sexual intercourse, and early age of onset of HIV. intercourse. sexual activity, to name a few assumptions.
Research over the last decade has revealed that people are not (in general) overly sexually active: Durex studies show that the average South African is literally average in terms of sexual activity, compared to the rest of the world. The same was found for the age of first sexual activity. It also turned out that multiple partners, although they pose a high risk of HIV transmission, are not as widespread as previously thought and cannot explain the rapid increases in overall HIV transmission within a community. The ‘AB’ (abstain and be faithful) strategy failed because people (in general, excluding the specific high-risk group) were already quite conservative in this regard.
Condoms, although a logical solution, did not have the impact that was expected. At first, the reason for this failure was attributed to lack of education and availability. However, when these were corrected, there was not much change, except for youth and sex workers (recreational sex). Other people resisted condoms for relationship reasons (trust issues, proof of love and commitment) and because it simply prevented them from having babies (procreative sex). The desire to have babies outweighs the risk of death, for many people. Count the number of pregnant peer educators if you question the mismatch between the ABC message and what people are actually doing.
Focus on the general rules, not the exceptions
There have always been, and always will be, people, behaviors, resources, and circumstances that are beyond the range of what is considered average or normal. These would require target-specific methods. However, for the vast majority of people and circumstances, the A2B4CT approach is fairly straightforward and well within current government health guidelines and protocols.
It is time to catch up, refocus and expend our energies and resources with a higher level of efficiency and impact.
The A2B4CT (A-BB-CCCC-T) approach
Fortunately, an entirely different prevention strategy has emerged in recent years, including eight different methods that we call, for lack of a better acronym, the A2B4CT approach:
Antiretrovirals (with emphasis on access and adherence)
Lactation (Exclusive, with ART for PMTCT)
Barriers (condoms, microbicides)
Circumcision (voluntary male medical circumcision)
Prevention/reduction of coinfections (TB, STIs; fungal, bacterial and parasitic infections)
Couples counseling (including multiple couples)
Community viral load reduction
Tests (HIV)
The A2B5CT approach is based on biology, not morality. You don’t need to change your personal beliefs: instead, you need to understand how it works and apply it.
The nature of the behavioral changes required is also different and they are related to the economy, gender equality and mental health issues, including motivation towards a better future, communication within relationships, stress and depression, and substance use (especially alcohol).
The results of the A2B4CT approach are impressive. A selection of results illustrates the impact of these prevention methods:
• For couples in which one person has HIV and is taking ARVs, and the other is HIV negative, the probability of transmitting HIV to the uninfected partner is close to zero (99.9%) after the partner treated reaches undetectable viral load (and where the person is adherent to ART);
• With the new PMTCT (Prevention of Mother to Child Transmission) protocols, when applied as intended, rates of mother to child transmission are reduced from 20-25% to levels close to 1%. This is an over 95% reduction in transmission;
• Voluntary Medical Male Circumcision (VMMC) reduces a man’s chance of becoming infected with HIV by about 50%, and the chance that he will later infect his regular partner by about 50% ( WHO).
Condoms have re-emerged as an effective prevention method, albeit with a different emphasis and application in the new A2B5C approach. For example, as a short-term protective measure while a couple waits for the infected partner’s viral load to drop to safer levels, so that conception of babies can occur without risk of transmission from one partner to another. Microbicides are being developed as another form of barrier against HIV transmission.
New opportunities require a new understanding
The new A2B4CT is grounded in biology: the nature of HIV and how viral load is the key to understanding transmission risk. Three biological terms must be thoroughly understood: viral load (VL), co-infections, and Langerhans cells. When these terms are understood and applied logically, a wide range of prevention methods becomes apparent, including individual, couple, and community interventions.
Understanding the general course of HIV viral load is essential to developing effective prevention strategies. Many medical experts say that viral load is more important than CD4 count in determining a person’s health and well-being.
New challenges
Naturally, this shift in focus has resulted in a host of new issues, such as ensuring adherence to ART treatment, early detection of pregnancy, and challenging traditional and religious beliefs regarding male circumcision, to name a few of the emerging challenges. . Furthermore, the fact that viral load is significantly affected by basic issues such as access to primary health care for co-infections, as well as the quality and quantity of food, water and sanitation, requires a much more integrated approach (mainstreaming). ) for HIV prevention.
Other challenges include a change in the nature of stigma. In the ‘old ABC’ era, stigma was largely based on the morality of sexuality and the fear of death. With the implementation of ART on a large scale, the new A2B4CT approach brings a different kind of stigma based on judgments of carelessness regarding health behavior.
Prevention messages are also changing because the threat of illness and death has been potentially removed. Young people, in particular, are skeptical about the need to reduce the risk of infection: “You get HIV and then you take the pills. What’s the problem?”
discussion points
The following is a short (incomplete) list of topics that will be discussed in relation to the new A2B4CT approach:
Viral load (VL): VL levels vary from infection to AIDS: What does this mean for specific prevention efforts?
• Window period; Higher VL and therefore risk of transmission; The person tests negative for HIV, but has the highest chance of transmission; ARS (acute retroviral infection): typical symptoms and practical interventions during HCT and primary health care visits;
• Sero-discordant couples (HIV+/HIV-): How does this happen?
• AIDS: high VL but low sexual desire;
• Pilot studies on PrEP (Pre-Exposure Prophylaxis);
• Use of substances (drugs): Various effects on QoL
Coinfections:
• Majority of infection: low VL, but ‘viral spikes’ during co-infections;
• How coinfections affect viral load (eg, tuberculosis, STIs, malaria, common parasites) and the role of primary health interventions (handwashing, kitchen hygiene, cooking methods) and treatment .
Antiretroviral treatment (ART) as prevention:
• It’s all about viral load…
• Adherence to treatment: the real challenge
• Noncompliance: partner infected with a drug-resistant strain
• Adherence monitoring: How? Whose?
• Reasons for non-adherence: Money (cost of transportation), distance, depression, alcohol and side effects.
• Traditional Mutis: What are the facts?
Medical Male Circumcision (MMC):
• Langerhans cells
• The difference between traditional and medical circumcision
• Recovery time
• Encourage / Motivate
Myths and facts about ‘cures’:
• The Berlin Patient: The First ‘Cure’?
• Babies being ‘healed’
• French patients who discontinued ART: No viral load
• Faith healing: HIV positive to HIV negative; What is it about?
Stigma:
• Self-stigma
• Pre-ART sex-death morality and fear-based stigma
• Patronizing post-ART stigma