Comprehensive Prevention

However, prevention messages that encourage women to have one partner ignore the social realities facing many women. Research in Kenya and Zambia shows that marriage can actually increase risk of HIV among young women.³⁰ Marriage increases the frequency of sex and hinders women’s ability to negotiate condom use or abstain from sex. For young women in particular, husbands tend to be older and tend to have higher HIV prevalence rates than those found among partners of unmarried girls.³¹ Promoting “be faithful” overlooks the possibility that partners in a relationship might unknowingly have different HIV serostatus.³² Moreover, for monogamy to work it must be mutual, and women often have little control over their husbands extra-marital partnering.

Other prevention approaches build on ABC. ABC+, for example, means that no opportunities should be missed to strengthen the skills and empowerment of individuals to practice the three preventive behaviors of abstinence, fidelity/partner reduction and condom use.⁴⁴ “CNN,” which stands for Condoms, Needles and Negotiation, was proposed to broaden prevention to address HIV transmission from use of unsterile injections, and to recognize that women often do not have the power to negotiate safer sexual practices, including condom use.⁴⁵

In 2007, the Global HIV Prevention Working Group proposed a “Comprehensive Prevention” approach [See Box 1: Components of Comprehensive Prevention], to address the range of interventions needed for people to practice the primary behaviors associated with HIV prevention. The interventions fall under four categories: Preventing sexual transmission; preventing blood-borne transmission, preventing mother-to-child transmission, and social strategies and supportive policies. For example, prevention programs should utilize a wide array of interventions to address fear of stigma, violence and discrimination from both partners and providers, which make sero-disclosure and requests for condom use difficult and sometimes dangerous.⁵⁰

Box 1: Components of Comprehensive Prevention

Preventing Sexual Transmission
· Behavior-change programs (to increase condom use, delay initiation of sexual behavior in young people, and reduce the number of partners) ·
Condom promotion
· HIV testing
· Diagnosis and treatment of sexually transmitted infections (STIs)
· Adult male circumcision

Preventing Blood-Borne Transmission
· Provision of clean injection equipment to injection drug users
· Methadone or other substitution therapy for drug dependence
· Blood safety (including routine screening of donated blood)
· Infection control in health care settings (including injection safety, universal precautions, and antiretroviral prophylaxis following potential HIV exposure)

Preventing Mother-to-Child Transmission
· Primary HIV prevention for women of childbearing age
· Antiretroviral drugs
· Prevention of unintended pregnancy in HIV positive women
· Breast feeding alternatives
· Caesarian delivery (in the case of high maternal viral load)

Social Strategies and Supportive Policies
· HIV awareness campaigns (including mass media)
· Anti-stigma measures
· Gender equity and women’s empowerment initiatives
· Involvement of communities and HIV-infected individuals
· Visible political leadership
· Engagement of a broad range of sectors in HIV awareness and prevention measures
· Legal reform to create an environment supportive of HIV prevention (such as laws decriminalizing needle possession)

Source: Global HIV Prevention Working Group, 2007. Bringing HIV Prevention to Scale: An Urgent Global Priority. Accessed online at Global HIV Prevention.org on February 11, 2008.

As this report details, family planning programs can help prevent unintended pregnancies, including among HIV-positive women, thereby contributing to the prevention of mother-to-child transmission of the virus. Male circumcision has been proven to reduce the likelihood of HIV transmission, and needs to be appropriately incorporated into HIV prevention efforts⁵¹ [See Box 2: Male Circumcision for HIV Prevention].

Please see the Appendix for this section's endnotes.