Comprehensive Prevention

Much has been written about the components of HIV prevention – with significant attention to the “alphabet” of prevention approaches, including Abstinence, Be faithful and Condoms (ABC), ABC+, Condoms Needles and Negotiation (CNN), and A-Z.^{12 13 14 15 16 17} However, the success of any approach—whether it be putting on a condom or taking a contraceptive pill—depends on human behavior.¹⁸

The three primary behaviors that can prevent sexual transmission of HIV—abstaining from sex, having sex with only one uninfected partner at a time, and using condoms—are well-known as the components of the ABC approach. Originating from early sexually transmitted infection (STI) prevention efforts, the ABC approach has a long, established public health history.¹⁹ Although recent ideological interpretations of the approach remain contentious, the behaviors themselves are the indisputable building blocks of preventing sexual transmission of HIV.

Evidence supports that delaying sexual debut can reduce the number of future partners and therefore, risk of HIV acquisition.^{20 21} However, a 2007 review of STD/HIV prevention programs in the U.S. found that there is currently no strong evidence to confirm that abstinence-only programs delay sexual initiation, hasten a return to abstinence, or reduce the number of sexual partners.²²

Mounting research shows that partner reduction, or the “B” of “be faithful”, deserves greater attention in HIV prevention strategies.^{23 24 25} Concurrent sexual partnerships (those that overlap in time) can facilitate the spread of HIV significantly faster than serial partnerships (consecutive partnerships that do not overlap in time).²⁶ Because HIV viral load—and thus HIV transmissibility—is much higher during the initial weeks or months of infection,²⁷ when one person in the network becomes infected, everyone in that network of concurrent relationships is placed at risk of infection. Partner reduction and increasing monogamy by men has been credited with contributing to declines in HIV prevalence in several countries, including Cambodia, the Dominican Republic, Ethiopia, Thailand, Uganda and Zambia).^{28 29} Figure 1 provides an illustration of HIV transmission in two hypothetical populations—one in which long-term concurrency is the norm and one in which serial monogamy is the norm.

 

Figure 1: Sexual Networking and HIV Transmission. 
Source: Stewart Parkinson, Population Services International. Cited in: Epstein H. 2007. The Invisible Cure: Africa, the West, and the Fight Against AIDS. New York: Farrar, Straus and Giroux.

Please see the Appendix for this section's endnotes.