Written by Sarah Chown
HIV prevention, which includes supporting the health and well-being of HIV-positive and HIV-negative men, is an ongoing challenge for ASOs and CBOs. Communities of gay men have been engaged in prevention efforts throughout the epidemic, and responded by producing safer sex resources, advocating for improved medication research and approval processes, demanding attention from politicians and the media, conducting their own research and developing unique prevention initiatives. However, the HIV epidemic is still alive and well in our communities.
There are many frameworks in use to guide HIV prevention efforts. Often, these are based in our disciplinary homes: people trained in medicine focus on medical approaches, public health people focus on population interventions, community members look to strengthen their communities, and so on. In many ways, these types of approaches make a lot of common sense: we all are just playing to our strengths. However, while we all work together to some extent, it is all too easy to get caught up in our own approaches and overlook new ways of collaborating.
In this blog, I will be taking a look at three of the many HIV prevention frameworks that can help us think outside our boxes, and consider new ways to strengthen our response. I will be briefly talking about three frameworks: highly active HIV prevention (Coates, Richeter & Caceres, 2008), integrating biomedical, behavioural and structural approaches (Tooley, 2012), and social and structural approaches (Collins, 2004). These three frameworks each suggest strategies that have yet to be adopted across public health institutions and research, and hold a lot of potential for future prevention work.
Highly active HIV prevention
King Holmes, from the University of Washington, first coined the term “highly active HIV prevention”, which made its way to academic literature in a 2008 Lancet article focused on improving behavioural HIV prevention strategies. David Wilson, an epidemiologist from Australia speaking at Canada’s recent HIV research conference, presented this concept as a framework that can strengthen current approaches to HIV and gay men. Although the original notion of highly active HIV prevention is not an approach specific to gay men, Terry Trussler discussed a “gay optimized” version of high active HIV prevention recently on this website.
According to Coates, Richter, and Caceres (2008), highly active HIV prevention engages four – often siloed – types of strategies to improve HIV-related outcomes: 1) behavioural change (e.g. consistent condom use, HIV testing), 2) treatment/antiretroviral/STI/antiviral (e.g. treatment for people with HIV and STIs), 3) biomedical strategies (e.g. vaccines (for STIs), PrEP, condoms, treatment as prevention) and 4) social justice and human rights. Each of these four strategies is implemented in the context of political leadership to scale up treatment and prevention efforts, and community involvement. By combining these four types of strategies, highly active HIV prevention creates a synergistic approach that has the potential to strengthen health outcomes more than any one of these strategies could alone.
Treatment as prevention (TasP) is one example of an intervention that can have maximum impact when implemented through the lens of highly active HIV prevention. TasP, is, at its core, a treatment-based strategy. However, to be effective, TasP requires behavioural change – individuals must follow their treatment regimens, seek regular health care, and continue to reduce the risk of HIV and STI transmission to their partners. TasP also benefits from social justice and human rights strategies, which advocate for universal access to health care (including (anonymous) HIV testing, and a primary care physician) and pharmacare programs that make HIV medications available at no (or low) cost. Social justice and human rights strategies that provide stable housing and income can also support adherence.
Integrating biomedical, behavioral and structural approaches
Len Tooley presented the idea of integrating biomedical, behavioural and structural approaches at the end of last year’s BC Gay Men’s Health Summit. This was included as part of the argument that HIV prevention efforts need to address the social inequities and marginalization that drive the HIV epidemic.
Tooley argued that we have seen that both behavioural and biomedical interventions can (and do) work, but that these interventions alone have not been sufficient to reduce HIV incidence in our communities. As such, Tooley proposed four new concepts to strengthen current approaches to addressing the HIV epidemic:
1. re-orient our understanding of social and structural drivers
2. embrace “combination approaches” that integrate biomedical, behavioural and structural interventions
3. recognize the ways societal forces impact individual (in)action
4. focus on long-term social transformation
Approaches to HIV prevention which consider these four concepts create new opportunities for HIV prevention efforts, and position us as an HIV movement at the forefront of changes that reduce social and health inequities. Tooley argued we need to “stop delineating too much between biomedical, behaviour and structural interventions”, and that in doing so, we will be able to maximize the potential of the HIV movement.
Black feminist approaches
Patricia Hill Collins, a leader in Black feminist thought, presents an argument to advance prevention thinking beyond biomedical and behavioural interventions in her book Black Sexual Politics: African Americans, Gender and the New Racism. “Why We Can’t Wait: Black Sexual Politics and the Challenge of HIV/AIDS” is the title of the chapter deals specifically with the HIV epidemic. Her argument highlights the need to consider the ways dominant social and gender norms shape the dynamics of HIV among African Americans:
“But what does prevention really mean? As the African American women in Mississippi and the African American gay men in major U.S. cities suggest, prevention requires going further than information about disease transmission and free access to condoms. Definitions of Black masculinity and Black femininity, the recognition of an array of sexual identities (straight, gay, lesbian, bisexual, and transgendered), questions concerning sexual practices and when "safe sex" is truly "safe," ideas about whether and when to get tested for the HIV virus and how to reveal the outcome to one's sexual partners, all are questioned by the presence of HIV/AIDS.” (p. 296)
This highlights the ways racism shape norms within Black communities, and the ways these norms in turn constrain individual behaviour in ways that facilitate ongoing transmission of HIV. Her analysis is an important example of what we can learn when we turn our attention to social factors, and the importance of considering interlocking oppressions (such as racism) in prevention efforts.
Throughout her chapter, Collins highlights the knowledge and lived experiences of people in communities with elevated HIV incidence rates, and rightly positions it alongside medical and professional knowledge that is typically seen to be more legitimate. This approach is central to Black feminist thought, and within the HIV movement, has been formalized into the “greater/meaningful involvement of people with HIV” (GIPA/MIPA) principle, and, in the case of drug users, the principle of “nothing about us without us”.
Collins closes her chapter with a call for HIV-related organizations and Black community organizations to work in partnership, along with other groups that have shared goals. In her words, “because HIV/AIDS (as is the case for virtually every social issue) does not affect just Black people, solutions require coalitions with other groups who share a similar agenda. Addressing the challenges of HIV/AIDS certainly requires a broad based, coalition politics” (p. 298). Coalition-based approaches can help us to begin to implement highly active HIV prevention and combination approaches.
Each of these three frameworks for HIV prevention encourages some form of collaborative work and call for greater integration between what are typically thought about as distinct strategies. This is no easy feat: for this goal to be realized requires all of us to recognize the limitations of our own work, and look for innovative ways to collaborate with people whose strengths lie in other approaches.
To do this, we must all continue to build partnerships and relationships which affirm each others’ work, and pool resources to support achieving our shared goals. These perhaps idealistic notions require equitable distribution of power within these relationships and in interactions with media, funders, policy makers and health care providers. Finally, we need to continue to consider ways of meaningfully engaging people who most directly experience HIV – both those who are at risk of HIV, and those who are living with it.
As Coates, Richters & Caceres (2008, p. 670) argue, “reductions in HIV transmission in entire countries or regions or in specific risk groups inevitably result from a complex combination of strategies and several risk-reduction options with strong leadership and community engagement that is sustained over a long time”. It is important that we learn lessons from earlier days of the epidemic, and heed the calls from scholars and advocates alike. To borrow from the title of Patricia Hill Collins’ chapter, we cannot wait to address the challenge of HIV/AIDS in our communities – and to do so effectively, we must find new ways to work together.
Writing this blog post has been an important exercise for me to reconsider my own work: what boxes am I working within? How can I do a better job working with, and learning from, my colleagues who are trained in other disciplines? Where do people directly affected by HIV fit into my work? While these questions are not easy ones to answer, that is not an adequate excuse to ignore them. At the very least, engaging with these questions is an interesting way to spend a Saturday afternoon. Ultimately, however, these are important questions we all need to consider to realize the full potential of the HIV movement.
· Greater, meaningful involvement of people with AIDS:
· Nothing about us, without us:
· Why we can’t wait: Black sexual politics and the challenge of HIV/AIDS (Patricia Hill Collins, 2004)
· Stick It To the Structures: Social and Structural drivers (Len Tooley, 2012):
· Behavioural strategies to reduce HIV transmission: how to make them work better (Coates, Richters
& Caceres, 2008)
· Gay Optimized Prevention (Terry Trussler, 2013):
 Differences between some aspects of the second strategy (treatment) and the third strategy (biomedical interventions) are not immediately apparent. Within the framework of highly active HIV prevention, biomedical interventions are those that “block infection or decrease infectiousness” – here, the focus is primary prevention, that is, preventing new infections (p. 670). In contrast, treatment-based strategies are part of tertiary prevention, that is, supporting people who become HIV-positive.