The New A2B4CT of HIV Prevention

This document focuses on critiquing the ABC sexual behaviour change strategy (Abstain, Be faithful, and use Condoms) of HIV/AIDS prevention in South Africa, explaining why and how it has not been effective and proposing another approach. "One of the failings of the old ABC approach was to make the exceptions the rule, and to focus upon these exceptions to deal with preventing HIV transmission in the general population: Multiple partners, infidelity, high frequency of sex, and early age of commencement of sexual activity, to name a few assumptions."

The authors re-focus thinking through facts derived from research on transmission. "The 'AB' (abstain and be faithful) strategy failed because people were (by and large, excluding high specific risk group) already pretty conservative in this regard." They then focus on a general approach. "There always has been - and always will be - people, behaviours, resources and circumstances that are beyond the range of what is considered average or normal. These would require target-specific methods. However, for the great majority of people and circumstances, the A2B4CT approach is pretty straightforward and within the current government health guidelines and protocols."

The A2B4CT (A-BB-CCCC-T) approach uses 8 strategies for prevention:

1. Antiretrovirals (with emphasis upon access and adherence)
2. Breastfeeding (exclusive, with antiretroviral therapy - ART - for prevention of mother-to-child transmission - PMTCT)
3. Barriers (condoms, microbicides)
4. Circumcision (voluntary male medical circumcision)
5. Co-infection prevention/reduction (tuberculosis, sexually transmitted infections - STIs; fungal, bacterial, and parasite infections
6. Couples counseling (including multiple partners)
7. Community viral load reduction
8. Testing (HIV)

"The A2B5CT approach is based upon 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 required behaviour changes is also different and are linked to economics, gender equity, and mental health issues, including motivation towards a better future, communication within relationships, stress and depression, and substance use (especially alcohol)."

An example of the effectiveness of this approach is offered as the following: "With the new PMTCT ... protocols - when applied as intended - mother-to-child transmission rates are reduced from 20 to 25% levels to close to 1%. This is a 95%+ reduction in transmission..."

This approach is based upon an understanding of viral load (VL), co-infections, and Langerhans cells and results in new challenges and issues, such as adherence to ART treatment, early pregnancy detection, traditional and religious beliefs regarding male circumcision, and the nature of stigma: "With large-scale ART implementation, the new A2B4CT approach brings a different kind of stigma based upon judgments of carelessness regarding health behaviour. Prevention messaging is also changing because the threat of illness and death has been potentially removed. The youth, in particular, are skeptical of the need to reduce the risk of becoming infected: 'You get HIV then take the pills. What’s the big deal?'"

The document concludes with detailed discussion points on the new approach.