Principles of positive prevention.

Abstract

After 2 decades of the death and devastation of AIDS, ever-increasing numbers of HIVinfected persons are able to live longer and healthier lives, chiefly as a result of effective antiretroviral treatment (ART). At the same time, there are larger pools of HIV-infected persons in many populations than before, which could result in increased HIV transmission if prevention efforts are not expanded. Thus, current efforts to develop more effective HIV prevention strategies for persons living with HIV/AIDS are timely and appropriate. As we focus more on “prevention for positives,” it may be useful to articulate some principles that reflect lessons learned to date—chiefly from prevention efforts aimed at “negatives”—and suggest future directions. HIV IS TRANSMITTED THROUGH HUMAN RELATIONSHIPS AND THUS SHOULD BE APPROACHED FUNDAMENTALLY AS A RELATIONAL PHENOMENON Whether transmission occurs through sexual intercourse, from mother to child during birth, by sharing injecting equipment, or by transfusing blood from 1 person to another, it virtually always involves 2 people in some sort of social relationship to each other. Yet, historically, most HIV prevention efforts, particularly in the developed world, have focused on reducing risk among individuals rather than dyads. Although some small-group and community interventions have been developed, tested, and implemented, individual-level psychosocial interventions have been the mainstay of HIV prevention research and practice. What is missing is a focus on the dynamics of the relationship in which transmission occurs. Relational dynamics are important and explain such fundamental things as why condom use is often inconsistent or lacking, even though people know it is an effective HIV prevention strategy. Negotiating over condom use and disclosure of HIV infection status require interpersonal and communication skills and a level of comfort that are not possessed by all. In many contexts, the social construction of sexual relationships renders those kinds of conversations moot or impossible. For example, women and men engaged in commercial or transactional sex cannot demand condom use by their partners if to do so jeopardizes their ability to earn payment (of whatever sort), and thus to survive. In more intimate relationships, conversing about condom use and infection status suggests a lack of love, fidelity, and trust, and for many people, the emotional risks of having this conversation are thought to be much greater than the potential risks of acquiring or transmitting HIV. Conversely, for those who do possess the necessary skills and comfort to discuss sexual intercourse before it happens, decisions can be made at the couple level to avoid HIV transmission, whether this means using condoms or engaging in “strategic positioning” during sex so as to reduce the risk of transmission (eg, among men who have sex with men [MSM], the HIV-infected partner in a serodiscordant couple may take the “receptive” position instead of the “inser