Prevention in Focus

Fall 2010 

A primer on positive prevention

Zak Knowles

Positive prevention programs are designed to promote healthy sexual and emotional relationships for people living with HIV as a way of reducing the transmission of HIV. These programs are developed by and for people living with HIV. This article will highlight the value of positive prevention initiatives as well as some of the challenges they face.

What is positive prevention?

From the beginning of the HIV epidemic in the early 1980s, HIV prevention campaigns have traditionally been directed at specific at-risk populations assumed to be HIV-negative. The focus was on how people can protect themselves from getting HIV. These campaigns often ignored the contributions that HIV-positive people can make and some messages were deemed to stigmatize people living with HIV.  

In the late 1990s prevention programs aimed at people living with HIV (positive prevention) started to emerge. There are many definitions of positive prevention; however, certain themes are common to many of them. For the purposes of this article, the following definition has been chosen.   

Positive prevention strategies are designed for people living with HIV to:

  • empower people living with HIV to take control of their sexual health as a way of preventing the transmission of HIV and other sexually transmitted infections (STIs);
  • promote full, satisfying and healthy emotional and sexual relationships;
  • promote the sexual and reproductive rights of everyone, regardless of HIV status; and
  • combat stigma and discrimination, to ensure equal access to services that can help improve the health and well-being of people living with HIV. 

For a positive prevention program to be successful, people living with HIV must be involved in all stages of development, from planning through to implementation and evaluation.

In Canada, positive prevention programs have been developed mainly by and for gay and bisexual men with HIV. However, the principles of positive prevention can be transferred to all people living with HIV, regardless of gender or sexual orientation.

An undue burden or a shared responsibility?

Positive prevention may be perceived in a negative light by some people living with HIV. Some fear that positive prevention programs could shift the responsibility for preventing HIV transmission solely onto people living with HIV.

Such a concern can only be addressed by positioning positive prevention as just one approach to HIV prevention. Combining HIV prevention strategies is now seen as the way to help prevent HIV transmission. Using a strategic combination of HIV prevention approaches helps ensure that everyone has access to effective prevention programming. Many approaches to HIV prevention have proven effective; however, HIV infections continue to occur. Additional strategies will hopefully further reduce the incidence of HIV. Positioning positive prevention this way should ensure that the responsibility for prevention rests on everyone’s shoulders, regardless of their HIV status.

A holistic approach

Whenever possible, positive prevention efforts should take a holistic approach to HIV prevention and address a wide range of health and social issues. However, not every positive prevention program will be able to include all these components. It is best for your organization to work with people living with HIV in your community to tailor programming to meet their needs.

Testing

In 2008, an estimated 65,000 people were living with HIV in Canada. Of these, an estimated 26%, or 13,900 Canadians, were not aware they had HIV.1 Positive prevention programs can include testing and counselling, to diagnose HIV and provide services that can help to ensure the ongoing health and well-being of people living with HIV.

Detecting all HIV infections, especially all new HIV infections, can help to prevent HIV transmission. Research shows us that almost half of new HIV infections may come from individuals who have been newly infected.2 This may be because people who are newly infected have significantly higher levels of virus in their blood and genital tracts and therefore may be more likely to transmit HIV to others.3, 4, 5,6 It could also be because people who are newly infected may be unaware of their HIV status. Identifying HIV early allows a person to make more informed decisions about their own and others’ health—to access treatment, practice safer sex, use drugs in a safer way, etc. Research does show us that the majority of people who know they have HIV take steps to prevent transmitting HIV to others.7,8,9,10

Supporting a healthy approach to sex

Positive prevention is not just about promoting the use of condoms but also about promoting and supporting healthy sexual relationships for people living with HIV.

Being sex-positive

Sex is an important part of our lives. It is therefore essential that service providers be sex-positive—that is, able to talk openly about sex in a straightforward and non-judgemental way. This will help to create an open dialogue, which will allow the service provider to understand the person they are talking to, what kind of sex they are having and if they are using condoms. Promoting safer sex within this dialogue is an important part of any positive prevention program. Not all people choose to have vaginal or anal sex but find fulfilling sexual expression in many other ways so it is good to be able to talk knowledgeably and frankly about different kinds of safer sexual activity. Because safer sex can mean different things to different people, it is important that service providers understand the sexual behaviours of their clients so they can ensure that messaging is tailored and relevant to the people they work with.

Communication skills

Negotiating sex and HIV disclosure are important elements of safer sex. People need to feel comfortable talking to their sex partners about their HIV status and the type of sex they want. This type of communication and negotiation skill may need to be taught. Positive prevention programs may be able to help people develop the skills they need to disclose their HIV status and to negotiate safer sex with their partners.

Condoms

Using a condom for vaginal or anal sex is the most effective way of reducing the risk of transmitting HIV and other STIs.11 Studies have shown that most people living with HIV take steps to ensure that their partners are not infected with HIV by using condoms during sex.7,8,9,10 However, some people living with HIV choose not to use condoms. Traditional safer sex messaging about condom use may not find traction among those people. This is one of the biggest positive prevention challenges that we currently face.

Risk reduction counselling

After an HIV-positive test result, people may receive counselling on safer sex and/or safer drug use to help prevent HIV transmission. For many people living with HIV, there are only limited opportunities for support and counselling services to help them maintain healthy sexual behaviours. Positive prevention programs can fill the gap and provide counselling services and psychosocial supports on an ongoing basis. These services focus on preventing HIV transmission through risk reduction counselling and also address issues that affect someone’s ability to participate in safer behaviours, such as depression, substance use, low self-esteem and other mental health issues, disclosure of HIV status, relationship and sexuality issues.

Sexually transmitted infections

The rates of STIs are increasing in Canada.12 HIV-positive gay men are disproportionately affected by STIs. For example, in Toronto, 33% of syphilis cases in 2008 were in HIV-positive men.13

We know that having a STI increases a person’s chance of passing and getting HIV.14 For people living with HIV, having an STI can be more serious because the STI may progress more rapidly, symptoms may be more severe, and it may be more difficult to treat than in those who are HIV-negative. Therefore, positive prevention programs may want to also incorporate strategies to prevent STIs, including encouraging regular STI testing.

Erectile problems

It has been estimated that about 40% of Canadian men aged 18 to 70 at some point experience problems getting or maintaining an erection (known as erectile dysfunction).15 There are many possible reasons for erectile dysfunction. Erectile dysfunction can be the result of personal factors such as stress, anxiety, depression, alcohol or drug use, or hormone imbalances. HIV itself or the side effects of certain anti-HIV drugs can also contribute to erectile dysfunction. Finally, some men cannot maintain an erection after they have put on a condom, so they may choose not to use condoms.

Men experiencing erectile dysfunction may feel uncomfortable discussing their sexual problems. Positive prevention programs can offer an arena in which men can meet and talk about their erectile problems. Positive prevention programs could also refer clients to healthcare providers or counsellors to help determine the cause of their problem and possible solutions. For some men, the use of prescription medicines (such as Viagra, Cialis or Levitra) may help them maintain an erection. For others, psychotherapy or counselling may be the key to overcoming the issue. In cases where condom use is the cause, it may be helpful to explore using a different type or size of condom, which may help some men maintain an erection.

Supporting reproductive health

Positive prevention programs could play a role in informing HIV-positive people of their reproductive options and in working to dispel myths about the risk of transmission during conception and delivery. Many women with HIV would like to have children. In British Columbia, for example, approximately 30% of young HIV-positive women wish to have a child in the future.16 This is only 7% lower than among the general population. With the proper treatment and care, an HIV-positive woman can have a healthy pregnancy and a healthy baby. Since the introduction of anti-HIV medications in the 1990s, the rates of mother-to-child transmission have plummeted from around 25% to less than 2%.17 Many people, including some healthcare providers, do not realize that mother-to-child transmission can be prevented. This lack of knowledge can lead to stigma and discrimination for women who choose to get pregnant. This can make it difficult for HIV-positive people to know who to trust or know where to go to talk about their desires for a child.

To reduce the risk of transmission between serodiscordant couples during conception, there are medical interventions that can be performed at fertility clinics.  Although these interventions are not currently accessible across Canada, more and more fertility clinics are accommodating the needs of people with HIV who wish to have children.

Reducing stigma and discrimination

For positive prevention strategies to work effectively, issues of HIV stigma and discrimination must be addressed. People living with HIV may choose not to disclose their HIV status to sex partners out of fear that they will be rejected or even face verbal or physical assault. This can make it difficult to negotiate safer sex options. Stigma and discrimination can also prevent some people living with HIV from seeking healthcare and support services. It is of the utmost importance that all positive prevention programs declare and demonstrate from the outset their commitment to equality and freedom from discrimination for everyone regardless of HIV status.

Much of this HIV stigma and discrimination arises from ignorance of how HIV is transmitted. Increased education about how HIV can (and cannot) be transmitted is needed to help remove the often irrational fears that some people have of HIV.

Two recent provincial campaigns that addressed HIV stigma directed at gay men are:

  • HIVstigma.com from the Ontario Gay Men’s Sexual Health Alliance
  • Stopserophobia.org from COCQ-SIDA in Quebec

Treatment support

Since the advent of highly active antiretroviral therapy (HAART) in the late 1990s, HIV has become a manageable chronic condition. People living with HIV can now expect to live longer, healthier lives. However, the decision to begin treatment can be a difficult one to make. Positive prevention programs can help people understand the pros and cons of treatment in order to help them decide when to start treatment. 

HAART works by reducing the amount of HIV in the blood, which allows the immune system to rebound. This leads to improved health for the individual. A lower viral load may also make someone less infectious. However, it is important to note that the virus will always be present in the body so people should be counselled to continue to use condoms or practice other kinds of safer sex even if they have an undetectable viral load.

Treatment with HAART is only beneficial when people take their prescribed medications consistently and at the right times. This is known as adherence. Adherence can become challenging when people need to take medications in private, when travelling, or when they experience unpleasant side effects and illness from the medications. Interventions could include providing information about HAART, suggesting strategies for overcoming these difficulties, and educating people so they know how important adherence is to the success of their treatment.

Emotional support

People living with HIV who experience depression or other emotional issues may have a poorer quality of life and may be more likely to engage in risky sexual behaviours. Therefore, positive prevention programs need to promote not only the physical, sexual and reproductive health of people living with HIV but also their emotional health.

For example, the rate of depression among people living with HIV has been estimated to be from two to six times greater than that among the general population.18 There are many reasons why people may feel depressed or stressed, such as financial or health worries, the break-up of a relationship, or worries about work. Changes in emotional health can make people who usually have safe sex engage in unsafe sexual practices. For example, some people may find it hard to negotiate condom use because they fear being rejected by their partner. Furthermore, some people may use drugs or drink alcohol to help them deal with an emotional issue, which can, in turn, increase the likelihood that they will have sex without using a condom.

Positive prevention programs could incorporate counselling aimed at helping people work through these issues and, hopefully, enable them to develop strategies that can help them negotiate safer sex with their partners.

Pulling it all together

First, any organization planning to deliver a positive prevention program must define what positive prevention means for that organization and agree on the values and principles. People living with HIV should be actively involved in making these decisions. Once the values and principles have been agreed upon, program planning can commence. This should be based on the needs and priorities of people living with HIV in your community.

Developing a positive prevention program or building on an existing one has two advantages. It can improve the quality of life of people living with HIV and aid in reducing HIV transmission in your community. A win-win. However, these programs should be positioned within a broader array of combined prevention programming that also targets HIV-negative people. No single intervention can be effective on its own.

Related article

For a discussion on positive prevention with community members, see Views from the front lines: Positive prevention.

Resources

Safer sex for the HIV positive—Collection of positive prevention articles and resources from thebody.com.

Pozitively healthy: a gay man’s guide to sex and health—Booklet on sexual health for gay men living with HIV from the Poz Prevention Working Group of the Ontario Gay Men’s Sexual Health Alliance

Poz prevention: knowledge and practice guidance for providing sexual health services to gay men—Practical manual for service providers who work with gay men

Toronto People With AIDS Foundation POZ prevention position paper

Poz prevention definition, values and principles—Principles for prevention work developed by the Poz Prevention Working Group and Approved by the Provincial Advisory Body of the Ontario Gay Men’s HIV Prevention Strategy

Positive Health, Dignity and Prevention—GNP+ and UNAIDS Technical Consultation report

Positive prevention tool kit from the University of California, San Francisco

References

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  • 12. STI Data Tables, Hepatitis C and STI Surveillance and Epidemiology Section, Community Acquired Infections Division, Centre for Communicable Diseases and Infection Control, Public Health Agency of Canada, 2009.
  • 13. Toronto Public Health. Communiqué – Newsletter of Communicable Disease Control, Sept 2009, Issue 19.
  • 14. Fleming DT, Wasserheit JN. From epidemiological synergy to public health policy and practice: the contribution of other sexually transmitted diseases to sexual transmission of HIV infection. Sex Transm Inf. 1999. 75:3–17.
  • 15. Fazio L, Brock G. Erectile dysfunction: management update. CMAJ. April 27, 2004; 170 (9)1429–37.
  • 16. Ogilvie GS, Palepu A, Remple VP, Maan E, Heath K, MacDonald G, Christilaw J, Berkowitz J, Fisher WA and Burdge DR. Fertility intentions of women of reproductive age living with HIV in British Columbia, Canada. AIDS. 2007 Jan;21 Suppl 1:S83-8.
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About the author(s)

Zak Knowles is CATIE’s Manager of Web Content. Before coming to CATIE he worked as an HIV Counsellor at Hassle Free Clinic, a sexual health clinic in downtown Toronto. Zak has been living with HIV for 20 years.