MISINTERPRETATION.html
LETTER
MISINTERPRETATION OF THE ‘SAFE SEX/NO SEX’ PREVENTION STRATEGY
To the Editor: We refer to the letter to the editor by MacPhail et al.
1 discussing the specifics of Whiteside and Parkhurst’s article in the April 2010 issue of the Journal.2
MacPhail et al. reported that they theoretically agreed with Whiteside
and Parkhurst that refraining from sex during the acute HIV infection
period might reduce the rate of HIV transmission when implemented on a
wide scale.1
They summarised the scientific logic of the ‘safe sex/no
sex’ prevention strategy, and explained what the acute HIV
infection period is and how critical it is in the transmission of HIV.
MacPhail and her colleagues showed interest in the ‘safe
sex/no sex’ behavioural intervention and its potential
significant contribution to global prevention efforts. However, they
misrepresent the core arguments Whiteside and Parkhurst propose. In
their letter they present the ‘safe sex/no sex’ strategy
incompletely. For example, they report that ‘The authors suggest
that a limited period of population-wide sexual abstinence might be an
effective and low-cost method of interrupting the transmission of
HIV’ and that ‘a limited period of abstinence might be
theoretically infective in limiting HIV transmission’, suggesting
that the strategy focuses solely on abstinence. While an important
aspect of the strategy, abstinence is not the entire approach, and
indeed the benefits of a month-long commitment to ‘safe
sex’ behaviour should not be disregarded owing to the perceived
infeasibility of a month-long commitment to ‘no sex’.
Along with considering a limited period of abstinence, Whiteside and Parkhurst promote ‘safe sex’ or sexual
activity engaged in by people who have taken precautions to protect
themselves against HIV infection, for instance by adhering to correct
and consistent condom use, reducing
concurrency, and promoting circumcision and microbicide gel use and
other HIV prevention measures. The key arguments for the ‘safe
sex/no sex’ prevention strategy are therefore not completely
expressed, being reduced to just abstinence. Whiteside and
Parkhurst’s article clearly elucidated that the potential
intervention would be an aggressive national campaign to ensure that
everyone who is sexually active in a population, whether HIV positive
or negative, either commit to 100% condom use or refrain from sexual
intercourse over a period of a month or longer.2
MacPhail et al. reported
on research with 37 individuals in Lilongwe, Malawi, and Johannesburg,
South Africa, to test this theory. Their research tested the ‘no
sex’ and ‘safe sex’ aspects of the proposed
prevention strategy as two distinct and potential interventions to
interrupt HIV transmission during the acute infection period. As a
result, their findings that there was limited support for the strategy
in a population of individuals with known HIV infection, and that there
is likely to be even less support from individuals who do not know
their status or do not perceive themselves to be at risk of HIV
infection, do not adequately indicate the potential challenges the
‘safe sex/no sex’ prevention strategy is likely to
encounter, as the study investigated ‘safe sex’ and
‘no sex’ as different interventions, not one as proposed in
the ‘safe sex/no sex’ prevention strategy. This does not
mean that MacPhail et al.’s
research is not important – it will help to articulate the
difficulties with a straight ‘no sex’ approach to the
intervention, as well as pointing towards other potential barriers. It
does not invalidate the intervention strategy, and perhaps even
suggests the need to test out a strategy that is focused on both
abstinence and safe sex.
We have reason to believe that, while difficult, an intervention
that focuses on promoting both ‘safe sex’ and ‘no
sex’ has the potential to be successful. In a recent qualitative
study of the ‘conceptual impact’ of this strategy, we found
that most of the participants (members of non-governmental
organisations (NGOs), academia, the Department of Health, the media and
HIV/AIDS researchers) were in favour of the ‘safe sex/no
sex’ prevention strategy (unpublished data). The great majority
of the positive respondents reported that it should be implemented
because it focuses on both infected and uninfected individuals without
necessarily requiring people to know their HIV status. The concern of
many participants was the personal or individual willingness and
commitment of both infected and uninfected individuals to abstain or
engage in safe sex, and not the support they would get in the
population to abstain or engage in safe sex, as reported by MacPhail et al.1
In our study, a handful of participants, 2 out of 4, were not in favour
of the idea that reported that the ‘safe sex/no sex’
prevention strategy would not work due to lack of interpersonal support
in the population.3
In our study, participants in favour of the ‘safe sex/no
sex’ prevention strategy believed that it would uphold and
promote rights of privacy of individuals and therefore cause less
stigma and discrimination based on HIV status. Participants explained
that this would make it easy to mobilise individuals and communities to
abstain from sex or engage in safe sex, as it can be done without
distinction of whether one is HIV-positive or negative. However,
organisers of the prevention strategy would be aware of the HIV status
of the populations as this would help them to monitor the average HIV
viral load in the population before, during and after the period of
abstinence and safe sex to see how much it impacted on infectiousness,
and to get better estimates of effectiveness in practices. The argument
by MacPhail et al. that the
‘safe sex/no sex’ prevention strategy may have less support
from individuals because they did not know their status or perceived
that they were not at risk of HIV infection1
was not reported as a barrier (in our study) to the feasibility and
acceptability of the ‘safe sex/no sex’ prevention strategy.3
This is attributed to the fact that the study investigated the
feasibility and acceptability of both ‘safe sex’ and
‘no sex’ as one strategy, implied by the ‘safe sex/no
sex’ prevention strategy championed by Whiteside and Parkhurst.
As we have found that in theory there is wide support for this prevention strategy (including support by MacPhail et al.),
it would be of benefit to the entire HIV/AIDS research community for it
to be properly articulated and debated. To reduce the strategy to a
period of abstinence, as MacPhail et al.’s
letter to the editor did, obscures the proposed strategy and may
prevent us from properly engaging with a very promising prevention
effort.
G Mutinta
A Whiteside
Health Economics and HIV/AIDS Research Division, University of KwaZulu-Natal, Durban
REFERENCES
1. MacPhail C, Pettifor A, Corneli
A. Feasibility and acceptability of sexual abstinence for interruption
of HIV transmission among individuals with acute infection – formative data from CHAVI 011. Southern African Journal of HIV Medicine 2011;12(2):46.
1. MacPhail C, Pettifor A, Corneli
A. Feasibility and acceptability of sexual abstinence for interruption
of HIV transmission among individuals with acute infection – formative data from CHAVI 011. Southern African Journal of HIV Medicine 2011;12(2):46.
2. Whiteside A, Parkhurst JO. Innovative Responses for preventing HIV transmission: The protective value of population-wide interruptions of risk activity. Southern African Journal of HIV Infection 2010;11(1):19-21.
2. Whiteside A, Parkhurst JO. Innovative Responses for preventing HIV transmission: The protective value of population-wide interruptions of risk activity. Southern African Journal of HIV Infection 2010;11(1):19-21.
3. Mutinta G, McAlister H, Ga’al K. An explorative study on the
‘conceptual impact’ of the ‘safe sex/no sex’
HIV prevention strategy. African Journal for HIV Research (in press).
3. Mutinta G, McAlister H, Ga’al K. An explorative study on the
‘conceptual impact’ of the ‘safe sex/no sex’
HIV prevention strategy. African Journal for HIV Research (in press).