EDITORIAL
The rapidly changing paradigm of HIV prevention: time to
strengthen social and behavioural approaches
John B. F. de Wit1,2
*, Peter Aggleton1,3
, Ted Myers4
and Mary Crewe5
1
National Centre in HIV Social Research, University of New South Wales, Sydney NSW 2052, Australia, 2
Department of Social
and Organizational Psychology, Utrecht University, Utrecht 3508 TC, The Netherlands, 3
School of Education and Social Work,
University of Sussex, Brighton BN1 9RH, UK, 4
Dalla Lana School of Public Health, University of Toronto, Toronto, ON,
Canada M5T 3M7 and 5
Centre for the Study of AIDS, University of Pretoria, Pretoria 0028, South Africa.
*Correspondence to: J. B. F. de Wit. E-mail: j.dewit@unsw.edu.au
Abstract
A decade after the world’s leaders committed
to fight the global HIV epidemic, UNAIDS notes
progress in halting the spread of the virus.
Access to treatment has in particular
increased, with noticeable beneficial effects on
HIV-related mortality. Further scaling-up
treatment requires substantial human and
financial resources and the continued investments
that are required may further erode
the limited resources for HIV prevention.
Treatment can play a role in reducing the
transmission of HIV, but treatment alone is
not enough and cost-effective behavioural prevention
approaches are available that in recent
years have received less priority. HIV prevention
may in the future benefit from novel biomedical
approaches that are in development,
including those that capitalize on the use of
treatment. To date, evidence of effectiveness
of biomedical prevention in real-life conditions
is limited and, while they can increase prevention
options, many biomedical prevention
approaches will continue to rely on the behaviours
of individuals and communities. These
behaviors are shaped and constrained by the
social, cultural, political and economic contexts
that affect the vulnerability of individuals and
communities. At the start of the 4th
decade of
the epidemic, it is timely to re-focus on strengthening
the theory and practice of behavioural
prevention of HIV.
Introduction
After almost three decades of a growing HIV pandemic,
successes in the global fight against HIV are
finally becoming evident. In its 2010 Report on the
Global AIDS Epidemic, the Joint United Nations
Program on HIV/AIDS (UNAIDS) boldly notes that
‘the world has turned the corner—it has halted and
begun to reverse the spread of HIV’ [1]. While these
words have been strongly criticized as reckless and
premature [2], there are grounds for some optimism
that concerted, programmatic efforts to promote universal
access to prevention, treatment, care and support
are having noticeable effects. Compared with
1997, when the HIV epidemic is thought to have
peaked, globally, 21% fewer adults and children are
estimated to have become infected with HIV in
2009 [1]. Also, in 2009 alone, 1.2 million more
people in low- and middle-income countries newly
received effective antiretroviral treatment (ART),
bringing the total number of people receiving such
treatment to 5.2 million, a 13-fold increase in only
5 years since 2004. As access to treatment has
increased, the estimated number of AIDS-related
HEALTH EDUCATION RESEARCH Vol.26 no.3 2011
Pages 381–392
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deaths has declined by 19%, from a peak of 2.1
million in 2004 to 1.8 million in 2009 [1].
These are truly remarkable achievements that
have only occurred in the decade since the member
states of the United Nations (UN), in 2001, convened
for the UN General Assembly Special Session
on HIV/AIDS and signed the Declaration of
Commitment on HIV/AIDS [3]. Global resolve to
fight HIV/AIDS has in particular been enabled by
substantially increased financial investments and
innovative public–private funding mechanisms
[4], supported by resource-rich countries and philanthropists,
including through the Global Fund to
Fight HIV, Tuberculosis and Malaria, the US President’s
Emergency Plan for AIDS Relief, the World
Bank and the Bill and Melinda Gates Foundation.
This global political and financial support is vital
for the HIV response in many countries as are the
wider innovations in global health governance incited
by the HIV response [5]. Achievements to
date illustrate that investments in sound and acceptable
programmes can alter the course of the HIV
pandemic in many low- and middle-income countries,
as previously have evidence-based responses
in developed countries [6].
Building on achievements
There are many compelling reasons for continued
vigilance and caution in celebrating achievements
in the global fight against HIV. Complacency is dangerous
[2] and, as noted more than a decade and a half
ago regarding the HIV epidemic among gay and
other men who have sex with men (MSM) in
resource-rich countries, the best way to loose the fight
against HIV is to declare victory and leave the field
[7]. In times of global financial constraints, funding
for the global fight against HIV continues to fall well
short of what is needed [2], while large increases in
spending for prevention and treatment of HIV will be
needed to control the epidemic in the future [8].
Understandably, many low- and middle-income
countries express concerns around the sustainability
of financial support to maintain and build on
successes that have been achieved [9]. Furthermore,
in many countries and regions, proven and welltargeted
responses need to be strengthened and their
coverage increased, rather than merely maintained,
highlighting that, to effectively curb the HIV pandemic,
much more funding and human resources
are needed to successfully scale-up programmes
[10]. While fewer people may become infected
annually, the estimated number of people newly
infected in 2009 was a staggering 2.6 million [1].
Also, at the same time that countries with the largest
epidemics in sub-Saharan Africa have seen HIV
incidence fall, incidence has increased in countries
in Eastern Europe and Central Asia [1]. Resourcerich
countries, including those that had successfully
contained the HIV epidemic early on, are now
experiencing a resurgence of HIV infections in
MSM, who continue to account for most infections
in these countries [11]. At the same time, new and
newly identified epidemics of HIV among MSM
are reported in Asia and Africa [12]. Globally, the
HIV prevention needs of MSM and other socially
marginalized communities, such as injection drug
users, remain particularly underserved [13,14].
As the worlds’ leaders committed themselves,
starting a decade ago, to ensuring universal access
to prevention, treatment, care and support [15],
a major focus has been on increasing the numbers
of people who receive ART [16]. Now that many
people living with HIV in resource-rich countries
can lead relatively normal lives and their life expectancy
has substantially increased [17], it is essential
also to ensure sustained access to treatment for people
who live in resource-poor countries, with resulting
benefits for individuals, families, communities,
societies and the world at-large. However, 15 years
after effective ART was first introduced, still only
one-third of the 15 million people living with HIV
estimated to need treatment actually receive it
[1,16]. Furthermore, as AIDS-related deaths decline
and more than 7000 people become infected every
day, the number of people living with HIV continues
to grow rapidly and was estimated at 33.3 million
in 2009 [1]. This growing population of people
living with HIV, combined with international expert
recommendations and guidelines supporting earlier
initiation of treatment [18,19], will only further
increase demand for treatment, including in subJ.
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Saharan Africa, the world’s region most affected by
HIV [16,19]. Of particular concern is that treatment
programmes already take up the largest share of the
budget for the HIV response that is available to
many low-and middle-income countries [9]. Moreover,
treatment programmes in poorer countries
typically are at least in part internationally funded,
usually for a limited period of time, increasing
concerns regarding their future sustainability [9].
Even at the recent, accelerated, pace of scaling up
access to treatment, it will take years to achieve
universal access for all in need, a target that was
originally, and aspirationally, set for 2010
[1,14,15]. At the same time, millions of people will
become newly infected with HIV. Despite major
achievements in providing access to treatment in
recent years, the number of people newly infected
with HIV continues to outpace the number of people
newly initiating treatment [20], with UNAIDS
data showing that for every person initiating ART
in 2009 two people became newly infected [1]. A
committee of experts tasked by the US Institute of
Medicine recently came to the conclusion that, in
Africa, the burden of HIV-related morbidity and
mortality cannot be alleviated through treatment
alone as ART can reach only a fraction of those
who need it and costs are unsustainable [20].
The increasing acknowledgement of the (practical)
limitations of ART in curbing the HIV epidemic
anywhere soon has contributed to a recognition of
the continued importance of HIV prevention
[21,22], and underlies the UNAIDS calls to action
for HIV prevention [23], and for a prevention revolution
[24]. Moreover, as HIV infection, at least in
theory, is easily preventable, it is also a public health
and human rights imperative to focus on stemming
the HIV epidemic upstream. Unfortunately, HIV
prevention has received much less priority, funding
and demand and access to treatment has not been
matched by access to prevention [21,22].
Increased options and combination HIV
prevention
From the early years of the pandemic, many HIV
prevention programmes have been community
based and informed by a public health approach
[3], aiming to educate people about HIV, facilitate
access to services and encourage preventive behaviours
[25]. Behavioural prevention programs that
make use of a range of theory-based approaches,
such as persuasive communication, social marketing,
peer education, diffusion of innovation and
cognitive-behavioural techniques [25], have
become particularly important in promoting change
in individuals, couples, families, small groups, networks,
institutions and entire communities, including
through HIV and sexuality education for young
people in and out of school [25,26]. However, thus
far none of the only nine identified, randomized
controlled trials (RCTs) of behavioural interventions
that included HIV infection as an outcome
have found effects on HIV [27].
Sustained changes in behaviour that are large
enough to affect the course of the HIV epidemic
are difficult to achieve [25]. In part, this is because
social, economic, political and environmental
factors affect HIV risk and vulnerability [28],
including poverty, gender inequality and social
exclusion. The importance of such structural factors
in the dynamics of the global HIV pandemic is
increasingly recognized and favours longer-term
development approaches to HIV prevention [3],
which address the social processes that shape and
constrain individuals’ behaviours and their possibilities
to protect themselves [28]. For instance, stigma
and discrimination of people living with HIV, sex
workers, injection drug users, MSM and transgender
persons limits access their access to prevention
and other services and women and girls cannot
always insist that their male partners use a condom.
A structural approach to HIV prevention highlights
the need for more prevention options, in particular
those that can be controlled by women [29], as well
as underscores the importance of comprehensive
HIV prevention to deal with complexity [23], of
which the promotion and protection of human
rights is a core part [24].
As Coates et al. [25] note, HIV prevention is neither
simple nor simplistic but requires a combination
of behavioural, structural and biomedical approaches
[3,22,23,25,28,30–32], integrated with treatment of
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HIV and other sexually transmissible infections [25],
and brought together in a sophisticated programmatic
mix that is appropriate in specific local epidemiological
contexts [31,33]. Recently, progress has
in particular been made with respect to biomedical
interventions, other than the male and female condom,
to reduce the likelihood of HIV transmission
[31], with the potential to substantially extend the
array of HIV prevention options in the future. Notably,
evidence is now available from three RCTs in
high prevalence countries in Sub-Saharan Africa,
which show that surgically safe circumcision in adult
men reduces the likelihood of these men becoming
infected with HIV through heterosexual intercourse
after wound healing by up to 60% [34]. However,
the direct benefits for female partners of circumcised
men are unclear [34] as is acceptability of (adult)
male circumcision as programmes are being rolled
out [31]. Progress is also being made in developing
a preventive vaccine against HIV infection [35]. A
first successful RCT now shows a 30% protective
efficacy of a prime-boost combination of two vaccine
candidates in a general population sample of
men and women mostly at heterosexual risk [36].
A biomedical HIV prevention approach that is
currently seen as particularly promising is the use
of ART for the prevention of HIV infection and
transmission [37]. Antiretroviral drugs are already
routinely used to prevent transmission from HIVinfected
mothers to their child and for occupational
post-exposure prophylaxis (PEP) in health care
workers; PEP is recommended to prevent HIV
infection after likely sexual exposure to HIV
infection, also known as non-occupational PEP or
N-PEP [37]. A novel use of ART for prevention that
is being investigated for efficacy is as pre-exposure
prophylaxis (PrEP), which involves the use of antiretroviral
drugs by people who are not infected with
HIV before possible exposure to the virus to reduce
the likelihood that they become infected. There is
now initial evidence that the use of antiretroviral
drugs for PrEP can offer some protection against
HIV infection. A RCT among women in South
Africa showed that coitus-related use of a vaginal
gel containing antiretroviral drugs reduced HIV
infections in women by 39% [38]. A RCT of a daily
oral regimen of antiretroviral drugs in MSM in six
countries in the Americas, Asia and Africa, found
a 44% reduction in HIV infections among men and
transgender women who had sex with men [39].
While PEP and PrEP aim to protect uninfected
individuals, ART can also be used strategically to
reduce the infectiousness of HIV-infected individuals
and limiting the likelihood of onward transmission
[37]. At least in theory, a strategy of universal
testing for HIV and immediate initiation of treatment
upon HIV diagnosis (i.e.universal test and treat) may
contribute significantly to the reduction and elimination
of the HIV epidemic [40]. Support for the universal
test and treat approach comes from ecological
studies in MSM in San Francisco and injection drug
users in British Columbia, showing population-level
associations between increased HIV testing, wider
ART coverage, decreased viral load and decreased
annual numbers of new HIV diagnoses [41,42].
Reality constraints of new prevention
technologies
The diverse current and future uses of ART for prevention
have the potential to affect the course of the
HIV epidemic at the population level, and strengthen
and perhaps even radically change HIV prevention.
In view of the recent evidence, it is not surprising that
enthusiasm for the range of treatment-based HIV prevention
strategies is growing [43], with some commentators
noting that prevention as a strategy to
defeat HIV finally came of age [44]. However, despite
the potential future benefits of treatmentas-prevention,
there are still major caveats that need
to be addressed before PrEP and universal test and
treat programmes can be confidently implemented
as population interventions. These include the need
for more and robust evidence to support the efficacy
and effectiveness of treatment-as-prevention approaches
in a wider range of communities and settings
[37,45,46]. Observations from Australia
caution that high uptake of testing and ART among
MSM does not necessarily result in fewer HIV infections
[45]. Also in other countries where MSM have
good access to HIV testing and antiviral treatment,
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the HIV epidemic in this community is resurging
[11]. This may be because for universal test and treat
to be effective in reducing HIV incidence, very high
levels of coverage in a population are required [47],
above what is already being achieved in resourcerich
countries today [48]. There is also evidence to
show that, despite the fact that a high proportion of
HIV-infected MSM in Australia are on ART and
have undetectable viral load, the per-contact probability
of HIV transmission due to unprotected anal
intercourse is similar to estimates reported from
developed country settings before ART became
widely available. [49]. Furthermore, mathematical
modelling shows that, even when treatment of
HIV-positive partners in serodiscordant couples is
optimal, there is the potential for substantial
increases in HIV incidence when condom use
declines [50]. The risk that more reliance on treatment-based
prevention options increases risk taking
that could offset any prevention benefits is not yet
well understood [37].
Treatment-based prevention requires the provision
of and access to sophisticated health services, which
not only increases medicalization of healthy individuals
using PrEP [37] but also requires human and
financial resources that, realistically, may be difficult
if not impossible to be made available and sustained
[9,37]. Moreover, a stronger reliance on treatment for
HIV prevention may compound problems with access
to ART for those in need [37] and may come at
the expense of other prevention approaches that are
already compromised by the emphasis on treatment
[48]. As investments in other forms of (behavioural)
prevention decrease, there is even a potential that
overall coverage and intensity of HIV prevention
decreases, at least in the short term, and new HIV
infections may increase as a result. Experience with
providing ART to those in need has shown that rolling
out treatment programmes takes money and time
and is also restricted by the availability of sufficient
services and qualified health care staff [1,9,16]; there
is no reason to expect that this will be any different
when rolling out treatment for prevention. In fact, the
challenges in bringing treatment-for-prevention programmes
to scale are powerfully illustrated by disconcerting
experiences with the provision of ART
for the prevention of mother-to-child transmission
of HIV. While substantial progress is being made
[1,16], there is a long way to go in achieving the
elimination of mother-to-child transmission, a goal
that is generally considered feasible [1]. Notably, in
2009, only an estimated 53% of pregnant women in
low- and middle-income countries, who presumably
were known to be HIV positive, received antiretroviral
medication to prevent mother-to-child transmission.
Importantly, merely 26% of pregnant women
were tested for HIV [1], suggesting substantial
unmet need regarding HIV diagnosis that will also
affect other forms of treatment for prevention.
In the current climate, there is, nevertheless, considerable
momentum to further develop, test and
bring to scale proven and potential biomedical
options for HIV prevention and these new prevention
technologies, in particular the universal test and treat
approach, are heralded as a ‘paradigm shift’ and
‘game changers’ [48]. This has the paradoxical effect
of strengthening the dominance of treatment over
prevention, which has also been strongly criticized
by leading medical experts [22], and more generally
perpetuates the dominance of medical over behavioural
and social approaches, and signals a disquieting
re-medicalization of the response to HIV [48].
Nguyen et al. [48] discursively note a ‘medical triumphalism’
that touts new prevention technologies
as potentially more effective than old prevention
technologies of condoms use, based on what they
consider inappropriate comparisons. It is true that,
as some biomedical prevention scientists note, evidence
from RCTs that show an impact on HIV
infection is only available for treatment-as-prevention
approaches [37]. It is equally true, however, that social
and behavioural approaches to prevention remain
particularly underfunded [3] and that in the past decades
only nine RCTs of behavioural prevention have
been reported that looked at HIV incidence as an
outcome, none of which showed a significant effect
[27]. At least 31 trials have been conducted of biomedical
prevention that, overwhelmingly (25 of 31;
80%), also failed to find an effect [51]. Only one trial
has looked at the effects of structural interventions on
HIV incidence and found no effect [52]. It is also true
that not all RCTs were adequately designed to assess
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effects on HIV incidence [27,51], which at least in
part reflects difficulties in securing funding for the
required large scale studies, and that RCTs, in
particular those using HIV incidence as an outcome,
can pose serious challenges, especially for
the evaluation of interventions requiring large
scale implementation and/or targeting more distal
determinants [53] and should not be the only
evidence that is relied on [51]. Many (complex)
behavioural interventions have been tested in
RCTs that showed substantial effects on behaviour
[54] but these findings are often dismissed
because they rely on potentially biased selfreports
that do not provide adequate surrogate
indicators of HIV infection [27,53], without
a much needed in-depth consideration of complex
design, measurement and conceptual issues that
inform the evidence for HIV prevention interventions
[32,51].
Continued importance of social and
behavioural prevention
Despite statements to the contrary by some [51,55],
partly effective biomedical prevention options are
yet again (perceived to be) presented as a magic
bullet by others, a promise they are unlikely to live
up to, but that nevertheless distracts from investment
in other approaches [48]. However, it is absolutely
clear that new prevention technologies, including
male circumcision and the use of treatment for prevention,
are not and cannot be replacements for
social and behavioural prevention, even when
proven effective and when they can realistically
be brought to scale. The extent and importance of
the social and behavioural implications of new prevention
technologies are not adequately considered
in current debates and may be substantially underestimated.
The same is true for the ethical implications
of the use of treatment for prevention when
access to these same drugs to mitigate morbidity
and mortality is still limited, as well as the implications
of providing toxic drugs that can cause viral
resistance to healthy people who may be less likely
to optimally adhere to treatment regimens [37]. At
the very minimum, the implementation of new prevention
technologies will also require social and
behavioural approaches to promote uptake and support
adherence [25,27], including understanding
and addressing the individual, social, economic
and political factors that affect acceptability and
accessibility. Furthermore, health education and
behaviour change programmes remain needed to
counter any unintended increases in risk behaviour,
which have already been linked to the availability
of ART, at least in MSM [56].
There is a more important role to play for social
and behavioural prevention than merely as complements
to biomedical prevention strategies, as some
surmise [57]. Importantly, while treatmentas-prevention
and other new prevention technologies
may possibly attenuate the impact of social,
economic and political inequalities that shape differences
in HIV risk and vulnerability, they do not
change or remove these inequalities and vulnerabilities
and cannot replace structural approaches to
HIV prevention. Social and behavioural approaches
also remain much needed to address the prevailing
stigma in families, communities and health care
settings [25], which profoundly affects and restricts
access to prevention, treatment, care and support
services for people living with HIV and minority
communities most affected by HIV that are also critical
for successful implementation of new prevention
technologies[9]. Hayes et al. [53] propose a practical
conceptual framework of the determinants of sexual
HIV transmission that operate on at least three reciprocally
interacting levels, ranging from the microbiological
and cellular levels through the individual
and local community levels, to the population and
global levels. Each of the multiple determinants in
the causal chain provides a potential target for prevention
and the framework in particular highlights
the potential value of combination prevention.
Strengthening behavioural prevention
in social contexts
The history of the multidisciplinary fields of health
education and health promotion convincingly
documents that social and behavioural approaches
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to promote public health have long come of age
[58]. Building on the wide diversity of conceptual
and condition-specific traditions in health education
[59] and health promotion [60], a wide range of
approaches to HIV prevention have been developed
and continue to be refined [61], which, in a diversity
of populations, have been shown to effectively
reduce behaviours that put individuals at-risk for
HIV infection [25] and create supportive social
environments that attenuate vulnerability [28].
There is now a large body of evidence that has
been synthesized in numerous reviews and metaanalyses
of original studies and summarized in
a meta-analysis of 18 meta-analyses [54]. This
body of research convincingly shows that significant
effects of behavioural prevention on sexual
risk of HIV infection can be found in a range of
population groups, including adolescents, heterosexual
adults, gay and other MSM, (injection)
drug users, people living with HIV, ethnic minority
groups, STI clinic patients and people with
mental illness [54]. Significant effects have been
obtained using a range of behavioural outcome
measures, in particular increased condom use,
reduced unprotected sex and reduced numbers of
partners; there is some evidence suggesting that
behavioural prevention can also reduce rates of
sexually transmissible infections [54]. Evidence
is also accumulating, including from low- and
middle-income countries [62], that a range of
behavioural prevention methods can be effective
in promoting sexual risk reduction [63]. This
includes proven approaches, such as individual
counselling, group programs, peer education and
community social influence and empowerment
[64], as well as couples counselling [65], computer-based
interventions delivered online and offline
[66] and mass media campaigns [67].
Curriculum-based sex and HIV education in
schools also improves preventive sexual behaviours
[68]. Importantly, while it is sometimes
thought that frank, comprehensive sex education
may hasten sexual initiation or increase sexual
behaviour in young people, there is strong evidence
that it may in fact delay sexual initiation
and reduce sexual behaviour [69].
Major achievements are being made in social and
behavioural HIV prevention [3,25], but there is
much room for improving knowledge of HIV,
providing access to basic HIV prevention services,
including voluntary counselling and testing and
addressing the large unmet need for condoms
[1,9,32]. Most-at-risk populations, marginalized in
many societies, remain particularly underserved
[1,13,14]. It is now time to re-balance approaches
to HIV prevention and strengthen the reach and
coverage of proven behavioural prevention programs.
As Coates et al. [25] have argued, behavioural
prevention science can also do better, which
includes better establishing the effectiveness and
longer-term effects of proven interventions [54]. It
is also critical to strengthening the translation of
effective program into practice [25,32,54,70] and
address barriers to implementation related to the
evaluation of the nature of the evidence for different
prevention approaches, the availability of financial
and human resources, as well as social factors
that affect the implementation of evidence-based
policies and programs, such as cultural values, religious
beliefs and regulatory systems regarding
lifestyle, sexual diversity and drug use. What is also
most needed is an expansion of the theories that
guide behavioural prevention, away from the current
dominance of mostly individual-level theories
of motivation and skills [25,70], and towards theories
that account for multiple levels of influence
on behaviour, including from structural factors
[25,70,71].
Overview of contributions
At the start of the fourth decade of the HIV epidemic,
this special issue of Health Education
Research aims to contribute to the much needed
strengthening and dissemination of the theory and
practice of behavioural approaches to HIV prevention.
This timely special issue brings together 15
papers that address current issues in HIV prevention
in a range of developed and developing country
settings. The reported studies broadly reflect three
different conceptual and practical perspectives that
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constitute important pillars of HIV prevention:
health psychology, health communication and the
pedagogy of HIV education.
Noar et al. [72] address the need for new
prevention options for African Americans in the
USA, who are disproportionately affected by
HIV. In view of the evidence supporting computer
technology-based interventions, they developed
a computer-delivered individually tailored intervention
for heterosexually active African Americans.
The many advantages of computer-based interventions,
in particular their potential to combine large
reach with relatively low cost, offer much promise
for the future of HIV behavioural prevention.
Latino gay men also face multiple barriers to
HIV prevention and there is in particular a lack of
programmes that integrate prevention messages
with cultural norms and address issues of social
marginalization from gay as well as Latino communities.
Vega et al. [73] report on a culturally responsive
multi-layered HIV prevention intervention,
originating in the community, to promote effective
community leadership, provide HIV education
and address internalized homophobia. The initial
positive effects of the program merit further
investigation.
The study by Li et al. [74] contributes to building
the evidence base for HIV behavioural prevention
outside of the United States. Rather than presenting
a new intervention, these authors address the potential
of a culturally adapted intervention for young
people. Cultural adaptation not only makes good
use of existing resources, the positive findings from
this quasi-experimental evaluation also provide
much needed evidence regarding the usefulness of
prevention programmes, and perhaps also their underlying
theory, in other cultural contexts.
The following two papers illuminate factors that
affect the effects of proven and novel behavioural
interventions. Schmiege et al. [75] previously
demonstrated the efficacy of a theory-based HIVprevention
intervention for justice-involved adolescents,
who engage in high levels of risky sexual
behaviour. They now show that adolescents’ level
of positive outlook significantly moderated program
effects on outcomes and theoretical mediators,
with strongest effects for those scoring
relatively lower on positive outlook. De Vet et al.
[76] note that forming implementation intentions,
that is action plans that specify when, where and
how a person will act, is a promising method to
promote condom use. Their study, however, suggests
that it is hard for young women to form high
quality plans for condom use. Implementation
intentions for preparatory behaviours, that is buying,
carrying and discussing condoms, were of better
quality, implying that it is important to ask
individuals to form implementation intentions for
preparatory behaviours rather than for the target
behaviour alone.
With a focus on one component of a broader HIV
prevention communication campaign in Malawi,
Creel et al. [77] provide an evaluation of a mass
media radio programme to reduce HIV-related
stigma. Stigma is thought to hinder HIV prevention
in a number of ways. The study demonstrates the
utility of radio diary programmes, featuring men and
women living with HIV, in reducing HIV-related
stigma in the larger community. An enhancement
to the intervention involving listener group discussions
may not add further benefit but in fact, may
lead to polarization, which further demonstrates the
complexity in understanding stigma and the complexity
of addressing it in HIV prevention.
Ditmore and Allman [78], in an international
study conducted across multiple continents,
uniquely examine communication within research
processes for biomedical HIV prevention trials
among sex workers. Their paper, which focuses
on issues of consultation, translation, research literacy,
respect and participant feedback, focuses on
the complexity of communication and factors that
affect it. In doing so, the authors dispel a dominant
myth that sex workers may be against research, and
shed light on how ethical practices and structural
changes will enhance participation and the quality
of research.
Cain et al. [79], in an ethnographic study among
Xhosa-speaking people in South Africa, provide
understanding of sexual communication within both
private and public contexts. The authors present
a useful framework for understanding both literal
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and emotional aspects of communication, between
educators and community and between sexual partners.
The paper suggests as sexual communication
is influenced both by gender roles and power differentials,
HIV prevention education that incorporates
universal terminology may facilitate greater acceptance
free of emotive cultural connotations.
Mutchler et al. [80] acknowledge that most
research on sexual communication has focused on
the interpersonal with fewer studies on cultural and
social expectations of that communication. Their
analysis of HIV risk in dyadic interviews between
young gay men and other young men and between
young gay men and heterosexual female friends,
conducted in the USA, examines how sexual scripts
differ within these different conversational contexts.
The authors conclude that assumptions about
group-level communication patterns merit revisiting
in HIV prevention initiatives.
In a study of gay and bisexual men in France,
Adam et al. [81] explore the association between
online erotic chatting and sexual risk taking.
Unexpectedly, they observed that Internet conversations,
which include fantasizing about unprotected
anal intercourse, may lead to greater actual
sexual risk taking. This is an interesting twist on
a common belief that communicating fantasies
about unsafe behaviour does not manifest itself
physically in forms of risk behaviour.
Turning to questions of education, the importance
of locating HIV pedagogy within a strong
theoretical base is discussed in the paper by Miedema
et al. [82], which argues for a more detailed
exploration of the theoretical assumptions underpinning
different forms of HIV-related education.
Differentiating between approaches that are ‘scientifically’
informed, those that draw upon notions of
‘rights’ and those which are overtly ‘moralistic’ in
the sense that they promote conservative moral
positions concerning sexual practices, this paper
discusses the strengths and limitations of different
types of HIV-related education. It argues for a more
rigorous conceptual grounding of different forms of
pedagogic practice in pursuit of HIV prevention
and for a better understanding of how teachers
may be supported in their HIV work.
Goldman et al. [83], drawing on research in
Australia, make a strong argument for engaging
with sexuality education using concepts such as
Anderson and Krathwohl’s taxonomy of the cognitive
domain and Gardner’s work on Interpersonal
Intelligence. Such a combination, it is argued, will
provide teachers with a more theoretically informed
basis from which to develop the curriculum,
enabling a more rewarding interaction with
students. By locating age and gender appropriate
educational interventions within a more structured
and theoretical approach, it should prove possible to
progressively enhance the quality of sexuality
education.
The paper by Hatcher et al. [84] addresses the
ways in which, through the promotion of critical
consciousness, the daily reality of women’s lives
serve as the basis for expanded discussion about
the deeply rooted health issues of sexuality, HIV/
AIDS and domestic violence. The curriculum,
which was based on the work of Paulo Freire,
encouraged women participants in Limpopo, South
Africa to examine ‘normal’ cultural practices in
a new light through critical reflection. Through this
process and the development of a critical consciousness,
they were able to see and understand that they
shared common problems and were able to find
shared solutions to these problems. Both individual
and collective solutions and actions to problems
were developed and, importantly, individual people
felt able to take action and make decisions when
they were supported by the collective understanding
of the issues, in ways that had not been possible
when they believed they were alone in confronting
issues of health or sexuality, HIV and AIDS or
violence.
Taking up the challenge to HIV pedagogy from
the perspective of biomedical interventions, Davis
[85] argues that it is the very nature of such interventions
that allows for a greater critical, social
theoretical input into HIV education. This view is
supported in the paper by Hatcher et al. [84] who
argue for a reinterpretation and application of the
work of Paulo Freire and the development of a critical
consciousness in HIV pedagogy. Such a critical
consciousness they argue would allow for analysis,
Strengthening social and behavioural HIV prevention
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mobilization and a constructive understanding of
HIV and the social environments in which it is
being addressed.
Finally, the work of Mason Jones et al. [86]
looks at the effectiveness of HIV pedagogy in process
through an evaluation of peer education. In this
paper, peer educators chosen by staff or those who
had volunteered were contrasted with those who
had been chosen by the pupils. Despite some small
variations, no significant differences were found
between the two groups—the paper suggesting far
more research is needed into peer educator characteristics
and their recruitment to ensure more effective
HIV pedagogy of this kind.
What all these papers show is that the debates
about effective HIV pedagogy are shifting towards
more critical, theoretical positions and a questioning
of the assumption that there is a simple body of
knowledge that can be unproblematically imparted
to a range of people. For effective HIV pedagogy,
we need rigour and critique together with an appropriately
sophisticated understanding of theory and
practice. But if this is true in the field of education,
it is also true across all the fields of HIV prevention
that have been discussed. We hope this special issue
of Health Education Research serves both as
a reminder of what has been achieved, as well as
the challenges that remain as we work critically to
re-socialize the international response to HIV and
AIDS.
Conflict of interest statement
None declared.
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