Goals

The Knowledge, The Will and The Power (KWP) is a collaborative plan of action to minimise the number of sexual HIV acquisitions and transmissions involving African people in England. The shared programme goal of KWP is to "minimise the number of sexual HIV acquisitions and transmissions involving African people living in England." KWP was originally published in printed format, but now exists mainly in the form of this dynamic website, and associated training interventions and briefings.

KWP outlines what we will do and how we intend our activity to contribute to our overall shared goal of reducing HIV transmissions. To approach this task we have attempted to answer the following questions:

  • What is the most up-to-date information regarding new HIV infections involving Africans in England and which segments of the population are most likely to be involved?
  • What behaviours (or inactions) are causing (or failing to prevent) these new infections?
  • What are the essential values that support our decisions about how to undertake HIV prevention with Africans in England?
  • What unmet needs (ignorance, lack of motivation, lack of power) facilitate these behaviours (or inactions) and which segments of the population are most likely to have which needs unmet?

KWP is concerned with preventing future sexual HIV transmissions. It does not address prevention needs related to mother-to-child transmission, or transmission during needle-sharing or medical interventions. Information and guidance on those modes of transmission can be found elsewhere (see for instance: Audit, Information and Analysis Unit 2007, Health Protection Agency Centre for Infections et al. 2008, Department of Health 2008).

On this website, ‘we’ refers to the National African HIV Prevention Programme collaborating agencies (called the NAHIP agencies). KWP is not a statement of everything that all NAHIP agencies do, but of what we have in common.

We are concerned with all people living in England who consider themselves African, irrespective of their country of birth, current nationality, ethnic group or religion, and irrespective of the length of time they have been in England or how long they will stay. This population will include those on short-term visas, with temporary and permanent leave to remain, students, asylum seekers, irregular (or undocumented) migrants, those with unresolved immigration applications and British and EU citizens.

We are concerned with the future sexual activity of African people in England. Meeting their HIV prevention needs will increase their ability to avoid HIV transmission with sexual partners in this country, as well as any sexual partners they have elsewhere. We are therefore concerned with sexually active African men and women and those who will be sexually active in the future. This includes African men and African women who will have sex with men, women or both.

We are also concerned with non-consensual sex but this plan does not address unintended pregnancy or other sexually transmitted infections, except where they increase the likelihood of HIV transmission.

We are concerned with African people acquiring HIV during sex and African people passing on HIV during sex. We are therefore concerned with both HIV infected Africans (diagnosed and undiagnosed) and HIV negative Africans. We are concerned with Africans passing HIV to their sexual partners whether or not they have had their own infection diagnosed. This will include Africans acquiring HIV from non-Africans and Africans passing HIV to non-Africans, as African people living in England do not have sex only with other Africans. Therefore meeting the sexual HIV prevention needs of Africans will also benefit the sexual health of other ethnic groups.

This website describes, in broad terms the chain of influence outlined below.

diagram demonstrating how interventions influence change which ultimately reduces HIV incidence

The phrase HIV prevention intervention refers to any finite, defined and purposeful action intended to meet HIV prevention needs. Even if the level of HIV prevention needs were the same in different groups, some groups may differentially benefit from interventions to meet those needs. No single intervention can meet all HIV prevention need for all Africans. We require a range of different interventions, coming from diverse sources, all contributing to the overarching goal of minimising HIV incidence.

Our collective capacity to reduce new HIV infections relies on collaboration between NAHIP contracted agencies as well as working with organisations beyond the programme, including non-HIV and non-African organisations. Our success rests on the commitment of a diverse group of organisations and individuals with different histories and constituencies, including both large, securely-funded organisations and small community groups. This diversity demands a multi-level approach to realise the goals of HIV prevention. To this extent, every person’s contribution to, and support of this vision is crucial.

The ultimate goal of HIV prevention involving African people in England is fewer HIV infections. To achieve this, interventions aim to exert influence and reduce need among a broad array of individuals and structures, including African people themselves. This combined influence supports the reduction of HIV-risk behaviours and HIV transmission facilitators among African people, with a resulting reduction in HIV incidence. The chain of influence shown above demonstrates these relationships between action, aim and outcome. The how and why elements of HIV prevention interventions targeting African people, denoted in the second and third boxes, constitute the content of KWP. What the interventions referred to in the first box entail, is covered in great detail in the direct contact interventions and structural interventions sections of this site.

Values

This section reviews the values and ethical principles that guide the ways in which the NAHIP agencies seek to influence individuals’ sexual behaviours. It presents a theoretical approach to influencing HIV transmission-related behaviour that is informed by the shared ethics and values of NAHIP partners.

In order to reduce the number of HIV transmissions to and from Africans living in England, NAHIP agencies agree that HIV prevention interventions require sound evidence where possible, as well as practical experience and logic. All information or data, in the process of becoming evidence, must be placed within a theory, which is in turn tested by practice.

Which theories we start with, and therefore what data we collect to test them, is guided by our ethics and values. For instance, we can imagine that at a population level, if everyone was force-fed a daily dose of vitamins, this might improve health. However, such an approach runs counter to basic rights and freedoms (such as the freedom to control one’s own body) and it would be rejected as a public health option, regardless of its possible effectiveness.

If health is a fundamental human right, it follows that sexual health and well-being is also a basic human right. Good health stretches beyond just the avoidance of illness, and good sexual health extends beyond the management of STI and HIV risk. Sexual and reproductive health and well-being involves the ability to freely participate in the enrichment that sexual activity can bring, including: pleasure, sensuality, intimacy, conception and emotional expression (World Health Organisation 2006). Ensuring that people’s sexual and reproductive health needs are met can go a long way toward meeting HIV prevention goals. The highly diverse population of Africans resident in England do not approach sexual contact, intercourse, reproduction or condom use in a single way, or attach to these things the same degree of importance, nor would we expect them to.

The Ottawa Charter for Health Promotion established the international standard for promoting good health. It states that health promotion is the process of enabling people to increase control over, and to improve their health (Canadian Public Health Association et al. 1986). Health promotion fosters conditions in which people have the maximum control over their own lives. In the broadest sense, health promotion interventions work towards the continual improvement of the fundamental conditions for health, which include: peace, shelter, education, food, income, ecological stability and equality.

The more social stability and equality there is across a given population, the more likely it is that health and sexual health needs are met, and the more likely it is that interventions to improve health will be accessed and implemented by people who need them. Where basic needs are met and human rights are prioritised, individuals are more able to make informed decisions about their sexual lives.

NAHIP partners increase the control Africans have over HIV in their lives: People make sexual choices every day, often in conjunction with their sexual partners. Health promotion interventions can only indirectly influence sexual decision-making. It is not possible to control the sexual behaviour of African people in England. Successful interventions will be based on increasing the control that people have over their behaviour.

Health promoters are responsible for improving people’s knowledge, will and power. The responsibility for sexual decision-making belongs to the people who have sex. In health promotion the ends do not justify the means - NAHIP agencies do not bully, intimidate, stigmatise or misinform people in order to reduce their HIV risk behaviours. Denying people information and resources to restrict their options or influence the decisions they may make, is a breach of sexual rights.

African people in England who want to reduce their risk of acquiring or passing on HIV will often require support to help them do so. Different people will require different paths - that is the nature of diversity. Effective health promotion enables people to determine the right path for themselves. It can also help them to reflect on whether changing their social, emotional or material circumstances could help them reach their goals.

Acknowledging people’s freedom to make decisions does not stop health promoters from being clear about the relative effectiveness of different means of reducing HIV transmission risk. Indeed, one element of quality prevention includes unambiguous, accessible guidance on avoiding HIV risk. People should be encouraged to examine the potential consequences of their actions, while being given the opportunity to acquire the skills, confidence and resources to increase the control they have over their sexual lives.

There is a difference between making authoritative statements about the most effective ways of avoiding HIV transmission and making normative or judgmental statements about right and wrong ways to behave. NAHIP partners enhance trust in their own expertise by their use of clearly evidenced information, their professionalism and their capacity to reduce unmet need. Partner organisations do not employ tactics that make people feel chastised or judged for their sexual behaviour, or for any other aspect of their life, nor do they diminish one group in order to achieve a particular aim for another. In this way, NAHIP agencies resist the stigma that is often associated with HIV.

An ethic of collective care: The rights of individuals and couples to determine their own sexual behaviour are central to the values underlying KWP. At the same time, people are enmeshed in their social world. Ubuntu describes an ethic of community, most clearly articulated in the Bantu family of languages. This notion that a person is a person through other people also emerges in sayings in a number of southern African languages including Ndebele, Xhosa and Zulu (Tutu 2000), across central, southern and eastern Africa (Murithi 2006). It refers to the mutual care, belonging and interdependence that is initially fostered within extended families and can be broadened to one’s community.

The people around us shape the contours of our lives to the extent that our respect and concern for their well-being can positively influence our own. Such values can play a significant role in the reduction of HIV transmission, where people come to recognise that their own health impacts on health and well-being at a familial and communal level. Ubuntu is an ethic that encourages people to act to improve the community around them. In doing so they also strengthen themselves. NAHIP partners exhibit through the delivery of all interventions, an ethic that promotes the value of the individual as a part of the community. In HIV prevention terms, ubuntu can foster people’s motivation to avoid sex with a risk of HIV transmission.

As with any effort to increase and strengthen group norms, it is important to recognise the potential for ubuntu to be used in ways that may castigate others, or to alienate those who choose not to identify with a particular community. Such activity would not help to meet HIV prevention need, and we mention this simply to highlight the ways that group values can be employed for destructive as well as constructive purposes.

HIV transmission basics

Men and women with HIV can pass it to male and female partners through a limited number of sexual acts. There are four sexual organs that can be involved in the acts that transmit HIV: the penis, the vagina, the anus and the mouth. Prevention can occur by avoiding a sexual act that risks infected bodily fluid reaching the mucous membrane of their sexual partner, or by ensuring the use of a barrier during a sexual act which will blocks the body fluid carrying the virus.

The success of interventions to minimise the sexual transmission of HIV among African people requires that those funding, planning and delivering them attend closely to the five necessary conditions for sexual HIV transmission, which are:

  1. Sexual contact occurs between infected and uninfected partners (HIV sero-discordant sex);
  2. which includes a sexual act that provides a route for HIV to pass from the infected to uninfected partner (for example intercourse without a condom);
  3. through which a quantity of specific body fluid (semen, vaginal fluids, anal mucous or blood) containing HIV is transferred from the infected to uninfected partner through either a mucous membrane (in the vagina, penis or anus) or directly to the bloodstream (through broken skin);
  4. with a sufficient concentration of HIV particles (called viral load) in the bodily fluid of the person with HIV; to
  5. an uninfected partner who is susceptible to HIV infection. HIV prevention interventions benefiting African people in England should enable individuals considering sex to disrupt one or more of these conditions.

The acts which NAHIP partners believe are capable of transmitting HIV are shown below.

chart outlining sexual acts that expose partners to infection where one person has HIV

The number of new HIV infections occurring through each of these routes is poorly understood. We think the majority of transmissions occur through unprotected vaginal intercourse (UVI) because this is common and it has a higher probability of transmission than all other acts except unprotected anal intercourse (UAI).

Unprotected vaginal intercourse (UVI) is a common behaviour. About half of intercourse events involving Africans are unprotected. Reporting on their last occasion of intercourse, 51% of women reported that it was unprotected, compared to 43% of men (Mayisha II Collaborative Group 2005). Engagement in UVI by Africans with diagnosed HIV is also relatively common: 43% percent of women and 37% of men with diagnosed HIV reported unprotected intercourse in the last year (Chinouya & Davidson 2003). However, the majority had UVI with partners they knew also had HIV. Far fewer Africans with diagnosed HIV engaged in UVI with a partner they did not know also had HIV (Elford et. al. 2007). The number of HIV sero-discordant unprotected intercourse events could be reduced both by reducing the number of intercourse events and by increasing condom use during intercourse.

Reducing the proportion of sexual sessions that feature intercourse: NAHIP partners consider it both feasible and ethical to reduce the proportion of sexual sessions that feature intercourse. Although many Africans equate ‘sex’ with ‘vaginal intercourse’, NAHIP partners believe it is possible to influence people so that they are able to choose non-penetrative sexual acts instead of intercourse if they choose to have sex, especially with a new partner.

  • NAHIP partners aim to influence Africans so that they reduce the proportion of sexual sessions that feature vaginal or anal intercourse (in order to reduce the number of HIV sero-discordant unprotected intercourse events).The needs associated with choosing non-penetrative sex are described in African targets and aims.

Transfer of body fluid: The body fluid in which HIV is transmitted differs by the sexual act which presents the potential route for transmission. The more of the body fluid that is transferred, the more likely HIV infection is to occur. Preventing infection could occur through preventing body fluids being passed from infected to uninfected partners. When HIV comes through the penis of an infected man the virus is carried in his pre-cum (pre-ejaculatory fluid) and semen.

  • NAHIP partners aim to influence HIV positive African men so that they avoid ejaculating into their partner if they have unprotected intercourse. The needs associated with withdrawal are described elsewhere.

It is widely accepted that receptive partners are more at risk than insertive partners. That is, in HIV sero-discordant unprotected vaginal intercourse, an uninfected woman with an infected man is more susceptible to HIV infection than an uninfected man is with an infected woman, and in HIV sero-discordant anal intercourse an uninfected receptive partner (male or female) is at greater risk than an uninfected insertive partner. These biological susceptibilities relate to the area covered by the mucous membranes of the different organs, and the quantity and infectiousness of body fluids involved (vaginal fluids, semen, anal mucus).

When HIV comes from the vagina of a woman infected with HIV, the virus is carried in her vaginal fluids. NAHIP partners do not think it is feasible to influence Africans to reduce the transfer of vaginal fluid during sero-discordant vaginal intercourse. However, HIV transmission is more likely to occur during UVI between an uninfected man and an HIV infected woman if the woman is menstruating (Mattson et al. 2007). NAHIP agencies think it is possible to reduce the number of UVI events that occur when HIV infected women are menstruating.

  • NAHIP partners aim to influence HIV-infected African women so that they avoid unprotected intercourse during their period.

When HIV comes from the anus (of either an infected man or woman) during anal intercourse the virus is carried in anal mucus and, if there is anal trauma, in blood. NAHIP agencies do not think it is feasible to influence Africans such that less anal mucus or blood is passed during unprotected anal intercourse.

Increasing male and female condom use: During HIV sero-discordant intercourse, male or female condoms can block the route through which HIV is transmitted. Many Africans are familiar with condoms, given that 40% of African people with diagnosed HIV participating in the Padare project (Chinouya & Davidson 2003) used a condom on some occasion in the last four weeks. NAHIP partners consider it feasible and ethical to increase the proportion of intercourse events that feature male or female condoms.

  • NAHIP partners aim to influence Africans so that they increase the proportion of vaginal and anal intercourse events that feature male or female condoms (in order to reduce the number of HIV sero-discordant unprotected intercourse events).The needs associated with using male and female condoms are described in the African targets and aims section.

Reducing condom failure: A male condom can break when applying it to the penis or during use, and it can slip off during use. In addition to manufacturing errors, condom failures can occur when they are not used correctly. Common behaviours that can cause male condom failure include: using a condom after its use-by date has expired; damaging the condom when opening it; unrolling the condom before putting it on the penis; using an oil-based lubricant (which damages rubber); not using any oil-free lubricant. A recent review of the global literature spells out the extent of male condom failure among those who use them, and the most significant contributing factors (Sanders et al. 2012).

Female condoms (eg. Femidoms) are not degraded by the use of oil-based lubricants and are more durable than male condoms, giving them a longer shelf life. Reducing female condom failure requires: correct knowledge of where and how it is inserted, and ensuring that male and female condoms are not used at the same time (as this increases friction). NAHIP partners believe it is feasible and ethical to influence all these behaviours and therefore reduce condom failure.

  • NAHIP partners aim to influence Africans so that they reduce the behaviours causing condom failure and increase the correct use of male and female condoms (in order to reduce the number of HIV sero-discordant unprotected intercourse events). The needs associated with consistently using male and female condoms successfully are described in the African targets and aims section.

More research is needed on which are the most common causes of condom failure among Africans living in England. To read our briefing sheet on male condom use and failure among African people click here.

Post-exposure prophylaxis (PEP): Post-exposure prophylaxis (PEP) involves taking a one month course of anti-HIV drugs starting within 72 hours of exposure to HIV (Fisher et al. 2006). PEP decreases the likelihood of HIV infection by inhibiting viral replication following HIV exposure. The sooner PEP is taken, the more likely it is to prevent infection, though it does not prevent infection for 100% of people exposed (Tsai et al. 1998, Roland et al. 2005). Prompt access to PEP will be most feasible among people who already have some understanding of HIV treatments.

  • NAHIP partners aim to increase awareness and availability of PEP for African people who may have been sexually exposed to HIV. The needs associated with obtaining PEP are described in the African targets and aims section.

HIV facilitators

We think that everyone is susceptible to HIV infection if they are exposed, and  where the necessary conditions for HIV transmission exist. However, not every exposure results in transmission. There are some things that increase or decrease an individual’s susceptibility to HIV. In the list that follows, the first four items fall into the category of what is often referred to as New Prevention Technologies (or NPTs). For an excellent overview on these technologies, visit AVAC's Research Literacy Database.

Suppresed viral load: For HIV to be transmitted in a body fluid, that body fluid must contain sufficient HIV particles to be infectious. During sero-discordant unprotected intercourse, transmission is more likely to occur when the HIV infected partner has a higher viral load (Quinn et al. 2000, Gray et al. 2001). Viral load is higher when HIV has been recently acquired (acute infection), when someone becomes ill, and if they have another sexually transmitted infection (STI). Viral load is likely to be lower if the person is on anti-HIV treatments.

In the summer of 2011, at the IAS conference in Rome, the results were released from a couples study examing HIV treatment and transmission. That trial (named HPTN 052) showed that in serodiscordant couples—where one partner is HIV-positive and the other negative—antiretroviral treatment can significantly reduce the risk of HIV transmission between heterosexual couples. The trial will have wide-ranging implications for the future of HIV prevention, and further detail is available either here in the full journal article describing the results, or here in a plain language summary.

The findings from HPTN 052 help to confirm what many scientists were already discussing. In 2008, a consensus statement by the Swiss Federal Committee for HIV/AIDS asserted that people with HIV are not sexually infectious if they are treatment adherent, have had an undetectable viral load for at least six months and have no other STIs (Vernazza et al. 2008, or see here for an unofficial translation into English). Although there is international consensus that higher viral load increases infectiousness, there is not a consensus that an undetectable viral load means someone is not infectious (Bernard 2008, Centres for Disease Control and Prevention 2008), not least because a range of co-factors beyond STI infection are thought to influence the likelihood of transmission.

It is important to bear some of these additional issues in mind when considering the impact of the results of the HTPN 052 study. Although the clinical trial demonstrated a 96% protective effect where a person with HIV has an undetectable viral load, it is worth remembering that the circumstances of a clinical trial are never replicated in 'real world' dynamics. Where adherence is not perfect, viral load will be influenced, and in the absence of very regular monitoring, such individuals can't be certain of their current viral load.

Nonetheless, the recent evidence supporting the promotion of HIV treatment to suppress the viral load of people with diagnosed HIV for the purposes of prevention offers enormous possibility to the many combined factors that can help individuals reduce their likelihood of passing it on. Recent treatment guidelines for people with HIV produced by BHIVA suggest that consultants should discuss the preventive implications of starting ARV treatment, even before it is clinically indicated.

HIV diagnosis is the necessary gateway to clinical care and to reduced infectiousness through access to anti-retroviral treatment. In the second National Survey of Sexual Attitudes and Lifestyles 44% of African women and 36% of African men in the UK reported having had an HIV test at least once (McGarrigle et al. 2005). The large proportion of diagnoses among Africans with HIV-related symptoms indicates a long time gap between infection and diagnosis (Burns et al. 2008). This is reinforced by the estimate that 42% of the black Africans who were diagnosed with HIV in 2007 had a CD4 cell count of 200 cells/mm3 or less, indicating that their HIV infection had remained undiagnosed for a significant period of time (Health Protection Agency 2008) .

The presence of another sexually transmitted infection in a person with HIV can increase their viral load (Rottingen et al. 2001). It is therefore vital that the sexual health of people with diagnosed HIV is maintained through screening for other STIs.

In order to reduce viral load in people with HIV, NAHIP partners aim to:

  • Minimise the length of time between Africans with HIV migrating to England and having their infection diagnosed.
  • Minimise the length of time between Africans living in England acquiring HIV and having their infection diagnosed.
  • Maximise the proportion of Africans with HIV who are successfully taking anti-HIV treatments.
  • Minimise the length of time Africans with HIV have untreated sexually transmitted infections.

PEP: If an uninfected person is exposed to HIV, post-exposure prophylaxis (PEP) can be used to try and ensure they do not become infected. ‘Post-exposure’ indicates that PEP is taken after a person has been exposed to body fluids which may contain HIV. PEP is normally taken for one month after a single risk event. PEP normally consists of three or four anti-HIV drugs, which need to be taken for 28 days, following possible exposure to HIV. The drugs used in PEP are the same as the drugs used for treatment of diagnosed HIV. To be effective, it is important to start taking PEP as soon as possible, and no later than three days (72 hours) after the risk event, and to take all the doses, at the right time. Although PEP is not 100% effective, there have been few reports of HIV infection after the use of PEP. See the British HIV Association's guidance on the prescription of PEP in order to better understand how clinical decisions are made in its administration following sexual exposure. Also, there is a KWP briefing sheet on PEP that reviews some of the evidence to date, as well in information on awareness of PEP from the Bass Line surveys.

PrEP: Pre-exposure prophylaxis is a newer strategy which involves the use of antiretroviral medications in people who do not have HIV infection (but who have a high likelhood of exposure) in order to avoid infection. Some people have compared this to the use of anti-malarial prophylaxis in advance for those who may be exposed. In May 2012, the drug Truvada was licenced by the American Food and Drugs Administration for use as PrEP, so more may be known soon about its efficacy in wider populations. There have been some trials undertaken to test the effectiveness of PrEP, and their findings are summarised on AVAC's PrEP Clinical Trials page, along with ongoing studies. PrEP demonstrates partial effectiveness in different trials with different groups of people, and is likely to be of most benefit at an individual level in combination with other forms of prevention. AVAC has also devised a briefing sheet that summarises what is known about PrEP so far.

Male circumcision: Removal of the penile foreskin is thought to reduce the susceptibility of men to sexually transmitted infections, including HIV. A review of observational studies from Africa shows regional variation in HIV prevalence which coincides with male circumcision – areas where males are not usually circumcised were found to have higher rates of HIV prevalence (Bailey et al. 2001). Bailey and colleagues argued that the studies were not supported by evidence found in Europe where HIV acquisition among men is associated with injecting drug use and unprotected anal intercourse. This review found a protective effect of male circumcision against HIV infection with a few studies indicating some protective and less a non-protective effect. Prospective studies have also found a protective effect of male circumcision save for confounders such as the degree of circumcision, religions and age of circumcision (Bailey et al. 2001).

Authors of a randomised controlled trial in South Africa conclude that male circumcision provides a degree of protection against acquiring HIV infection, equivalent to what a vaccine of high efficacy would have achieved (Auvert et al. 2005). Male circumcision is associated with a significantly reduced risk of HIV infection among men in sub-Saharan Africa, particularly those at high risk of HIV (Weiss et al. 2000, Bailey et al. 2007, Grey et al. 2007). No studies on the role of circumcision on HIV prevention have been conducted in the UK.

NAHIP partners are not attempting to increase circumcision among African men in England. They do want to ensure that all Africans know that it is still possible for a circumcised man to acquire HIV through his penis during unprotected intercourse with an infected partner, and that circumcised men with HIV can still pass their infection to an uninfected sex partner during unprotected intercourse.

Other sexually transmitted infections (STIs): The presence of a genital infection increases vulnerability of both men and women to HIV if they have unprotected intercourse with an HIV infected partner. Where an STI results in broken skin in the genital area (such as a chancre or an ulcer), HIV is more likely to be transmitted and acquired (Dickerson et al. 1996, Fleming & Wasserheit 1999, Bonell et al. 2000).

  • NAHIP partners aim to reduce the amount of time that Africans have untreated sexually transmitted infections. The needs associated with STI diagnosis are described in African targets and aims.

Pregnancy: Recent evidence from a large-scale, long term study undertaken in a number of countries has identified that female to male and male to female HIV infection is more likely during pregnancy (Mugo et al. 2010). The authors note that immunologic, physiologic and behavioural changes during pregnancy are all likely to contribute to this increase in susceptibility for both partners.

Hormonal Contraception: There was a range of emergent evidence reported in early 2012, finding that long-acting hormonal contraception delivered by injection, such as Deepo-Provera had significantly contributed to HIV acquisition among women in African countries (Heffron et al. 2012) (this article has been made freely available by the Lancet). NAM has summarised a some of the key issues arising from this growing body of evidence, particularly from studies at the 2012 CROI conference, focusing on recent findings that while hormonal contraceptives appear to contribute to increased HIV incidence, they do not seem to have an effect on disease progression.The World Health Organisation has recently stated that “the data were not sufficiently conclusive to change current guidance. However, because of the inconclusive nature of the body of evidence on possible increased risk of HIV acquisi­tion, women using progestogen-only injectable contraception should be strongly ad­vised to also always use condoms, male or female, and other HIV preventive measures”.The WHO technical statement from February 2012 is available here. AVAC have also issued a two-page briefing on the topic which helps to clarify the WHO statement, which will be useful for all of those giving advice on the issue. The most recent International AIDS Conference held in Washington in July 2012 did not help to shed any further light on the issue, as findings were presented that contine to be contraditory (a good summary of them is made available here on aidsmap). It is worth noting that none of these latter reviews examined data on studies specifically designed to examine the relationship between hormonal contraception and HIV, instead they were secondary reviews asking the question of data from studies collected for other purposes. There are therefore calls for such research to be urgently undertaken.

Female genital mutilation: The World Health Organisation defines female genital mutilation (FGM) as a range of procedures involving “the partial or complete removal of the external female genitalia or other injury to the female genital organs whether for cultural or any other non-therapeutic reason”. FGM is also known as female circumcision or female genital cutting. The Female Genital Mutilation Act (2003) prohibits FGM in the UK and the taking of girls or women out of the UK for the procedure. Of the 28 African countries where FGM has been widely practised, half have introduced legislation forbidding it, although application of these laws can be challenging (World Health Organisation 2008). Legal measures require additional supporting information and other community-oriented measures that promote increased public support for ending the practice. For more information, and to see examples of community development in action, visit the UK-based organisation FORWARD, an anti-FGM campaigning and awareness-raising organisation.

At least some forms of FGM can lead to chronic problems with delayed healing, urinary tract infections, pelvic inflammatory disease, genital injury and obstetric complications due to vaginal tearing during sex (World Health Organisation 2008). All of these features probably leave women with FGM more vulnerable to HIV acquisition, as well as being more likely to pass it on. NAHIP agencies support the legislative prevention of FGM in the UK and elsewhere. The organisations provide advice, referral, and HIV prevention support for women who have experienced FGM.

Harmful vaginal practices: Some methods for cleaning the vagina as well as the use of substances that tighten, dry or heat the vaginal area in preparation for sex can cause increased inflammation and lacerations. Specifically, some practices have been linked with disruption of the vaginal tissues and the loss of healthy vaginal bacteria (Hilber et al. 2007) . Bacterial vaginosis can result when the chemical balance in the vagina is disturbed. The presence of bacterial vaginosis, alongside other vaginal tissue disruption and lacerations makes the transmission of HIV more likely. NAHIP agencies think there is too little evidence of harmful vaginal practices during or prior to HIV sero-discordant intercourse (Fenton et al. 2002, Dodds et al. 2008) to make it worth introducing specific interventions to reduce their use. However, awareness of such practices and their potential impact on transmission will be of value to those providing support and advice to people involved in potentially sero-discordant sex.

Knowledge, will and power

The values and ethics that underpin the NAHIP partners’ approach to influencing behaviours include:

  • a human rights approach to sexual and reproductive health;
  • an approach to HIV prevention that is focussed on HIV while being mindful of the broader social and health issues faced by Africans;
  • clear delineation between the roles and responsibilities of health promoters; and the rights of people to make their own decisions about the sex they choose;
  • valuing and nurturing mutuality and interdependence among Africans living in England.

Within this ethical framework NAHIP partners will increase three things that all people need in order to act to reduce HIV transmission: the knowledge, the will and the power (Fisher & Fisher 1992). All three needs are important and HIV prevention interventions should aim to meet those that are least well met in the target population.

diagram displaying how having knowledge, will and power needs met contributes to risk reduction

The figure above gives an overview of the way that the knowledge, the will, and the power collectively contribute to people’s capacity to reduce the risk of HIV transmission. The remainder of this section describes in some detail the way that each of these three factors combine to influence decision-making and action.

The knowledge: African people with an opportunity for sex need to know what HIV is and how it is and is not transmitted. They also need to know what they can do to reduce the risk of getting HIV, and of passing it on if they are infected. People need to be aware that HIV transmission is harmful, and to know what actions they can take to make that harm less likely to occur.

Very few Africans have never heard of HIV. However, there are different levels of knowledge related to different risk-reduction options. Not everyone needs to know everything. Too much information can be as unhelpful as too little. However, the benchmark for all information given by NAHIP partners is the reality of the HIV epidemic. We endeavor to make sure people know what living with HIV is like, what the real risks are and what can be realistically done about them.

Although knowledge is necessary for action, it is not sufficient. Knowledge is not enough. People also need to want to act and they need to be able to act.

The will: In addition to the knowledge and understanding of HIV risk, people require the will to act to reduce risk.The will to take HIV preventive action is influenced by the perceived benefits and costs of risk behaviours and the risk-reducing alternatives. For example, someone considering whether or not to begin a discussion with a new sexual partner about testing for HIV might be thinking of avoiding HIV transmission (benefit) versus the possibility of putting off their partner (harm).

Someone else may think that condoms reduce sexual pleasure (harm) without recognising that they also bring protection from HIV (benefit). In each case, such thinking my result in unprotected intercourse. For the individuals involved, in the context of uncertain outcomes (such as HIV transmission), these benefits and potential harms must be weighted for their judgements of how likely different outcomes are.

This suggests HIV prevention interventions could attempt to:

  1. reduce what people think is good about unsafe sex and / or increase what they think is harmful about unsafe sex;
  2. increase what they think is good about risk-reduction and / or reduce what they think is harmful about risk-reduction.

We can imagine this attitudinal process of weighing up benefits and costs as a see-saw, that tips in favour of one side or the other. The tipping point will depend on how important the potential benefits are to the individual (or indeed, how many benefits stack up) and how significantly they regard the potential harms. For instance, someone dependent on a sexual relationship for financial and emotional stability may not want to risk introducing condoms into the relationship if they think it may cost them all the benefits of that relationship.

In addition, the extent to which people value the benefits of avoiding participation in HIV transmission will depend on how much they value themselves and their sexual partners.

Knowledge influences motivation. For example, knowing that there is effective HIV treatment and whether or not they are entitled to it enables people to make a better judgement about the potential harms and benefits of taking an HIV test and therefore their will to do so.

The will to reduce risk is also influenced by what we think is acceptable to those who are significant to us, by what we think our significant others would do in the same situation, and by how much we want to conform with our significant others. In other words we emulate the attitudes of those we hold in esteem. So friends and family, and sports and music personalities, as well as other people who are well-regarded, can influence the attitudes and motivation of others to reduce their HIV risk. If we believe that people we respect are willing to participate in activities that reduce the risk of HIV transmission (for instance, by knowing their HIV status, by using condoms, by avoiding unprotected intercourse with multiple partners, etc.) we are more inclined to do the same.

Building up these norms at a community level is what is meant by developing a ‘safer sex culture’. This includes encouraging people to know that within their peer group it is acceptable to discuss HIV and it is desirable to reduce risks during sex. However, undertaking HIV prevention that aims to influence and shift these norms requires close consideration of the capacities, priorities and degree of social conformity in the target population.

Although the will to act is necessary, it is not sufficient. The will to reduce risk is not enough. People also need to know what they can do to reduce risk and they have to have the power to do so. They need the knowledge, the will and the power.

The power: People may understand the importance of a particular behaviour (knowledge), and they may want to undertake it (will) but lack the actual capacity (power) to do so. In order to act on their intention to reduce risk, people need to have the necessary material resources, skills, and opportunities. Things that increase Africans’ power to act to reduce HIV risk therefore include:

  • access to (male and/or female) condoms and lubricant;
  • access to HIV testing;
  • being able to properly use condoms;
  • assertiveness and other interpersonal skills;
  • being free of physical force; and
  • having a choice.

Where resources are lacking, choice is constrained. Condoms cannot be used by someone who has no access to them. Also, some of the behaviours that relate to the avoidance of HIV transmission require specific skills – particularly those relating to negotiation and communication. Acquiring skills requires other resources such as access to the internet, or mobility.

An individual’s power is influenced by their status relative to others in the family, in the community, and in the country where they live. Therefore, the extent to which others consider them a valued and respected member of the community will have direct impact on the resources they can bring to bear in avoiding HIV transmission. Furthermore laws and policies that influence the planning and delivery of local and national services significantly affect the extent to which individuals have the power to avoid participating in HIV transmission.

Although the power to act is necessary, it is not sufficient. The power to reduce risk is not enough. People also need to know how they can act and they need to want to do so.

KWP uses a harm reduction approach: NAHIP's aim for African people having sex is that they reduce HIV risk behaviours and increase preventative behaviours. The specific behaviours NAHIP partners are trying to influence are shown in the figure below.

flowchart of sexual decision-making that can reduce HIV incidence

They include both transmission behaviours (which we are trying to reduce) and prevention behaviours (which we are trying to increase). The needs described here arise directly from the values and theories outlined in the previous sections. Other values and other theories of influence will necessarily result in a different understanding of need. Our general model of need is that in order to reduce the risk of HIV transmission, people require the knowledge of HIV risk and prevention, the will to avoid risk behaviours, and the power to enact preventative behaviours. NAHIP agencies believe that there are very few contexts in which people are unable to reduce their risk of involvement in HIV transmission.

Many factors influence how people respond to that opportunity and we recognise that an individual’s choices might change from one opportunity to the next. For example, people may want to decline some opportunities for sex but not others. They may have intercourse with some sexual partners but not others. They may want to always use condoms unless they meet someone they trust, with whom they negotiate a monogamous relationship, and where they both test for HIV and decide not to use condoms. The summary of African aims describes the needs associated with each of these choices.

NAHIP agencies recognise that even if someone has all their HIV prevention needs met, they may still engage in risk behaviours. This is the meaning of freedom. However, we believe that someone who has their HIV prevention needs met is less likely to take a risk than if they do not have these needs met, including any individual or couple that wishes to conceive. Meeting HIV prevention needs will support people to better manage HIV risk during sexual intercourse on more occasions. This can be described as a harm-reduction approach to HIV prevention.

Structural influence is central to KWP: Just as Africans with an opportunity for sexual risk require knowledge, motivation and ability to reduce the HIV risk-related behaviours they are involved in, so the many actors involved in African people’s lives can help them do so. Friends and family and other members of social networks can support each other to reduce risks. Researchers can do useful investigations and policy advisors and decision-makers can lobby for and make enabling policy. All health, education and social services can act in a way that makes them accessible, acceptable and effective for African people.

Many of the features of African lives in England that were discussed in the Africans in England section have a significant role to play in people’s power to act to reduce risk. Recognition of the structural and contextual elements of peoples’ lives within HIV prevention interventions is a cornerstone of the ‘combination prevention’ approach (Global HIV Prevention Working Group 2008). For instance, a regular and sufficient income, adequate housing and access to health services and information will all contribute to individuals’ skills and capacities to participate in HIV prevention. Legislation and policy at local, regional and national levels will all have a part to play in shaping the power of individual African people to avoid participating in HIV transmission.

However, all these actions also require the knowledge, the will and the power to do them. As well as directly influencing African people who may have sex, NAHIP partners must increase the power, will and the knowledge of other actors to also meet their HIV prevention needs. The African targets and aims section outlines the knowledge, the will and the power NAHIP partners aim to directly increase in African people with an opportunity for sexual risk. The structural targets and aims section outlines the knowledge, the will and the power of all other key actors to act in a way that ensures Africans have the knowledge, the will and the power to reduce their HIV prevention risks.

Page last updated: 31 July 2012