ABSTRACT
HIV is a blood-borne virus transmitted by sexual practice, particularly penetrative intercourse (vaginal or anal) with an HIV-infected person; by the sharing of HIVcontaminated needles and syringes; from an HIV-positive mother to her child during birth and breast feeding; and via the transfusion of HIV-infected blood and blood products. It is estimated that over 25 million people have died of AIDS and 33 million people are living with HIV, with 95 per cent living in low/middle income countries (UNAIDS 2007; Cohen et al. 2008). In 2007 2.5 million people became infected with HIV, while 2.1 million people died of AIDS (UNAIDS 2007). Each year, prevalence has increased as new infections outstrip the number of deaths. So although the global incidence rate is thought to have peaked, the absolute number of HIV infections continues to grow (UNAIDS 2007). In response to what is a growing global crisis, questions have been raised concerning the efficacy and effectiveness of HIV prevention efforts, particularly those addressing sexual transmission. As sexual transmission accounts for the majority of HIV infections, this chapter focuses on HIV prevention with reference to sexual practice, that is, on the promotion of ‘safe sex’. Why has safe sex been so difficult to achieve? HIV-prevention ‘failure’ is a function of at least three factors: the promotion of non-efficacious or ineffective HIV-prevention strategies; the ineffective promotion efficacious strategies; and a failure to address the sociocultural and political factors driving/producing sexual risk. The first two factors are to a large extent a function of the third: the failure to address the sociocultural and political contexts in which sexual practice and associated sexual risk is enacted, and HIV-prevention education is positioned. In order to address these questions I focus on the social aspects of HIV prevention and in particular on the difference between sexual ‘behaviour’ and sexual ‘practice’. First, however, it is necessary to distinguish between efficacy and effectiveness. Many public health researchers appear to confuse or conflate the two (e.g. see Potts et al. 2008). Effectiveness is different from efficacy in important ways. Aral and Peterman (1998) define efficacy as ‘the improvement in health outcome achieved in a research setting, in expert hands, under ideal circumstances’ and they define effectiveness as ‘the impact an intervention achieves in the real world, under resource constraints, in entire populations, or in specified subgroups of a population’ (p. 33). So while effectiveness is the improvement in a health outcome in the real world, efficacy refers to whether, under ideal conditions, a particular prevention tool works. So, for example, condoms when used correctly and consistently under
clinical trial conditions prevent HIV transmission in 95 per cent of cases, in real life their effectiveness falls somewhat short of 95 per cent – because in real life they are not always used and, when used, they are sometimes not used properly.
