Positive prevention: HIV transmission risk reduction interventions for people living with HIV/AIDS.
Subject: Antiviral agents (Dosage and administration)
Antiviral agents (Research)
HIV infection (Risk factors)
HIV infection (Care and treatment)
HIV infection (Prevention)
HIV infection (Research)
Author: Kalichman, Seth C.
Pub Date: 03/22/2007
Publication: Name: Southern African Journal of HIV Medicine Publisher: South African Medical Association Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2007 South African Medical Association ISSN: 1608-9693
Issue: Date: Spring, 2007 Source Issue: 28
Topic: Event Code: 310 Science & research
Geographic: Geographic Scope: South Africa Geographic Code: 6SOUT South Africa
Accession Number: 182468700
Full Text: HIV prevention programmes require scaling up in southern Africa, and interventions that target people living with HIV/AIDS (positive prevention) should be included in all comprehensive HIV prevention plans. Positive prevention interventions have been tested in the USA and have been demonstrated effective in reducing HIV transmission risks. Lessons learned from US trials can be used in selecting and adapting positive prevention interventions for use in southern Africa. Efforts to implement positive prevention will be enhanced by reducing institutionalised AIDS stigmas and culturally held AIDS denialism and by increasing access to HIV/AIDS care services including antiretroviral therapies and sexually transmitted infection detection and treatment. Positive prevention should not replace, but rather should augment, generalised HIV prevention interventions targeting high-risk populations.


The history of HIV prevention has followed similar trajectories across cultures. Soon after HIV is identified as a viable threat to a population there are efforts to disseminate educational and motivational messages to the masses. When clearly stated, behaviourally targeted and personally relevant generalised prevention messages do raise awareness and undoubtedly reduce high-risk behaviours in at least some population segments. However, many individuals at risk, perhaps those at greatest risk, are not reached by mass education efforts and remain unaffected by generalised prevention messages. A second phase of HIV prevention is then implemented that focuses on further enhancing motivation and developing risk reduction behavioural skills. Interventions such as community-based voluntary counselling and testing (VCT), risk reduction counselling and targeted community programming are examples of second-generation HIV prevention interventions, several of which have been demonstrated effective in southern Africa. (1-3) These intervention approaches are important because they engage people at high risk for HIV infection, including people who are HIV infected but have not yet tested HIV positive.

In what is now a third phase of HIV prevention programming, there is a growing movement to implement HIV transmission risk reduction interventions for people who have tested HIV positive, referred to as positive prevention. The US Centers for Disease Control and Prevention (CDC) has declared positive prevention the focal point of US national AIDS prevention policy. (4) There are also calls for the immediate adaptation and implementation of positive prevention for use in southern Africa. (5) In addition, the South African National Strategic Plan for HIV prevention has included positive prevention as one of its central recommendations. (6)

In this article, I review the research basis for positive prevention and discuss its potential utility in southern Africa. I will focus on one intervention in particular that has been widely disseminated in the USA and is currently being adapted for use in Africa. I conclude with recommendations for moving forward with positive prevention initiatives in southern Africa.


The first positive prevention interventions were tested in rigorous randomised clinical trials conducted in the USA. Positive prevention has used several intervention delivery formats, including individual counselling, brief medical care provider messages, and small support-group style workshops. The interventions have also been designed for delivery in clinical and community settings and have been aimed to reduce risk in men and women with diverse HIV risk histories. Table I summarises the interventions that have been shown most effective in reducing HIV transmission risk behaviours among people living with HIV/AIDS as tested in randomised controlled trials.

Two meta-analyses of the positive prevention intervention literature concluded that the interventions described in Table demonstrate significant short-term and long-term reductions in unprotected intercourse, especially with uninfected sex partners and those whose HIV status is unknown. (13-14) It should be noted that these effective interventions share several common features. All the effective interventions were based on sound theories of behavioural change, typically social cognitive theory that emphasises building behavioural skills. The interventions were also intensive, highly interactive, and aimed toward sustained behaviour change. Although the approaches varied, their goals were clearly directed to reduce HIV transmission risks. The interventions did vary considerably in terms of their formats. Some interventions were delivered in multiple small-group sessions, whereas others were delivered by care providers in routine clinical services. The two meta-analyses did examine several other interventions that reported risk behaviour outcomes, but they were not well focused on risk reduction and did not demonstrate substantial preventive outcomes.


Research is now demonstrating the need for and promise of positive prevention delivered in southern Africa. Studies conducted in Uganda, Botswana, South Africa, and other countries in sub-Saharan Africa are showing that men and women who have tested HIV positive experience difficulty consistently practising safer sex. For example, Bunnell et al. (15) found that 47% of HIV-positive men and 21% of HIV-positive women were sexually active prior to initiating ARVs, with 45% of these persons reporting unprotected intercourse in a 3-month period. Simbayi et al. (16) found that 7% of HIV-positive men and women in Cape Town reported having recently engaged in unprotected intercourse with a partner who was not known to be HIV infected. Importantly, it was more common for people to report unprotected sex with an uninfected partner to whom they had not disclosed their HIV status than with a partner who they had told. This finding was extended in a subsequent study that showed that the best predictor of failing to disclose HIV status to sex partners was experiencing AIDS-related stigma and discrimination.

Another critical factor in the continued practice of HIV transmission risk behaviours among people living with HIV/AIDS is their access to antiretrovirals (ARVs). Optimally, antiretroviral therapy (ART) reduces HIV concentrations (viral load) in the genital tract that parallel reductions in the blood, potentially lowering HIV infectiousness. Adherence to virus-suppressing ARV regimens can therefore play an important role in HIV prevention, especially in patients who do not have co-occurring sexually transmitted infections. (17)

In contrast to research conducted in Europe and the USA, it appears that receiving ARVs in southern Africa is associated with lower rather than higher levels of HIV transmission risk behaviours. For example, a study conducted in Cote d'Ivoire (18) compared HIV-related sexual risk behaviour among sexually active people being treated with ARVs with that in people not being treated and found that fewer ARV-treated sexually active patients had unprotected sexual intercourse during the previous 6 months. Furthermore, more sexually active males and females who were on ART than their counterparts who were not reported that they had used condoms during the last sexual intercourse. In a prospective analysis, Bunnell et al. (15) observed reductions in HIV transmission risk behaviours following the start of ARVs. Also Simbayi et al. (19) reported that nearly half of people with HIV in Cape Town who were not taking ARVs engaged in unprotected sex with uninfected partners and failed to disclose their HIV status to their partners. Fig. 1 shows a conceptual framework for linking institutional AIDS stigma and AIDS denialism to HIV/AIDS discrimination, barriers to disclosure, and failure to engage HIV treatment and care services, which in turn can foster continued HIV transmission risk behaviours.



Effectively implementing positive prevention in southern Africa will require multiple approaches delivered at individual and structural levels in clinical and community settings. One positive prevention intervention approach that is currently being adapted and tested in South Africa and Botswana is Healthy Relationships. (7) The Healthy Relationships intervention has been widely distributed throughout the USA as a part of the CDC's Dissemination of Effective Behavioural Interventions programme. Research being conducted by the Human Sciences Research Council in Cape Town systematically adapted the intervention activities and video material for use in indigenous African communities. Healthy Relationship therefore represents one intervention in the US standard of care for positive prevention.

Using concepts derived from previous mental health and public health interventions for populations affected by AIDS, Healthy Relationships was designed to reduce HIV transmission risks in people living with HIV/AIDS. The intervention uses a highly interactive approach that includes educational, motivational and behavioural skills building components. In addition, like all effective behavioural interventions the content is tailored for gender and risk behaviour history. The intervention content is also made personally relevant to people living with HIV/AIDS. For example, the intervention is framed around the challenges of establishing and maintaining healthy and satisfying relationships in the face of living with HIV/AIDS. Table II summarises the Healthy Relationships intervention content within the five group sessions.

As suggested by a panel of community advisors, Healthy Relationships encapsulates HIV transmission risk reduction within the context of managing HIV disclosure decisions. Initial skills for making effective HIV disclosure decisions are built in reference to disclosing HIV status to non-sex partners, particularly family members, friends and employers. The intervention content transitions to address issues of HIV disclosure to sex partners using the same principles and intervention techniques that were introduced in the initial disclosure skills-building activities, contextualised and reframed for disclosure to sex partners. Healthy Relationships does not promote or even encourage HIV status disclosure. Rather the intervention explicitly targets reductions in transmission risk behaviours regardless of whether or not disclosure occurs.

The final segment of the intervention addresses building skills for reducing HIV transmission risk behaviours. Risk reduction strategies arise naturally in the context of disclosing HIV status, with different implications for practising protected and unprotected sex with HIV-positive partners, HIV-negative partners, and sex partners of unknown HIV status. Skills building activities established in the two disclosure segments to specifically build skills for reducing HIV transmission risk behaviours are generalised for safer sex skills. The Healthy Relationships model attempts to build behavioural skills within an initial behavioural domain and then carries the skills forward to related behaviours ultimately addressing risk reduction strategies with partners of varying HIV statuses.

The three behavioural domains of the intervention components (i.e. disclosure to non-partners, disclosure to partners, and safer sex) were conceptualised as potentially stress-producing situations for people living with HIV/AIDS and therefore framed the intervention activities accordingly as stress reduction skills and strategies. Making effective decisions as to whether to disclose HIV status to family, friends, employers, or sex partners and reducing HIV transmission risk behaviours were therefore viewed as coping responses (Fig. 2). Healthy Relationships therefore integrates a mental health conceptualisation to achieve behaviour changes that have public health implications. Each of the intervention components was geared to build self-efficacy for either making effective HIV status disclosure decisions or reducing HIV transmission risks.

The original randomised trial that tested Healthy Relationships demonstrated promising behavioural outcomes over a 6-month follow-up period. Results of the randomised trial showed that Healthy Relationships resulted in significantly less unprotected intercourse and greater condom use at the follow-up assessments. Specifically, 34% of the Healthy Relationships group members reported non-HIV-positive sex partners at the 6-month follow-up relative to 42% of the control intervention, a significant difference. In addition, rates of unprotected vaginal and anal intercourse with non-HIV-positive partners were significantly lower among the Healthy Relationships groups than the comparison intervention at the 3-month and 6-month follow-ups. Mathematical modelling showed that HIV transmission risk behaviours with non-HIV-positive sex partners would result in significantly fewer new HIV infections from the Healthy Relationships intervention relative to the time-matched control condition. Reductions in potential new HIV infections were greater for HIV-positive men with male sex partners as well as for HIV-positive men with female sex partners.

Subsequent secondary analyses of the Healthy Relationships outcomes demonstrated that the intervention effects were at least partially accounted for by improvements in mental health and coping with emotional stress of living with HIV/AIDS. This finding supports the original model of Healthy Relationships, which specifies that risk reduction will be enhanced by increased stress management (Fig. 2). The potential for Healthy Relationships to address mental health and coping in relation to transmission risk behaviours may be particularly well suited to South Africa, where depression and other mental health challenges are observed in people living with HIV/AIDS.

Although previous research has shown a strong association between HIV/AIDS and depression in Africa, much of this research predated the availability of ART. However, it appears that depression is persistent among people with HIV/AIDS even in the ARV era.20-21 The considerable amount of psychological distress reported by people infected with HIV is at least in part accounted for by internalised AIDS stigmas. Depression is also part of the expected emotional reaction to learning one is infected with HIV. Of course, depression is widely considered a predisposing risk factor for HIV infection among at-risk populations. A unique feature of the Healthy Relationships intervention is its explicit aim to reduce HIV transmission risk behaviours by addressing stigma experiences, disclosure, social support and other mental health issues.


Effectively implementing positive prevention in southern Africa will require reductions in AIDS-related stigmas and denialism to allow people at risk to get tested and engage people with HIV/AIDS into care services. Scaling up access to ARVs can help to further reduce AIDS stigmas and normalise HIV infection as a chronic health condition. Increasing ARV uptake can have the added benefit of reducing HIV infectiousness when HIV-suppressive regimens are adhered to and patients receive aggressive STI detection and treatment services.

Positive prevention holds great promise to fill an important gap in HIV prevention programming. However, we must never delude ourselves by placing all of our prevention resources in just one strategy, especially not positive prevention. Generalised epidemics demand interventions that will capture individuals who are HIV infected but have not yet been tested positive. Positive prevention will only be effective when delivered side by side with effective primary prevention interventions that target high-risk populations, within which many people are untested HIV positive. HIV prevention programming must remain comprehensive and positive prevention should be considered an integral part of any comprehensive HIV prevention plan.


(1.) Voluntary HIV-1 Counselling and Testing Efficacy Study Group. Efficacy of voluntary HIV-1 counselling and testing in individuals and couples in Kenya, Tanzania, and Trinidad: A randomized trial. Lancet 2000; 356: 103-112.

(2.) Kalichman SC, Simbayi LC, Vermaak R, Cain D, Jooste S, Peltzer K. HIV/AIDS risk reduction counselling for alcohol using sexually transmitted infections clinic patients in Cape Town South Africa. J Acquir Immune Defic Syndr 2007; 44: 594-600.

(3.) Allen S, Serufilira A, Bogaerts J, et al. Confidential HIV testing and condom promotion in Africa: Impact on HIV and gonorrhea rates. JAMA 1992; 268: 3338-3343.

(4.) Centers for Disease Control and Prevention. Advancing HIV Prevention: New Strategies for a Changing Epidemic--United States. MMWR Morb Mortal Wkly Rep 2003; 52(15): 329-332.

(5.) Bunnell R, Mermin J, DeCock K. HIV Prevention for a threatened continent: Implementing positive prevention in Africa. JAMA 2006; 296: 855-858.

(6.) South African Department of Health. HIV & AIDS and STI National Strategic Plan 2007-2011. Pretoria: South African National AIDS Council (SANAC), 2007.

(7.) Kalichman SC, Rompa D, Cage M, et al. Effectiveness of an intervention to reduce HIV transmission risks in HIV positive persons. Am J Prev Med 2001; 21: 84-92.

(8.) Margolin A, Avants SK, Warburton LA, Hawkins KA, Shi J. A randomized clinical trial of a manual-guided risk reduction intervention for HIV-positive injection drug users. Health Psychol 2003; 22: 223-228.

(9.) Richardson JL, Milam J, McCutchan A, et al. Effect of brief safer-sex counselling by medical providers to HIV-1 seropositive patients: a multi-clinic assessment. AIDS 2004; 18: 1179-1186.

(10.) Wingood GM, DiClemente RJ, Mikhail I, et al. A randomized controlled trial to reduce HIV transmission risk behaviours and sexually transmitted diseases among women living with HIV: The WILLOW Program. J Acquir Immune Defic Syndr 2004; 37: S58-S67.

(11.) Rotheram-Borus MJ, Swendeman D, Comulada S, Weiss RE, Lightfoot M. Prevention for substance using HIV positive young people: telephone and in-person delivery. J Acquir Immune Defic Syndr 2004; 37: S68-S77.

(12.) Rotheram-Borus MJ, Lee MB, Murphy DA, et al. Efficacy of a preventive intervention for youths living with HIV. Am J Public Health 2001; 91: 400-405.

(13.) Crepaz N, Lyle C, Wolitski R, et al. Do prevention interventions reduce HIV risk behaviours among people living with HIV? A meta-analytic review of controlled trials. AIDS 2006; 20: 143-157

(14.) Johnson BT, Carey MP, Chaudoir SR, Reid AE. Sexual risk reduction for persons living with HIV: research synthesis of randomized controlled trials, 1993 to 2004. J Acquir Immune Defic Syndr 2006; 41(5): 642-650.

(15.) Bunnell R, Ekwaru J, Solberg P, et al. Changes in sexual behaviour and risk of HIV transmission after antiretroviral therapy and prevention interventions in rural Uganda. AIDS 2006; 20: 85-92.

(16.) Simbayi LC, Kalichman SC, Strebel A, Cloete A, Henda N, Mqeketo A. Disclosure of HIV status to sex partners and sexual risk behaviours among HIV positive men and women, Cape Town, South Africa. Sex Transm Infect 2007; 83: 29-34.

(17.) Kalichman SC, DiBerto G, Eaton LE. Associations among HIV concentration in blood plasma and semen: Review and implications of empirical findings. Sex Transm Dis (in press).

(18.) Moatti JP, Prudhomme J, Traore DC, Juillet-Amari A, Akribi HA Msellati P, Cote D'Ivoire HIV Drug Access Initiative Soci-Behavioural Evaluation Group. Access to antiretroviral treatment and sexual behaviours of HIV-infected patients aware of their serostatus in Cote d'Ivoire. AIDS 2003; 17: S69-77.

(19.) Simbayi LC, Kalichman SC, Cloete A, Strebel A, Henda N. Morbidity, social support, depression and HIV risk behaviour among people living with HIV/AIDS receiving ARV treatment in Cape Town, South Africa. Submitted, 2007.

(20.) Olley BO, Seedat S, Stein DJ. Self-disclosure of HIV serostatus in recently diagnosed patients with HIV in South Africa. Afr J Repr Health 2004; 8: 71-76.

(21.) Olley BO, Zeier MD, Seedat S, Stein DJ. Post-traumatic stress disorder among recently diagnosed patients with HIV/AIDS in South Africa. AIDS Care 2005; 17: 550-557.

This paper is based on a Plenary Presentation at the 3rd South African AIDS Conference, Durban 2007 and was supported by National Institute of Mental Health grants R01-MH71164. Correspondence should be addressed to Seth Kalichman, University of Connecticut, Department of Psychology, 406 Babbidge Road, Storrs, CT 06269, USA. Phone (860) 208-3706, e-mail seth.k@uconn.edu

Seth C Kalichman, PhD

University of Connecticut, Storrs, CT, USA

Study          Target              Intervention        Intervention
               population          content             format

Kalichman      Men and women       Healthy             Five 2-hour
et al. (7)     of diverse risk     Relationships,      small support
               histories at a      designed to         group style
               community-based     reduce sexual       workshops with
               AIDS service        HIV transmission    6 - 10 partici-
               organisation,       risk behaviours     pants and
               Atlanta, GA         in relation to      community-based
                                   disclosure of       group
                                   HIV status to       facilitators
                                   sex partners.
                                   Grounded in
                                   social cognitive
                                   theory, uses
                                   coping effec-
                                   tiveness skills
                                   training focused
                                   on HIV-related
                                   stressors and
                                   sexual risk-
                                   producing situa-
                                   tions; skills
                                   for self-disclo-
                                   sure decisions;
                                   development and
                                   maintenance of
                                   safer sex prac-
                                   tices; and role-
                                   playing scena-
                                   rios presented
                                   in popular films.

Margolin       Substance use       Harm Reduction,     Individual
et al. (8)     treatment pa-       weekly indivi-      substance abuse
               tients all on       dual substance      counselling,
               AARV therapy        abuse               daily methadone,
               and receiving       counselling,        case management,
               methadone main-     case management     and 48 1-hour
               tenance in a        and methadone       sessions of harm
               substance abuse     coupled with        reduction
               treatment           motivational        delivered over
               programme, New      interviewing;       24 weeks
               Haven, CT           videos for
                                   modelling and
                                   practice of
                                   needle cleaning
                                   and correct
                                   condom use; harm
                                   reduction nego-
                                   tiation role
                                   plays; and
                                   sharing informa-
                                   tion with peers.
                                   These standard
                                   elements were
                                   integrated with
                                   additional group
                                   therapy that
                                   addressed medi-
                                   cal, emotional
                                   and spiritual
                                   needs as well as
                                   skills to avoid
                                   substance use
                                   relapse and
                                   improve ARV

Richardson     Infectious          Partners in         Ongoing inter-
et al. (9)     disease clinic      Prevention,         vention with
               patients,           brief messages      messages
               southern            grounded on         delivered at
               California          social psycho-      each clinic
                                   logical theory      visit; each pa-
                                   of message fra-     tient received
                                   ming, messages      a minimum of 1
                                   emphasised im-      session; 3 - 5
                                   portance of pa-     min each, over
                                   tient-provider      10 - 11 months
                                   teamwork; loss-
                                   framed preven-
                                   tion messages
                                   were most effec-
                                   tive and were
                                   delivered along
                                   with brochures
                                   and posters.

Wingood        Women attending     Willow, based on    Four 4-hour
et al. (10)    health care         social cognitive    small support
               clinics in          theory and          group style
               Alabama and         theory of gender    workshops with
               Georgia             and power, the      6 - 10 women
                                   intervention        participants
                                   discussed gender    and community-
                                   pride, personal     based peer
                                   achievements,       educators
                                   managing abusive
                                   partners, iden-
                                   tifying socially
                                   people, trans-
                                   mission risk-
                                   behaviour educa-
                                   tion, debunking
                                   myths, safer sex
                                   and negotiation
                                   skills, condom
                                   use skills, dis-
                                   healthy from

Rotheram-      Adolescents and     CLEAR, social       One-on-one
Borus et       young adults        action theory       counselling
al. (11,12)    with substance      based: Module 1,    intervention
               abuse histories     Stay Healthy        delivered in 3
               in New York,        (coping with        different
               San Francisco,      HIV; implemen-      modules, each
               Los Angeles         ting new daily      module being 6
                                   routines to stay    1.3-hour
                                   healthy; issues     sessions. Also
                                   of disclosure;      tested in a
                                   participating       telephone-
                                   in health-care      delivered format
                                   Module 2, Act
                                   Safe (reduce
                                   substance use
                                   and unprotected
                                   sex; identify
                                   risk behaviour
                                   triggers; modify
                                   patterns of
                                   substance use;
                                   increase self-
                                   efficacy for
                                   condom use and
                                   skills); and
                                   Module 3, Being
                                   Together (iden-
                                   tify values that
                                   define personal
                                   identity as a
                                   person living
                                   with HIV; reduce
                                   negative emotio-
                                   nal reactions to
                                   HIV; increase
                                   perception of
                                   personal self-
                                   control; reduce


Session 1     Welcome group members, state the goals of the group and
              agree on group rules; ice-breaker activity to establish
              group cohesion; initial discussion of stress and HIV
              status disclosure; provide PRF for personal stress levels
              and disclosure experiences; group process of PRF; view
              movie scenes for disclosure decision role play; continuum
              of risks for disclosure activity; light-comedy videotape
              to end group on upbeat note

Session 2     Communication skills applied to disclosing HIV status to
              family and friends and other persons who are not sex
              partners: active listening and assertiveness; identifying
              and managing triggers and barriers for HIV status dis-
              closure, establishing problem solving skills and decision
              making skills for HIV disclosure; integrating skills into
              action; skills practice in role plays setup within movie

Session 3     Review of HIV disclosure skills; applying disclosure
              decision skills to relationships with sex partners; risks
              of disclosing and not disclosing HIV status to sex
              partners; personalised feedback report for disclosure
              experiences; group discussion of issues of disclosing HIV
              to sex partners; applying listening skills, assertive-
              ness, problem solving and decision; skills to disclosure
              situations for sex partners; role playing decisions to
              disclose to sex partners using movie scenes specified to
              gender and sexual orientation

Session 4     Implications of decisions to disclose and to not disclose
              HIV status to sex partners; potential adverse reactions
              and problem solving; group discussion of safer sex in
              HIV-concordant and HIV-discordant relationships; PFR for
              sexual risk behaviours; sexual risk behaviour continuum
              activity; review of active listening skills, trigger
              identification and management, problem solving and
              decision making skills adapted to sex and safer sex

Session 5     Continuum of safer sex decisions; condom use and the pros
              and cons of condoms; managing condom aversions and condom
              use anxiety--condom use desensitisation exercises; condom
              skills proficiency training; initiation, negotiation, and
              communication skills for safer sex; role plays within
              movie scenes to integrate disclosure decisions and safer
              sex skills
Gale Copyright: Copyright 2007 Gale, Cengage Learning. All rights reserved.