‘Positive prevention’ and its implications for responsibility

Until relatively recently, HIV prevention interventions aimed explicitly at people who know their HIV-positive status were rare, although some prevention campaigns had made explicit attempts to ensure they did not exclude people who knew they were HIV-positive. What became known as ‘positive prevention’ became formalised in 2003, when the CDC announced a new national initiative focused on “prevent[ing] new infections by working with persons diagnosed with HIV and their partners.”²

The CDC called for incorporating HIV prevention into the ongoing medical care of all HIV-positive people in clinical settings; providing those individuals with brief behaviour risk-reduction interventions in the clinic setting with referrals for additional prevention and related services; and also providing counselling and referral services to their partners.³

Although taking further measures to support HIV-positive people’s HIV prevention efforts may in itself seem like a reasonable public health strategy, how the strategy is framed has important implications for people living with HIV. The CDC approach – to ask diagnosed HIV-positive people to discuss their sexual risk-taking behaviour and to name their sexual contacts who may have been exposed to HIV – was criticised by people living with HIV, their advocacy allies and legal experts for “placing the responsibility for avoiding infections on the shoulders of HIV-positive people”⁴ and, in states where individuals could be prosecuted for having unprotected sex with or without disclosing their HIV-positive status, “expos[ing] patients to an unacknowledged risk of criminal prosecution.”⁵

Since then, internationally focused programmatic guidance on ‘positive prevention’ has been developed by number of organisations, including the CDC,⁶ the International HIV/AIDS Alliance,⁷ UNAIDS^8,9 and the World Health Organization (WHO).¹⁰ Despite these efforts, there remains a lack of clarity about the concept, in particular whether its main beneficiary is people with HIV or broader public health aims.¹¹

Subsequently, in 2009, the Global Network of People Living with HIV (GNP+), in partnership with UNAIDS, established a new, human rights-based approach to positive prevention known as “positive health, dignity and prevention.” This links HIV prevention with programmes that aim to improve the wellbeing of people living with HIV. Key elements include  ensuring access to not just to antiretroviral treatment, but more holistic care, including sexual and reproductive health, and psychosocial wellbeing including integrated mental health services. One of the key principles of positive health dignity and prevention is that “preventing HIV transmission is a shared responsibility of all individuals irrespective of HIV status” which ideally “requires a supportive and protective legal and policy environment free of stigma and discrimination.”¹¹