Reducing the overall HIV-burden in South Africa: is ‘reviving ABC’ an appropriate fit for a complex, adaptive epidemiological HIV landscape?

Abstract

This article questions the recommendations to ‘revive ABC (abstain, be faithful, condomise)’ as a mechanism to ‘educate’ people in South Africa about HIV prevention as the South African National HIV Prevalence, Incidence and Behaviour Survey, 2012, suggests. We argue that ABC was designed as a response to a particular context which has now radically changed. In South Africa the contemporary context reflects the mass roll-out of antiretroviral treatment; significant bio-medical knowledge gains; a generalised population affected by HIV that has made sense of and embodied those diverse experiences; and a government committed to confronting the epidemic. We suggest that the situation can now be plausibly conceptualised as a complex, adaptive epidemiological landscape that could benefit from an expansion of the existing, ‘descriptive’ prevention paradigm towards strategies that focus on the dynamics of transmission. We argue for this shift by proposing a theoretical framework based on complexity theory and pattern management. We interrogate one educational prevention heuristic that emphasises the importance of risk-reduction through the lens of transmission, called A-3B-4C-T. We argue that this type of approach provides expansive opportunities for people to engage with the epidemic in contextualised, innovative ways that supersede the opportunities afforded by ABC. We then suggest that framing the prevention imperative through the lens of ‘dynamic prevention’ at scale opens more immediate opportunities, as well as developing a future-oriented mind-set, than the ‘descriptive prevention’ parameters can facilitate. The parameters of the ‘descriptive prevention’ paradigm, that maintain — and partially reinforce — the presence of ABC, do not have the flexibility required to develop the armamentarium of tools required to contribute to the management of a complex epidemiological landscape. Uncritically adhering to both the ‘descriptive paradigm’, and ABC, represents an historically dislocated form of prevention — with restrictive options for reducing the overall burden of HIV-related challenges in South Africa.

Keywords: anticipatory HIV literacy, complex adaptive epidemiological landscape, descriptive prevention, dynamic prevention, pattern management