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.

Weak signal detection: A discrete window of opportunity for achieving ‘Vision 90:90:90’?

“…Since that time there have been limited – but diverse – responses to the call to apply complexity theory to the HIV/AIDS epidemic (Burman, Aphane & Delobelle 2015 ; Burman, Aphane, Mtapuri & Delobelle 2015 ; Burman, Moerschell, Mamabolo, Aphane & Delobelle 2015 ; Fiorella 2013 ; Lich, Ginexi, Osgood & Mabry 2013 ; Silvestri 2013 ). Situated amongst the call for new tools and methodologies and attempts to articulate responses have been some compelling critiques of HIV/AIDS policies and approaches that ignore these complexities (Nguyen, Bajos, Dubois-Arber, O'Malley & Pirkle 2011 ; Stillwaggon 2012 ).…”

Expanding the prevention armamentarium portfolio: A framework for promoting HIV-Conversant Communities within a complex, adaptive epidemiological landscape

“…Kippax et al . ( 2013 :1373) argue that change processes are normalised through community ‘dialogue [through which] social practices are modified and other practices, such as safe sexual practices … are produced [and] norms that enable and sustain safe sex … are built’—also see Campbell, Nhamo, Scott, Madanhire, Nyamukapa, Skovdal, et al ( 2013 ) and Laher, Cescon, Lazarus, Kaida, Makongoza, Hogg, et al ( 2012 ) for similar arguments in southern African contexts. This argument parallels recent thinking in rural innovation studies, influenced by complexity science that promotes an evolutionary, process-oriented perspective of change.…”

The process of developing distributed-efficacy and social practice in the context of ‘ending AIDS’

“…[and that] analytical tools need to be designed to capture these dynamics" (Piot et al, 2008, p. 853). Since that time there have been several attempts to do that (Leach, Scoones, & Stirling, 2010;Stillwaggon, 2012) and recently it has been argued that the HIV epidemic represents a 'complex adaptive epidemiological landscape' (Burman, Aphane, & Delobelle, 2015a).…”

“…However, it is providing researchers with novel ontological opportunities to re-examine the HIV epidemic (Burman et al, 2015a) -which may gradually facilitate new bio-social frameworks for contributing to the 'end of AIDS'.…”

“…Based on this conceptualisation of change, Burman et al (2015a) argue that the HIV epidemic can be characterised as a complex adaptive system influenced, and constrained, by dynamic second order interconnections -some of which are nonlinear. The change process within such a system reflects shifts in dynamics between -and within -a virus-humanenvironment landscape that generates and sustains patterned first order emergence, Figure 1.…”