Uncomfortable Knowledge: PEPFAR, HIV Risk Reduction and Safer Sex

Carrie Cafaro and William J. Bicknell

HIV prevention that focuses on abstinence, faithfulness and condoms (ABC) has not worked well, particularly in sub-Saharan Africa. We present the data in support of a more nuanced approach to safer sex that emphasizes riskreduction and increases prevention options consistent with the new, more liberal, recently reauthorized, President’s Emergency Plan for AIDS Relief (PEPFAR) language that calls for evidence-based interventions. It is time to consider the benefits of promoting realistic substitutes for intercourse, specifically oral sex — equivalent in risk to sex with a condom — as well as mutual and self-masturbation. We explore the reasons behind the resistance to promoting safer sex and suggest ways forward.