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ABC Approach to HIV Prevention: a Policy Analysis

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ABC Approach to HIV Prevention: a Policy Analysis The ABC Approach to HIV Prevention: A Policy Analysis A Selection of Articles on A, B and C from On Public Policy Issues & Implications 1995, the time period during which HIV prevalence was declining, key Beyond Slogans: Lessons changes in behavior occurred. From Uganda’s Experience • Fewer Ugandans were having sex at young ages. The proportion of With ABC and HIV/AIDS young men who had ever had sex decreased substantially and the By Susan A. Cohen median age at which young women began having sex rose from 15.9 in Between the late 1980s and mid- (STDs) as well as unintended preg- 1988 to 16.3 in 1995. Importantly, 1990s, at a time when HIV/AIDS was nancy and the abortions or however, among those people who well on its way toward ravaging Sub- unplanned births that inevitably fol- were having sex, overall levels of Saharan Africa, Uganda achieved an low, both in Sub-Saharan Africa and sexual activity did not decline. extraordinary feat: It stopped the in other parts of the world. spread of HIV/AIDS in its tracks and • Levels of monogamy increased. saw the nation’s rate of infection Meanwhile, U.S.-based social conser- Sexually active men and women of plummet. As word of the “Uganda vatives in and out of government— all ages, particularly the unmarried, miracle” spread, journalists, even as they pay homage to the ABC were less likely to have more than researchers, policymakers and advo- mantra—continue to confuse all of one sexual partner in a 12-month cates all descended to try to ascer- these issues. For them, ABC has period in 1995 than in 1989. Other tain how it was accomplished. become little more than an excuse research has found that the propor- and justification to promote their tion of men reporting three or more By now, Uganda’s success story has long-standing agenda regarding peo- sexual partners also fell during the become virtually synonymous with ple’s sexual behavior and the kind of period. the so-called ABC approach to sex education they should receive: A HIV/AIDS prevention, for Abstain, Be for unmarried people, bolstered by • Condom use rose steeply among faithful, use Condoms. And, indeed, advocacy of B, but for most people, unmarried sexually active men and it is clear that some combination of “anything but C.” women. Among unmarried women important changes in all three of who had had sex in the last four these sexual behaviors contributed weeks, the proportion who used con- Uganda and ABC both to Uganda’s extraordinary doms at last intercourse rose from reduction in HIV/AIDS rates and to Measuring sexual behavior change. 1% in 1989 to 14% in 1995; among the country’s ability to maintain its Among public health experts, it is by unmarried men, condom use rose reduced rates through the second now generally agreed that during the from 2% to 22%. half of the 1990s. Beyond that, how- critical time period between the late ever, the picture becomes consider- 1980s and mid-1990s, positive Additional risk factors and epidemi- ably less clear. changes in A, B and C behaviors ological impact. The relationship occurred and that all of these between individual sexual behavior ABC refers to individual behaviors, changes played a role in reducing and HIV risk is further complicated, but it also refers to the program HIV rates. Uganda’s HIV prevalence however, by many other factors that approach and content designed to steadily increased until about 1991, overlay a simple A, B and C analysis. lead to those behaviors. Researchers when it peaked at about 15% (30% The risk of exposure is greater, for and public health experts continue among pregnant women in urban example, in the presence of other to study both and to delve into the areas). It then turned sharply down- STDs and it appears to be lower for many and varied complex relation- ward through the mid-1990s and circumcised men. The number of a ships among them. This information reached 5% (14% for pregnant urban man or woman’s sexual partners is critical to determining to what women) by 2001. matters, but so does the duration of extent the Uganda experience really relationships, the extent to which is replicable and what from that The findings of an analysis released relationships might overlap, fre- experience productively might be by The Alan Guttmacher Institute in quency of sex, specific sexual prac- exportable to other countries. At the November 2003, A, B and C in tices, how consistently and correctly same time, much more research is Uganda: The Roles of Abstinence, condoms are used with different needed into the relevance of the Monogamy and Condom Use in HIV partners, and the stage of infection ABC approach for the prevention of Decline, are consistent with the cur- of an HIV-positive partner. other sexually transmitted diseases rent consensus. Between 1988 and The Guttmacher Report on Public Policy December 2003 1 In high-prevalence settings, ascer- to be tested and counseled, improv- early ages is prevalent, a similar taining exactly which behavior ing the status of women, involving media campaign is beginning to change or combinations of changes religious organizations, enlisting tra- show results. According to a recent can have the most impact in reduc- ditional healers, and much more.” summary from the USAID-sponsored ing HIV infection among the popula- YouthNet project, “More than half of tion as a whole is the focus of more The evidence, therefore, points to the youth who recalled the ads said recent studies. Indeed, based on the the existence of a range of comple- the ads had influenced how they Uganda experience and drawing on mentary messages and services handle boy/girl relationships through an understanding of the epidemiol- delivered by the government and a abstaining from sex, not giving into ogy of STDs more generally, scien- wide diversity of nongovernmental sexual pressure, and always using a tists are now concluding that other organizations. To be sure, those mes- condom/contraceptive when having things being equal, even if absolute sages included the importance of sex.” monogamy is not attained, having both young people delaying sexual fewer sexual partners, especially initiation and “zero grazing” HIV/AIDS rates also are declining in concurrently, may be the most sig- (monogamy). But contrary to the Cambodia, Thailand and the nificant behavior change for a popu- assertions of social conservatives Dominican Republic, three other lation overall. (Whether this is that the case of Uganda proves that countries where various combina- always the most significant protec- an undiluted “abstinence-only” mes- tions of ABC behavioral changes tive factor at the individual level sage is what makes the difference, appear to have played an important may be another matter.) there is no evidence that abstinence- role. In Cambodia and Thailand, the only educational programs were epidemic spread mainly through Creating behavior change. It is not even a significant factor in Uganda prostitution. Both countries are possible to make a direct and simple between 1988 and 1995. adopting a “100% condom use” pol- link between the changes that took icy in brothels, and it is yielding place in Uganda and the policies or positive results. In the Dominican Beyond Uganda programs that may have caused Republic, meanwhile, the infection them to happen. The widely held Encouraging signs also are beginning rate has slowed mainly due to men view among Ugandans and outside to emerge from other countries having fewer sexual partners as well analysts, though, is that increases in where HIV/AIDS had become a gen- as to increased condom use. all three of the ABC behaviors led to eralized epidemic. In Zambia, for reduced HIV rates following a com- example, HIV rates appear to be Finally, Brazil has so successfully prehensive national message that declining, at least among urban stemmed the tide of HIV/AIDS that HIV prevention was of the utmost youth. The U.S. Agency for only half the number of Brazilians are importance to the country and the International Development (USAID) infected today as the World Bank had responsibility of all of its citizens. notes that “clear, positive changes in predicted only a few years ago. The message was delivered in differ- all three ABC behaviors” have taken Brazil’s case may be atypical in one ent ways through a multiplicity of place. Indeed, it would seem that the sense because of the government’s approaches, programs and types of HEART (Helping Each Other Act decision to make free antiretroviral organizations and was buttressed by Responsibly) program, a major drugs available to anyone who quali- a level of political commitment to USAID-funded media campaign fies for AIDS therapy. But it is equally forthrightly addressing the AIDS cri- there, may deserve much of the atypical within Latin America sis that was unique among African credit. This program, which was because of the government’s decision governments. President Yoweri designed for and by youth, promotes to promote frank talk about sex as Museveni himself exhorted both abstinence and condom use. well as condom distribution pro- Ugandans, and still does, to practice One year after the campaign’s initia- grams. Indeed, the Brazilian Health A, B and C. Further, as Harvard tion, indications are that young peo- Ministry announced plans in August medical anthropologist Edward ple exposed to its comprehensive 2003 to distribute condoms to sexu- Green observed recently, “ABC is far messages are 46% more likely to be ally active high school students in from all that Uganda has done.” delaying or stopping having sex and five Brazilian cities to prevent not Uganda, he noted, “pioneered 67% more likely to have used a con- only HIV/AIDS but also teenage preg- approaches towards reducing stigma, dom the last time they had sex, nancy.
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