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. Officials are particularly con- bringing discussion of sexual behav- compared with those who were not cerned about preventing HIV-positive ior out into the open, involving HIV- exposed. teenage girls from becoming pregnant infected people in public education, and then transmitting HIV/AIDS to persuading individuals and couples In Jamaica, where HIV rates are still their newborn infants. relatively low but sexual activity at

The Guttmacher Report on Public Policy December 2003 2 Beyond HIV and ABC have merit, should not strict “absti- from the risk of HIV/AIDS from her Despite the evidence from Uganda nence fatigue” be considered a clear husband who may have other sexual and these other countries, U.S. HIV and present danger? partners? And for a young woman prevention policy is focused on pro- who has so far abstained from sex moting abstinence. Indeed, Global To be sure, living in the midst of high altogether, must she wait until she is AIDS Coordinator Randall Tobias HIV/AIDS prevalence can be a strong already sexually active until she is personally endorsed a provision in motivator for behavior change. As entitled to the full and accurate recently enacted U.S. law requiring Harvard’s Green wrote recently, in information necessary to protect that at least one-third of all U.S. countries “where infection rates herself from unplanned pregnancy assistance to prevent HIV/AIDS glob- exceed 30% and funerals for family and disease? These are just some of ally be reserved for “abstinence- and friends are held several times a the questions raised by the ABC until-marriage” programs (“U.S. week, abstinence and faithfulness are approach to sexual risk reduction. AIDS Policy: Priority on Treatment, attractive alternatives to death.” Conservatives’ Approach to Presumably, more and more-careful “What happened” in Uganda Prevention,” TGR, August 2003, page condom use would be an attractive between the late 1980s and mid- 1). In effect, this makes “abstinence- alternative in the face of these cir- 1990s happened in a specific place until-marriage” advocacy the single cumstances as well—and the experi- and time and under very specific cir- most important HIV/AIDS prevention ence of high-prevalence communities cumstances. There is much to be intervention of the U.S. government. in the United States from roughly the learned from it. But advocates and same time period during which policymakers seeking the simplicity Social conservatives pressed for this Uganda turned its rates around indi- of a single program model to repli- result because, at least with regard cates that, indeed, this was so. The cate should be cautioned that to the general population, they dis- critical questions, therefore, become: Uganda’s experience may have lim- miss the effectiveness of risk-reduc- What behaviors may be more or less ited implications—even for making tion strategies such as those that realistic for individuals to both further gains in that country, let promote correct and consistent con- achieve and sustain—especially as alone for other countries, other time dom use. Some, like Joseph Loconte the imminent crisis begins to ebb? periods and the range of reproduc- of the Heritage Foundation, go fur- And how best can they be encour- tive health concerns beyond HIV ther, denouncing even those pro- aged to do so? that women and men face. Public grams that target particular high-risk health experts and researchers, groups with risk-reduction messages Finally, that Brazil and Jamaica, to meanwhile, have a special responsi- on the grounds that they “legitimize name just two countries, have linked bility to recognize and explicate the promiscuity, prostitution and illegal HIV/AIDS prevention strategies with complexities of these questions, drug use.” Instead, he and others the prevention of unintended preg- even as they redouble their efforts to advocate a strict “risk elimination” nancy is a reflection of the complex answer them. approach—which itself must be realities of life and sexual relation- ships. Women, especially, often are This is the third in a series of articles regarded as a risky strategy, given examining emerging issues in sex education that risk elimination depends on trying to prevent both simultane- and related efforts to prevent unintended 100% compliance 100% of the time ously. How useful or relevant is the pregnancy and sexually transmitted ABC approach for the broader range diseases. The series is supported in part by a (see related story, page 4). grant from the Program on Reproductive of reproductive health–related condi- Health and Rights of the Open Society Conservatives further assert that the tions individuals face in everyday Institute. The conclusions and opinions life—especially a segmented expressed in these articles, however, are availability of condoms has a “disin- those of the author and The Alan Guttmacher hibiting” effect on people’s sexual approach that targets different mes- Institute. behavior. By that logic, what could sages to different groups of people be more disinhibiting than the rather than recognizing that the promise, and increasing reality, of same people may need different HIV treatment? Certainly, correct messages at different stages of life? and consistent contraceptive and Even if a woman abstains until mar- condom use is difficult for ordinary riage, for example, she is likely to people to maintain over long periods still want and need “C”—be it of time. But if reports on the recent Condoms or other Contraception— rise in HIV incidence in the United in order to be able to plan her child- States pointing to “prevention bearing. Alternatively, how can a fatigue” as one of the contributors married woman who wants to become pregnant protect herself

The Guttmacher Report on Public Policy December 2003 3 Issues & Implications vention is obviously much smaller than the group of people who are not Understanding ‘Abstinence’: having sex. The size of the popula- tion of abstinence users, however, Implications for Individuals, has never been measured, as it has for other methods of contraception. Programs and Policies When does abstinence fail? The def- By Cynthia Dailard inition of an abstinence user also has implications for determining the The word “sex” is commonly at the individual and programmatic effectiveness of abstinence as a acknowledged to mean different levels, and clarifying all of this for method of contraception. The presi- things to different people. The same policymakers, remains a key chal- dent, in his July 2002 remarks to can be said for “abstinence.” The lenge. Meeting that challenge should South Carolina high school students, varied and potentially conflicting be regarded as a prerequisite for the said “Let me just be perfectly plain. meanings of “abstinence” have signif- development of sound and effective If you’re worried about teenage preg- icant public health implications now programs designed to protect nancy, or if you’re worried about that its promotion has emerged as Americans from unintended preg- sexually transmitted disease, absti- the Bush administration’s primary nancy and STDs, including HIV. nence works every single time.” In answer to pregnancy and sexually doing so, he suggested that absti- transmitted disease (STD) prevention nence is 100% effective. But scientif- Abstinence and Individuals for all people who are not married. ically, is this in fact correct? What does it mean to use absti- For those willing to probe beneath nence? When used conversationally, Researchers have two different ways the surface, critical questions most people probably understand of measuring the effectiveness of abound. What is abstinence in the abstinence to mean refraining from contraceptive methods. “Perfect first place, and what does it mean to sexual activity—or, more specifi- use” measures the effectiveness use abstinence as a method of preg- cally, vaginal intercourse—for moral when a contraceptive is used exactly nancy or disease prevention? What or religious reasons. But when it is according to clinical guidelines. In constitutes abstinence “failure,” and promoted as a public health strategy contrast, “typical use” measures how can abstinence failure rates be mea- to avoid unintended pregnancy or effective a method is for the average sured comparably to failure rates for STDs, it takes on a different conno- person who does not always use the other contraceptive methods? What tation. Indeed, President Bush has method correctly or consistently. specific behaviors are to be described abstinence as “the surest For example, women who use oral abstained from? And what is known way, and the only completely effec- contraceptives perfectly will experi- about the effectiveness and potential tive way, to prevent unwanted preg- ence almost complete protection “side effects” of programs that pro- nancies and sexually transmitted against pregnancy. However, in the mote abstinence? Answering ques- disease.” So from a scientific per- real world, many women find it diffi- tions about what abstinence means spective, what does it mean to cult to take a pill every single day, abstain from sex, and how should and pregnancies can and do occur to the “use” of abstinence as a method women who miss one or more pills of pregnancy or disease prevention during a cycle. Thus, while oral con- CONTRACEPTIVE EFFECTIVENESS RATES FOR be measured? PREGNANCY PREVENTION* traceptives have a perfect-use effec- tiveness rate of over 99%, their typi- CONTRACEPTIVE PERFECT TYPICAL Population and public health cal-use effectiveness is closer to 92% METHOD USE USE researchers commonly classify peo- (see chart). As a result, eight in 100 ABSTINENCE 100 ??? ple as contraceptive users if they or women who use oral contraceptives FEMALE STERILIZATION 99.5 99.5 their partner are consciously using will become pregnant in the first ORAL CONTRACEPTIVES 99.5–99.9** 92.5 at least one method to avoid unin- year of use. MALE CONDOM 97 86.3 tended pregnancy or STDs. From a WITHDRAWAL 96 75.5 scientific standpoint, a person would Thus, when the president suggests *Percentage of women who successfully avoid an unintended pregnan- be an “abstinence user” if he or she that abstinence is 100% effective, he cy during their first year of use. **Depending on formulation. Sources: intentionally refrained from sexual is implicitly citing its perfect-use Perfect use—Hatcher, RA, et al., Contraceptive Technology, 17th ed., 1998, activity. Thus, the subgroup of peo- page 216. Typical use—AGI, Fulfilling the Promise: Public Policy and U.S. rate—and indeed, abstinence is Family Planning Clinics, 2000, page 44. ple consciously using abstinence as a 100% effective if “used” with perfect method of pregnancy or disease pre-

The Guttmacher Report on Public Policy December 2003 4 consistency. But common sense sug- doms fail as much as 14% of the that exclusively promote “absti- gests that in the real world, absti- time, they should be given a compa- nence from sexual activity outside of nence as a contraceptive method rable typical-use failure rate for marriage” (“Abstinence Promotion can and does fail. People who intend abstinence. and Teen Family Planning: The to remain abstinent may “slip” and Misguided Drive for Equal Funding,” have sex unexpectedly. Research is What behaviors should be abstained TGR, February 2002, page 1). The beginning to suggest how difficult from? A recent nationally representa- law, however, does not define “sex- abstinence can be to use consis- tive survey conducted by the Kaiser ual activity.” As a result, it may have tently over time. For example, a Family Foundation and seventeen the unintended effect of promoting recent study presented at the 2003 magazine found that half of all 15–17- noncoital behaviors that leave young annual meeting of the American year-olds believed that a person who people at risk. Currently, very little Psychological Society (APS) found has oral sex is still a virgin. Even is known about the relationship that over 60% of college students more striking, the APS study found between abstinence-promotion activ- who had pledged virginity during that the majority (55%) of college stu- ities and the prevalence of noncoital their middle or high school years dents pledging virginity who said they activities. This hampers the ability had broken their vow to remain had kept their vow reported having of health professionals and policy- abstinent until marriage. What is not had oral sex. While the pledgers gen- makers to shape effective public known is how many of these broken erally were somewhat less likely to health interventions designed to vows represent people consciously have had vaginal sex than non- reduce people’s risk. choosing to abandon abstinence and initiate sexual activity, and how Abstinence is 100% effec- There is no question, however, that many are simply typical-use absti- increased abstinence—meaning nence failures. tive if ‘used’ with perfect delayed vaginal intercourse among consistency. But common young people—has played a role in To promote abstinence, its propo- sense suggests that in the reducing both teen pregnancy rates in nents frequently cite the allegedly real world, it can and the United States and HIV rates in at high failure rates of other contracep- least one developing country. tive methods, particularly condoms. does fail. Research by The Alan Guttmacher By contrasting the perfect use of Institute (AGI) indicates that 25% of abstinence with the typical use of pledgers, they were equally likely to the decrease in the U.S. teen preg- other contraceptive methods, how- have had oral or anal sex. Because nancy rate between 1988 and 1995 ever, they are comparing apples to oral sex does not eliminate people’s was due to a decline in the proportion oranges. From a public health per- risk of HIV and other STDs, and of teenagers who had ever had sex spective, it is important both to sub- because anal sex can heighten that (while 75% was due to improved con- ject abstinence to the same scien- risk, being technically abstinent may traceptive use among sexually active tific standards that apply to other therefore still leave people vulnerable teens). A new AGI report also shows contraceptive methods and to make to disease. While the press is increas- that declines in HIV-infection rates in consistent comparisons across meth- ingly reporting that noncoital behav- Uganda were due to a combination of ods. However, researchers have iors are on the rise among young peo- fewer Ugandans initiating sex at never measured the typical-use ple, no research data exists to young ages, people having fewer sex- effectiveness of abstinence. confirm this. ual partners and increased condom Therefore, it is not known how fre- use (see related story, page 1). quently abstinence fails in the real Abstinence Education Programs world or how effective it is compared But abstinence proponents fre- with other contraceptive methods. Defining and communicating what is quently cite both U.S. teen preg- This represents a serious knowledge meant by abstinence are not just nancy declines and the Uganda gap. People deserve to have consis- academic exercises, but are crucial example as “proof” that abstinence- tent and accurate information about to public health efforts to reduce only education programs, which the effectiveness of all contraceptive people’s risk of pregnancy and STDs. exclude accurate and complete methods. For example, if they are For example, existing federal and information about contraception, are told that abstinence is 100% effec- state abstinence-promotion policies effective; they argue that these pro- tive, they should also be told that, if typically neglect to define those grams should be expanded at home used correctly and consistently, con- behaviors to be abstained from. The and exported overseas. Yet neither doms are 97% effective in preventing federal government will provide experience, in and of itself, says any- pregnancy. If they are told that con- approximately $140 million in FY thing about the effectiveness of pro- 2004 to fund education programs

The Guttmacher Report on Public Policy December 2003 5 grammatic interventions. In fact, sig- most public health experts stress the Finally, there is the question of nificant declines in U.S. teen preg- importance of achieving desired whether delays in sexual activity nancy rates occurred prior to the behavioral outcomes such as delayed might come at an unacceptable implementation of government- sexual activity. price. This is raised by research funded programs supporting this indicating that while some teens particularly restrictive brand of To date, however, no education pro- promising to abstain from sex until abstinence-only education. Similarly, gram in this country focusing exclu- marriage delayed sexual activity by informed observers of the Ugandan sively on abstinence has shown suc- an average of 18 months, they were experience indicate that abstinence- cess in delaying sexual activity. more likely to have unprotected sex only education was not a significant Perhaps some will in the future. In when they broke their pledge than the meantime, considerable scien- those who never pledged virginity in To date, no education tific evidence already demonstrates the first place. Thus, might strate- program focusing exclu- that certain types of programs that gies to promote abstinence inadver- sively on abstinence has include information about both tently heighten the risks for people abstinence and contraception help when they eventually become sexu- shown success in delay- teens delay sexual activity, have ally active? ing sexual activity. fewer sexual partners and increase contraceptive use when they begin Difficult as it may be, answering program intervention during the having sex. It is not clear what it is these key questions regarding absti- years when Uganda’s HIV prevalence about these programs that leads nence eventually will be necessary rate was dropping. Thus, any teens to delay—a question that for the development of sound and assumptions about program effec- researchers need to explore. What is effective programs and policies. At a tiveness, and the effectiveness of clear, however, is that no program of minimum, the existing lack of com- abstinence-only education programs any kind has ever shown success in mon understanding hampers the in particular, are misleading and convincing young people to post- ability of the public and policymak- potentially dangerous, but they are pone sex from age 17, when they ers to fully assess whether absti- nonetheless shaping U.S. policy both typically first have intercourse, until nence and abstinence education are here and abroad (see related story, marriage, which typically occurs at viable and realistic public health and page 13). age 25 for women and 27 for men. public policy approaches to reducing Nor is there any evidence that the unintended pregnancies and Accordingly, key questions arise “wait until marriage” message has HIV/STDs. about how to measure the success of any impact on young people’s deci- abstinence-promotion programs. For sions regarding sexual activity. This This is the fourth in a series of articles examining emerging issues in sex education example, the administration is defin- suggests that scarce public dollars and related efforts to prevent unintended ing program success for its absti- could be better spent on programs pregnancy and sexually transmitted nence-only education grants to com- that already have been proven to diseases. The series is supported in part by a grant from the Program on Reproductive munity and faith-based organizations achieve delays in sexual activity of Health and Rights of the Open Society in terms of shaping young people’s any duration, rather than on pro- Institute. The conclusions and opinions intentions and attitudes with regard grams that stress abstinence until expressed in these articles, however, are those of the author and The Alan Guttmacher to future sexual activity. In contrast, marriage. Institute.

The Guttmacher Report on Public Policy December 2003 6 Issues & Implications ual partners than people in Asia or in western countries; rather, they Promoting the ‘B’ in ABC: are more likely to have ongoing simultaneous sexual relationships Its Value and Limitations in within a small circle of partners. Fostering Reproductive Health From Uganda, where HIV prevalence plummeted between the late 1980s By Susan A. Cohen and the mid-1990s, there is now strong evidence that positive It is probably fair to say that at the International Development (USAID) changes occurred in all three of the beginning of the pandemic, prevent- scientist James Shelton and his col- A, B and C behaviors. Experts are ing HIV/AIDS was all about “C”—for leagues in the April 10, 2004, issue coalescing around the conclusion, Condom use. Several years ago, how- of the British Medical Journal. however, that most of the decline in ever, social conservatives began pro- Indeed, it is a simple truth that the the overall national HIV infection moting “A”—for Abstinence—as the greater the number of sexual rela- rate was attributable to partner central component of a global HIV/ tionships individuals have, the more reduction—both men and women AIDS prevention strategy. And more likely it is that STIs, including HIV, having fewer casual sexual relation- recently, public health experts have will spread. Having concurrent part- ships. The same pattern can be seen begun extolling the value of “B”—for nerships, as opposed to consecutive in Thailand, which also experienced Be faithful, or “partner reduction”— ones, or “serial monogamy,” can a dramatic turnaround in HIV preva- as the indispensable but forgotten increase these rates exponentially. lence and where the proportion of middle child of the “ABC” approach. men reporting that they had engaged Relationships that overlap over long in casual and, especially, commercial As the political popularity of individ- periods of time link “sexually active sex dropped dramatically in the ual interventions has lurched from C people up in a giant network, not early 1990s. A similar partner-reduc- to A to B, it is now obvious that no only to one another but also to the tion dynamic seems to have one-size-fits-all approach to HIV/AIDS partners of their partner’s part- occurred among gay men during prevention can ever succeed for all ners…via a web of sexual relation- roughly the same period in Europe people at all times in all countries. ships that can extend across huge and the United States. Nevertheless, it is clear that attaining regions.” So wrote Princeton higher levels of B—which can range Despite the moralistic overtones of from absolute mutual monogamy B can mean lifelong terms such as “be faithful” and inside or outside of marriage to sim- “practice fidelity,” the epidemiologi- ply having fewer sexual partners, monogamy, serial cal fact of the matter is that changes especially fewer concurrent sexual monogamy, faithfulness in any of a wide range of B behaviors partners—has the greatest potential within a polygamous can significantly affect the rate of to reduce the HIV/AIDS infection rate marriage or an overall STIs and HIV/AIDS in a given popu- in a population overall. lation. Indeed, B can mean lifelong reduction in the number monogamy, serial monogamy, faith- Notwithstanding its epidemiological of one’s casual sexual fulness within a polygamous mar- impact, however, B alone—in what- partners. riage or an overall reduction in the ever form it may take—has its limi- number of one’s casual sexual part- tations when it comes to reducing an University’s Helen Epstein in a July ners, especially sexual partners who individual’s risk of HIV or other sex- 2004 New York Times Magazine are themselves at high risk. ually transmitted infections (STIs). article, “The Fidelity Fix.” In con- Increases in any of these behaviors Moreover, even in its purest form, B trast to serial monogamy, Epstein can make a large contribution to offers no protection at all against suggests, concurrency carries much lowering the rates of STIs and unintended pregnancy. greater risk “because it permits the HIV/AIDS at the population level. virus to spread to others quickly, rather than trapping it in a single Lowering STI and HIV Rates Lowering STI and HIV Risk relationship for months or even “It seems obvious, but there would years.” The prevalence of HIV infec- Of course, a single individual may be no global AIDS pandemic were it tion in Sub-Saharan Africa, she con- practice any number of variations on not for multiple sexual partner- cludes, is not due to the fact that the B theme over the course of his or ships,” wrote U.S. Agency for people in that region have more sex-

The Guttmacher Report on Public Policy October 2004 11 her sexual life. But while even modest condoms.” Put another way, when had been fueling the epidemic, and increases in the practice of any of one no longer practices A, one must thus increasing B behaviors. them among a given population group practice B and C together in order to will reduce that group’s rate of dis- reduce the risk and the rate at the Thailand, facing a more concen- ease infection, even perfect practice same time. trated epidemic, achieved the same of the most restrictive B behavior is end by following a different path. insufficient, by itself, to absolutely That country’s “100% Condom Getting to B eliminate an individual’s risk of expo- Program” requires condom use in sure. True, practicing abstinence If B is an important outcome, then every act of commercial sex. In fact, until marriage and mutual fidelity as with A and C, the real challenge condom use increased rapidly start- within that marriage presents the is to identify effective strategies and ing in 1988 to become almost uni- theoretical possibility of eliminating interventions for achieving it. And versal at brothels by 1993. the risk of STIs and HIV. (The possi- while it may seem counterintuitive, Interestingly, as Norman Hearst and bility is only theoretical, since one those relationships are not necessar- Sanny Chen explain in a March can only be certain of one’s own ily always direct. In the United 2004 article in Studies in Family behavior, not the behavior of one’s States, for example, a growing body Planning, although “the government partner.) For everyone else, however, of research indicates that encourag- did not directly discourage commer- the practice of B alone is insufficient ing teens to abstain and teaching cial sex, …mandatory condom use to eliminate, or even necessarily sub- them about contraception and pre- and the awareness of risk caused stantially reduce, risk of infection. vention of STIs can effectively lead many men to give up paying for sex. them both to postpone sexual inter- Thai men also reduced the numbers A woman who has remained absti- course and to reduce their risk of of their unpaid casual partners.” The nent until marriage and is faithful to pregnancy and disease when they do result of encouraging condom use in her husband, for example, but whose initiate sex. By contrast, most absti- Thailand, therefore, was to increase husband is either HIV-infected or is nence-only programs and strategies both C and B, which ultimately led have yet to demonstrate effective- to a sharp decline in the HIV infec- Unless sexually active in- ness in delaying teens’ sexual initia- tion rate. tion or in reducing the frequency of dividuals use condoms intercourse and number of sex part- correctly and consistent- ners (“Legislators Craft Alternative Fidelity and Fertility ly, even reducing the Vision of Sex Education to Counter Controlling fertility is a process that number of their sexual Abstinence-Only Drive,” TGR, May can span over 30 years of a woman’s 2002, page 1). life. This is a reality that is ongoing partners all the way to and universal, whether that woman one cannot protect them In Uganda, the trend toward people lives in a high HIV prevalence coun- from the risk of infection. having fewer sexual partners that try or a low-prevalence one. B took hold in the early 1990s appears behaviors may be epidemiologically sexually active outside the marriage, to be attributable to multiple factors significant in reducing STI and HIV is in fact at high personal risk of HIV and messages. President Museveni rates within her community or infection herself, notwithstanding took a direct approach, urging country, and may be critical to her own monogamy. Likewise, indi- Ugandans—mainly men—to practice reducing her own risk of disease, but vidual sexually active men and “zero grazing.” At the same time, they do nothing to help her time and women can significantly slow the Uganda billboards exhorted people space pregnancy. She needs C—not spread of HIV/AIDS in their commu- to “love carefully,” which carries just condoms for HIV prevention, nity by reducing the number of sex- multiple messages. Further, Uganda but condoms or other methods of ual partners they have. Unless these reinforced its ABC approach with contraception for family planning. individuals use condoms correctly numerous other societal initiatives, and consistently, however, even including promoting the status of Indeed, some 700 million women— reducing all the way to one cannot women and discouraging gender vio- more than half of all women in protect them from the risk of infec- lence and sexual coercion. developing countries—are at risk of tion. These facts lead Shelton and Ultimately, according to an analysis unintended pregnancy. About 200 his colleagues to conclude that “it by USAID’s HIV Behavior Change million of these women want to post- seems important and feasible to pro- Advisor Daniel Halperin, it was a pone, space or avoid future births mote monogamy and partner reduc- combination of interventions that but do not have access to effective tion alongside abstinence and use of contributed toward breaking down contraceptive services. They some of the sexual networks that account for the vast majority of the

The Guttmacher Report on Public Policy October 2004 12 76 million unintended pregnancies Further, as the report notes, starving providers may have unique capaci- that occur in the developing world reproductive health programs of ties, such as an expertise in dealing each year. Many of these pregnan- resources is also self-defeating in the with the sensitivities around sexual- cies are high risk: More than a half- fight against HIV/AIDS. As more and ity and confidentiality, that can ben- million women die each year of more HIV-positive women and men efit and inform confidential HIV test- pregnancy-related causes, 13% of the receive treatment and live longer ing and counseling. Likewise, deaths being attributable to unsafe lives, they will need access to family developments in HIV prevention abortion. Many hundreds of thou- planning services to help them live strategies involving behavior change sands more survive pregnancy but healthier ones. Without access to techniques may generate new and suffer lifelong debilitating illnesses or condoms, for example, they risk improved ideas for helping people to conditions as a result. Possessing the spreading the disease to their part- use condoms and other contracep- ability to determine the timing and ner. Without access to other contra- tives correctly and consistently and spacing of one’s children increases over a sustained period of time—an the likelihood that pregnancy can B behaviors may reduce age-old challenge intrinsic to human occur when it is safest and healthiest STI and HIV risk, but nature that now faces new urgency. for the woman and her child. they do nothing to help Yet, social conservatives, including Against the backdrop of the scourge time and space pregnancy. those within the Bush administra- of HIV/AIDS, however, even sustain- tion, continue to view HIV preven- ing, let alone increasing, support for ceptives, women risk an unintended tion and pregnancy prevention nar- family planning services has been pregnancy that may compound the rowly, simplistically and in a receding as a global health priority. threat to their own health and life segmented way. The facts show, and This is unsupportable on its own and may result in an HIV-infected reality dictates, that no single HIV terms. As reported in Adding It Up, a infant. prevention approach in isolation—A, joint report by The Alan Guttmacher B or C—is likely to work for most Institute and the United Nations Given that, at least in Sub-Saharan individuals over a lifetime. And the Population Fund (UNFPA), closing Africa, approximately 90% of all new battle against HIV/AIDS is unlikely the gap so that every woman at risk HIV infection is sexually transmit- to be won so long as it is viewed in a of unintended pregnancy has access ted, the need for more and better vacuum, without recognizing and to modern contraceptives would linkages between STI/HIV preven- taking into account the everyday save the lives of an additional 1.5 tion interventions and unintended challenges of everyday people—mil- million women and children annu- pregnancy interventions is clear (see lions of whom are trying to avoid ally, reduce induced abortions by related story, page 7). Family plan- HIV and other STIs and, at the same 64%, reduce illness related to preg- ning providers have decades of expe- time, to control when and whether nancy and preserve 27 million years rience in responding to the needs of to have children. of healthy life—at a cost of just $144 women, and increasingly men, per year of healthy life. across a world of cultures. These

The Guttmacher Report on Public Policy October 2004 13 Issues & Implications rhea, chlamydia, syphilis, chancroid, trichomoniasis, genital herpes and Public Health Advocates Say HPV. The panel considered 138 peer- reviewed articles in all. It determined Campaign to Disparage Condoms that “condition-specific” studies were sufficiently methodologically strong Threatens STD Prevention Efforts to warrant a definitive conclusion only for HIV and gonorrhea. By Heather Boonstra Accordingly, in its carefully worded summary report issued in July 2001, In 1999, social conservatives in efforts. But in the intervening few the panel concluded that consistent Congress initiated a new strategy to years, the political landscape has and correct condom use prevents (in further their moral agenda of pro- changed radically. Coburn and like- addition, of course, to pregnancy) moting abstinence outside of mar- minded colleagues are now transmission of HIV between women riage as official government policy— ensconced within the Bush adminis- and men and gonorrhea transmission claiming that condoms do not tration, and with the imprimatur of from women to men. Beyond that, protect against sexually transmitted government and the report of an NIH the panel concluded, the published diseases (STDs). Led by then-Rep. workshop on condom effectiveness to epidemiologic literature is insuffi- Tom Coburn (R-OK), a physician cite, a campaign to disparage the cient to warrant definitive state- and staunch proabstinence opponent value of condom use is in full swing, ments specific to the other six STDs of government-funded family plan- itself the cornerstone of an effort to considered by the panel. ning programs, they were successful undermine the very notion of sexual in attaching an amendment to the risk-reduction, or “safer sex.” That there are insufficient studies House version of the Breast and specific to the six other STDs Cervical Cancer Treatment Act man- Critics in the HIV and STD preven- reviewed by the panel to warrant a dating that condom packages carry a tion communities worry that the con- definitive statement does not mean, cigarette-type warning that condoms servative crusade to promote absti- however, that no assumptions can be offer “little or no protection” against nence outside of marriage comes at made about the protective effect of an extremely common STD, human too high a cost. Undermining people’s condoms with regard to those dis- papillomavirus (HPV), some strains confidence in the effectiveness of eases. Indeed, a critical conclusion of which cause cervical cancer. condoms threatens people’s health in the workshop summary report Although this directive was removed and even lives, they argue, since sex that largely has been overlooked is before the bill was enacted, Coburn among unmarried people is common that condoms are “essentially imper- and his allies were able to secure a in the United States and around the meable” to even the smallest of STD requirement that the Food and Drug world, and achieving correct and con- viruses. Based on that finding—that Administration (FDA) reexamine sistent condom use is difficult “studies…have demonstrated that condom labels to determine whether enough. Moreover, they insist, con- condoms provide a highly effective they are medically accurate with dom critics are selectively citing and barrier to the transmission of parti- respect to condoms’ “effectiveness intentionally misrepresenting findings cles of similar size to those of the or lack of effectiveness” in STD pre- from the NIH workshop report to but- smallest STD virus”—two important vention. They also were instrumen- tress their case; the conclusion that assumptions can be made and, in tal in convincing the National correct condom use does not offer a fact, are made in the workshop Institutes of Health (NIH)—along high degree of protection against the report itself. The first is that there is with the U.S. Agency for vast majority of STDs, not to mention a “strong probability of condom International Development (USAID), HIV and unintended pregnancy, is effectiveness” against so-called dis- the FDA and the Centers for Disease simply not warranted by the science, charge diseases that, as with HIV, Control and Prevention (CDC)—to they say. are transmitted by genital secre- convene a workshop in June 2000 to tions, such as semen or vaginal flu- evaluate published evidence on con- ids. Included here would be chlamy- The Workshop Report dom effectiveness. dia and trichomoniasis in addition to At the behest of Coburn and other gonorrhea. The second is, once At the time, Coburn’s anticondom condom critics, NIH in June 2000 again, that there is “a strong proba- views were widely considered convened a panel of experts for a bility of condom effectiveness” extreme. Certainly, they were, and two-day workshop to examine the against infections that are transmit- continue to be, out of step with body of evidence on the effectiveness ted through “skin-to-skin” contact— mainstream public health prevention of condoms in preventing the trans- provided, however, that the source mission of eight STDs: HIV, gonor-

The Guttmacher Report on Public Policy March 2003 1 of the infection is in an area that is American people [should] know the sheet concluded from the evidence covered or protected by the condom. truth of condom ineffectiveness” and that “latex condoms, when used con- Three “genital ulcer diseases”—geni- to advocate an approach that focuses sistently and correctly, are highly tal herpes, syphilis and chancroid— exclusively on promoting abstinence effective in preventing transmission as well as HPV fall in this category. for all people outside of a heterosex- of HIV…and…can reduce the risk of All can occur in genital areas that ual, monogamous marriage. other sexually transmitted diseases,” are covered or protected by con- the revised version emphasizes in doms, but they also can occur in Coburn’s views have the support of bold letters that abstinence is the areas that are not. Therefore, cor- other recent appointments to surest way to avoid STDs and warns rect condom use would be expected PACHA, including Joe S. McIlhaney, that condom use “cannot guarantee to protect against transmission of Jr., a physician and president of the absolute protection against any STD.” genital ulcer diseases and HPV in Medical Institute for Sexual Health some, but not all, instances. (MISH), a Texas-based medical insti- Linked to the crusade to promote tute he founded that promotes absti- abstinence outside of marriage, the The report goes on to raise a num- nence-only sex education messages. campaign to disparage condoms is ber of methodological challenges In a monograph on condoms and also going global. In an October 24, that make it difficult to study the STDs, billed as “the most compre- 2002, letter to USAID Administrator effectiveness of condoms against hensive scientific review of the sci- Andrew S. Natsios pushing for absti- specific STDs. The ideal study, a ence on condom effectiveness to nence-only programming by the randomized controlled clinical trial, date,” MISH provides an analysis of agency, Rep. Chris Smith (R-NJ) has not been used because it would the workshop report that, while fac- asserts that “[a]bstinence until mar- require control-group participants to tually correct, nonetheless asserts riage…is the Administration’s stated be counseled not to use condoms. that condoms do not make sex “safe priority in HIV/STD prevention.” So Such counseling is not considered enough” to warrant their promotion far, USAID has not signed on to a ethically acceptable—itself an for STD prevention. According to campaign disparaging the condom. implicit acknowledgement of con- MISH, because condoms are “not However, in December at a meeting dom effectiveness in STD prevention foolproof” and marriage is “generally of 30 Asian/Pacific nations in within the scientific community. As safe” from STD infection, the gov- Bangkok whose purpose was to dis- a result of these standards for study ernment should be only promoting cuss implementation of the design, none of the studies reviewed marriage and abstinence outside of International Conference on by the workshop panel was consid- marriage for STD prevention. Population and Development ered optimal, and any future studies Program of Action, U.S. officials will face similar challenges. Public health experts also point to demanded the deletion of a refer- the withdrawal of a fact sheet on con- ence to “consistent condom use” to doms from the CDC’s Web site and fight HIV/AIDS and other STDs (see The Anticondom Campaign the fact sheet’s subsequent revision related story, page 3). The official The NIH workshop report explicitly as another indication that condoms U.S. statement delivered by cautions that the “inadequacies of are being attacked at the highest lev- Assistant Secretary of State Arthur the evidence available…should not els. Members of Congress, as well as E. Dewey states that, because “con- be interpreted as proof of the ade- experts with the scientific, AIDS and doms are simply not 100% effective,” quacy or inadequacy of the con- reproductive health communities, the United States “promotes absti- dom.” Yet, condom opponents were reacted angrily when the fact sheet nence for the unmarried and fidelity quick to ignore the caution and was pulled. “Removal of this informa- for those who are married” as its jump to the conclusion they desired. tion…strongly suggests an ideological, primary STD prevention strategy. In July 2001, Coburn, no longer a rather than a scientific, agenda at member of Congress, issued a press work,” said Rep. Henry Waxman (D- A Dangerous Approach release headlined, “Condoms Do Not CA) in an October 21, 2002, letter Prevent Most STDs” and praised the signed by a dozen members of HIV and STD prevention advocates NIH report for finally exposing “the Congress to Department of Health acknowledge that condoms are not ‘safe’ sex myth for the lie that it is.” and Human Services Secretary “perfect.” They note that the cur- In his new job as co-chair of the Tommy G. Thompson. The fact sheet rent FDA labeling now under review Presidential Advisory Council on was eventually revised and reposted; does likewise, advising consumers HIV and AIDS (PACHA) and as one as with the MISH report, the new ver- that when used properly, latex con- of President Bush’s top advisors on sion is factually accurate but doms will help reduce the risk of HIV/AIDS, Coburn continues to use nonetheless portrays condoms in a HIV and other STDs, although no his influence to insist that “the negative light. Where the prior fact (Continued on page 14)

The Guttmacher Report on Public Policy March 2003 2 Condoms… STD expert Ward Cates, president of more biomedical research to clarify Continued from page 2 Family Health Institute, contends condom effectiveness against individ- that intentionally undermining pub- ual STDs. “We already know that method can guarantee 100% protec- lic confidence in the effectiveness of latex condoms do successfully pre- tion. Still, they say, condoms must condoms is not justified as a matter vent transmission of most STDs, but remain a key component of HIV and of science. He says the fact that that their effectiveness depends in STD prevention efforts both in the insufficient data exist to prove defin- large part on how consistently and United States and globally because, in itively that condoms protect against correctly they are used,” Darroch the words of the workshop summary some STDs—while technically says. “What health educators and ser- itself, “Beyond mutual lifelong true—has created an opening allow- vice providers really need from monogamy among uninfected cou- ing condom opponents to claim that research is a better understanding of ples, condom use is the only method condoms are inadequate. “While I’m the difficulties people face using con- for reducing the risk of HIV infection impressed with the thoroughness doms effectively, so that they can bet- and STDs available to sexually active and accuracy of the MISH report, its ter help sexually active couples want- individuals.” emphasis on condom failures can be ing to avoid disease or unintended distorted,” Cates says. “By such pregnancy to use condoms consis- In that light, experts in the field say dwelling on the failures, the suc- tently and correctly at every act of efforts to promote abstinence by dis- cesses of male condoms are intercourse. Our goal should be pro- paraging condoms are misguided obscured, and the method is unnec- grams that reinforce this message and because they could increase the like- essarily tainted,” he wrote. “From a that get through to people who are lihood that people will fail to use public health perspective, the data having sex and are at risk for STDs in condoms when they do have sex, clearly show that the glass is 90% full an unequivocal way the news that thus putting themselves at unneces- (that condoms are relatively effec- condoms are a necessary and effec- sary risk. “It is hard enough to con- tive) and only 10% empty (that data tive way to prevent infection.” vince people who choose to have are inadequate).” In an interview sex—even those who are at high risk Cates adds, “Thus, the question This is the first in a series of articles examining emerging issues in sex education of HIV—to use condoms,” says should not be whether condoms and related efforts to prevent unintended David Harvey, executive director of work if used (they do!), but rather pregnancy and sexually transmitted the AIDS Alliance for Children, what is the appropriate role of con- diseases. The series is supported in part by a grant from the Program on Reproductive Youth and Families. “The last thing doms in comprehensive HIV preven- Health and Rights of the Open Society we need is the government promot- tion programs.” Institute. The conclusions and opinions ing the idea that condoms do no expressed in these articles, however, are those of the author and The Alan Guttmacher good. This approach will undermine All of this leads Jacqueline E. Institute. the gains we have made and result Darroch, The Alan Guttmacher in more people with HIV and other Institute’s vice president for science, sexually transmitted infections.” to question the need for a great deal

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