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