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The ABC of AIDS Prevention
What exactly is the ABC approach?
Was this saying something new?
So why is this controversial?
What is the PEPFAR definition of ABC?
And what is the UNAIDS definition of
ABC?
Why is Uganda so often mentioned in
relation to the ABC of HIV prevention?
What happened in Uganda?
What worked in Uganda?
How does this relate to PEPFAR?
Is this a problem?
This page looks at strategies for preventing sexual
transmission of HIV, and in particular the much-discussed "ABC"
approach. So what exactly is the ABC approach, why does it cause
such controversy, and does it work?
One of the difficulties with the ABC approach is the
lack of a clear definition. The slogan seems to have first been
adopted by the Botswana government in the late 1990s. Seen on
billboards around the country it exalted the fact that:
"Avoiding AIDS as easy as...
A bstain
B e faithful
C ondomise"
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Since the late 1980s it had been known that
individuals could take action to either reduce or avoid altogether
the risk of becoming infected with HIV through sexual transmission.
The risk could be avoided altogether by avoiding any
sexual activities that could cause transmission of HIV (i.e.
Abstain) .
The risk could also be reduced, through avoiding
sexual intercourse other than with a mutually faithful uninfected
partner (i.e. Be faithful) or through the correct and
consistent use of condoms (i.e. Condomise).
So Botswana hadn't really developed a new approach
to HIV prevention, but rather a new way of putting across known risk
reduction and risk avoidance strategies.
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The ABC definition adopted by Botswana was not
particularly controversial. It was primarily a slogan used as part
of a general public AIDS awareness campaign, and it did not attempt
to define the circumstances under which the component parts of A, B
and C would be promoted and who they would be promoted to.
But since the use of this slogan in Botswana there
have been other variations which have more specific definitions,
most notably those adopted by the US-funded PEPFAR initiative, and
others adopted by UNAIDS.
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PEPFAR follows an ABC strategy through
"population-specific interventions" that emphasise:
• A bstinence for youth, including the delay of
sexual debut and abstinence until marriage
• B eing tested for HIV and being faithful in
marriage and monogamous relationships
• C orrect and consistent use of condoms for those
who practice high-risk behaviours.
Those who practice high-risk behaviours include "prostitutes,
sexually active discordant couple [in which one partner is known to
have HIV], substance abusers, and others". The PEPFAR definition
does not include the promotion of condoms to young people in
general.
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For UNAIDS, ABC means:
• A bstinence or delaying first sex
• B eing safer by being faithful to one partner or
by reducing the number of sexual partners
• C orrect and consistent use of condoms for
sexually active young people, couples in which one partner is
HIV-positive, sex workers and their clients, and anyone engaging in
sexual activity with partners who may have been at risk of HIV
exposure.
So the controversy arises from the differences between these two
definitions, and in particular the fact that with the PEPFAR
definition there is no promotion of condoms for young people, and
that with abstinence the emphasis is on abstaining until marriage.
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The ABC approach to HIV prevention is often said to
have started in Uganda, and it is said by some people to have been
the reason for Uganda's unique success in reducing its HIV
prevalence rate.
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When HIV was rapidly spreading through the
population of Uganda in the late 1980s, President Yoweri Museveni,
unlike most other African leaders at the time, recognised the danger
and took swift action showing forceful leadership. Uganda's response
was powerful and wide-ranging. The government launched an aggressive
media campaign involving posters, radio messages and rallies; they
trained teachers to begin effective HIV and AIDS education; and -
most importantly - they mobilised community leaders, churches and
indeed the public in general.
The government worked alongside many independent
organisations, using different messages to address different groups
of people according to their needs as well as their ability to
respond. Young people were encouraged to wait before first having
sex, or to return to abstinence if they were not virgins. All
sexually active people were given the message of "zero grazing",
which meant staying with regular partners and not having casual sex.
Those who did not abstain were encouraged to use condoms, which were
promoted to the population as a whole.
In order to encourage people to take up such
strategies - and to make them effective - action was taken to
encourage candid discussion of HIV and AIDS, to reduce stigma, to
better the status of women, to improve testing facilities, to treat
other sexually transmitted infections and to provide better care for
those already infected. Fear was also a part of the strategy, but
the campaigns explained how to avoid or reduce risk and so not be
overtaken by fear.
There is no evidence of the term "ABC" being used in
Uganda's campaigns at this time, although they did incorporate some
elements of abstinence, being faithful and using condoms.
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What appears to have worked in Uganda was a
combination of risk avoidance and risk reduction approaches. These
resulted in a fall in the annual number of new infections between
the late 1980s and mid 1990s, which in turn led to a reduction in
HIV prevalence. In later years, an increase in the death rate made a
significant contribution to further declines in prevalence, while
the number of new infections remained more or less unchanged.
What has been particularly important in Uganda has
been the combination of messages and approaches that have been used,
including the widespread promotion and distribution of condoms.
During the 1990s, a USAID funded scheme increased condom use from 7%
nationwide to over 50% in rural areas and over 85% in urban areas.
"The ABC approach in Uganda was and still is more
than just abstinence and needs to be balanced without any emphasis
on one aspect. Neither 'A' nor 'B' nor 'C' on its own can provide
the answer to reducing risk of infection that is practical for every
member of the population." - Dr Stella Talisuna, March 2005.
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For a while after being popularised in Botswana in
the late 1990s, the term ABC of HIV prevention was little used
elsewhere. But then, in December 2002, it was decided that America's
approach to the prevention of sexual HIV transmission would in
future be defined as ABC. This decision appears to have been largely
based on, and is now being promoted and is justified on, the basis
that ABC was what worked in Uganda.
But the ABC now being adopted by PEPFAR is
definitely not a Ugandan invention, and this term cannot
sufficiently describe the type of comprehensive approach developed
in Uganda.
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If, in countries where there is a high prevalence of
HIV infection resulting from sexual transmission, young people delay
having sex for the first time, then this risk avoidance will indeed
result in them avoiding infection whilst they are adopting this
approach.
However, abstinence until marriage does not always
ensure safety, because marriage in itself provides no protection
from infection. Many people are unsure of the HIV status of their
partners, and those who are faithful cannot be certain that their
partner is maintaining the same commitment.
Abstinence is not a realistic option for the
millions of women and girls who are in abusive relationships, or
those who have been taught always to obey men. People who do not
abstain should do everything possible to reduce risk, including
using condoms.
"condoms, when distributed with educational
materials as part of a comprehensive prevention package, have been
shown to significantly lower sexual risk and activity, both among
those already sexually active and those who are not." - UNAIDS,
October 2004.
Although PEPFAR-funded prevention programs using the
ABC approach as defined by them will result in fewer infections than
might otherwise have occurred, the result is still likely to be more
infections than would occur if a more comprehensive program were
adopted. TOP |
