|
|
 |
| |
| The ABC approach employs population-specific
interventions that emphasize abstinence for youth and other
unmarried persons, including delay of sexual debut; mutual faithfulness
and partner reduction for sexually active adults; and correct
and consistent use of condoms by those whose behavior places
them at risk for transmitting or becoming infected with HIV.
|
| |
| It is important to note that ABC is not
a program; it is an approach to infuse throughout prevention
programs. The ABC approach is distinctive in its targeting of
specific populations, the circumstances they face, and behaviors
within those populations for change. This targeted approach
results in a comprehensive and effective prevention strategy
that helps individuals personalize risk and develop tools to
avoid risky behaviors under their control. |
| |
| Abstinence programs encourage unmarried
individuals to abstain from sexual activity as the best and
only certain way to protect themselves from exposure to HIV
and other sexually transmitted infections. Abstinence until
marriage programs are particularly important for young people,
as approximately half of all new infections occur in the 15-
to 29-year-old age group. |
| |
| Delaying first sexual encounter can have
a significant impact on the health and well-being of adolescents
and on the progress of the epidemic in communities. In many
of the countries hardest hit by HIV/AIDS, sexual activity begins
early and prior to marriage. Surveys show that, on average,
slightly more than 40 percent of women in sub-Saharan Africa
have had premarital sex before age 20; among young men, sex
before marriage is even more common. |
| |
| A significant minority of youth experience
first sex before age 15. Internationally, a number of programs
have proven successful in increasing abstinence until marriage,
delaying first sex, and achieving "secondary abstinence"-returning
to abstinence-among sexually experienced youth. These programs
promote the following: |
- Abstaining from sexual activity as the most effective
and only certain way to avoid HIV infection;
- The development of skills for practicing abstinence;
- The importance of abstinence in eliminating the risk of
HIV transmission among unmarried individuals;
- The decision of unmarried individuals to delay sexual
debut until marriage; and
- The adoption of social and community norms that support
delaying sex until marriage and that denounce cross-generational
sex; transactional sex; and rape, incest, and other forced
sexual activity.
|
| Be faithful programs encourage individuals
to practice fidelity in marriage and other sexual relationships
as a critical way to reduce risk of exposure to HIV. Once a
person begins to have sex, the fewer lifetime sexual partners
he or she has, the lower the risk of contracting or spreading
HIV or another sexually transmitted infection. |
| |
| Some of the most significant gains in Uganda's
fight against HIV are a result of specific emphasis on, and
funding of, programs to promote changes in behavior related
to fidelity in marriage, monogamous relationships, and reducing
the number of sexual partners among sexually active unmarried
persons. Uganda's President Museveni, along with local religious
groups and other NGOs, promoted a consistent message of partner
reduction and fidelity, which contributed to a significant decline
in the number of sexual partners among both men and women in
Uganda. |
| |
| Between 1989 and 1995 the proportion of
men who reported one or more "casual" partners in the past year
fell from 35 percent to 15 percent; the proportion of women
with one or more casual partners in the past year fell from
16 percent to 6 percent, and the proportion of men reporting
3 or more "non-regular" partners in past year fell from 15 percent
to 3 percent. |
| |
| This significant level of behavior change
contributed to a reduction in estimated adult HIV prevalence
in Uganda from 15 percent in the early 1990s to about 4 percent
today. Be faithful programs promote the following: |
| |
- The elimination of casual sexual partnerships;
- The development of skills for sustaining marital fidelity;
- The importance of mutual faithfulness with an uninfected
partner in reducing transmission of HIV among individuals
in long-term sexual partnerships;
- HIV counseling and testing with their partner for those
couples that do HIV status;
- The endorsement of social and community norms supportive
of refraining outside of marriage, partner reduction, and
marital fidelity, by using strategies respect and respond
to local cultural customs and norms; and
- The adoption of social and community norms that denounce
cross-generational transactional sex; and rape, incest,
and other forced sexual activity.
|
| Correct and consistent Condom use
programs support the provision of full and accurate information
about correct and consistent condom use reducing, but not eliminating,
the risk of HIV infection; and support access to condoms for
those most at risk for transmitting or becoming infected with
HIV. |
| |
| Behaviors that increase risk for HIV transmission
include engaging in casual sexual encounters, engaging in sex
in exchange for money or favors, having sex with an HIV-positive
partner or one whose status is unknown, using drugs or abusing
alcohol in the context of sexual interactions, and using intravenous
drugs. Women, even if faithful themselves, can still be at risk
of becoming infected by their spouse, regular male partner,
or someone using force against them. |
| |
| Other high-risk persons or groups include
men who have sex with men and workers who are employed away
from home. Existing research demonstrates that the correct and
consistent use of condoms significantly reduces, but does not
eliminate, risk of HIV infection. Studies of sexually active
couples for example, in which one partner is infected with HIV
and the other partner is not, demonstrate that latex condoms
provide approximately 80-90 percent protection, when used
consistently. |
| |
| To achieve the protective effect of condoms,
people must use them correctly and consistently, at every
sexual encounter. Failure to do so diminishes the protective
effect and increases the risk of acquiring a sexually transmitted
infection (STI) because transmission can occur with even a single
sexual encounter. Latex condoms, when used consistently and
correctly, are highly effective in preventing transmission of
HIV. |
| |
| In addition, correct and consistent use
of latex condoms can reduce the risk of other sexually transmitted
diseases (STDs), including gonorrhea, chlamydia, and genital
ulcer diseases. While the effect of condoms in preventing human
papillomavirus (HPV) infection is unknown, condom use has been
associated with a lower rate of cervical cancer. Persistent
infection with "high-risk" types of HPV is the main risk factor
for cervical cancer. Condom use programs promote the following: |
- The understanding that abstaining from sexual activity
is the most effective and only certain way to avoid HIV
infection;
- The understanding of how different behaviors increase
risk of HIV infections;
- The importance of risk reduction and a consistent risk-reduction
strategy when risk elimination is not practiced;
- The importance of correctly and consistently using condoms
during every sexual encounter with partners known to be
HIV-positive (discordant couples), or partners whose status
is unknown;
- The critical role of HIV counseling and testing as a risk-reduction
strategy;
- The development of skills for obtaining and correctly
and consistently using condoms, including skills for vulnerable
persons; and
- The knowledge that condoms do not protect against all
STIs.
|
| To identify the most strategic prevention
interventions, countries must first gain an understanding of
the types and degrees of risk behavior that fuel the epidemic
locally. It is recommended that countries develop their prevention
strategies through a two-step situation analysis that addresses
questions of "who is doing what, with whom, where, and why." |
| |
| In the first step, available epidemiological
data should be applied to estimate the proportion of new infections
that are associated with specific behaviors such as prostitution,
early onset of sexual activity among youth, transmission through
sexual networks, etc. Efforts should be made to review prevalence
data available through national serosurveys, antenatal clinic
surveillance, and/or voluntary counseling and testing clinics,
to assess different infection burdens by age and by gender.
|
| |
| For example, high HIV prevalence among
young women, and among older men, may point to transmission
that is fueled by cross-generational sex. Population-level surveys
featuring behavioral indicators, such as demographic health
surveys and behavioral surveillance surveys should also be carefully
reviewed to assess the extent to which certain types of behaviors
represent important opportunities for preventing new infections.
|
| |
| In Botswana, for example, reported levels
of condom use are quite high, but so are reported numbers of
concurrent sex partners, suggesting that approaches emphasizing
partner reduction could have strategic benefits over those that
prioritize additional condom promotion. |
| |
| It is recommended that this first step
produce information relevant to each of the following considerations: |
- Who are the core transmitters?
- What are the specific behaviors through which HIV is transmitted?
- What are the specific behaviors that represent the most
strategic targets for averting new infections?
- What are some of the specific prevention/intervention
needs of women, youth, and "vulnerable" populations?
- What are some of the specific prevention/intervention
needs of people living with HIV/AIDS (PLWHAs)?
- How can the "ABCs" be applied appropriately? (Note: ABC
must be balanced at the portfolio level, i.e. all three
components must be represented in the country's prevention
strategy, but individual programs must be appropriately
designed to meet the needs of the target audience.)
- What are the priorities for abstinence?
- Partner reduction is a critical behavioral determinant
in many cases; how is it being addressed?
- In what circumstances are condoms critical?
|
| Having identified these behavior change
priorities, the second step should seek to understand more specifically
who is engaging in risk-related activities, where to reach these
people, and what individual and structural factors could be
leveraged to promote change. |
| |
| Participatory and/or rapid assessment approaches,
employing qualitative and/or quantitative methods, can help
to characterize transmission risk among specific groups or in
specific settings. In addition, one of the most important components
of this step involves developing a better sense of the supporting
environment for specific kinds of initiatives and prevention
opportunities. |
| |
| Many of the interventions that are believed
to have contributed to Uganda's success originated from pre-existing
structures, organizations, and networks. This type of information
is often collected through observation and experience, but reviewing
local media and conducting strategic interviews with key local
and national stakeholders from a variety of backgrounds can
help to generate a good picture of the supporting environment.
Some other critical questions to consider in this stage include: |
| |
- What is national political, social, and cultural leadership
saying or doing (or not) about AIDS and about behavior change
and prevention?
- What networks or institutions are engaged (or not) in
HIV prevention? (Schools, churches, NGOs, local government
units, workplaces, etc.)
- What are community leaders doing or saying (or not) about
HIV prevention? " How is information about HIV/AIDS being
shared within personal networks? Are people talking about
HIV/AIDS? To what extent does stigma present a barrier to
effective action?
- What are the gender inequities that foster the spread
of HIV?
- What are the other social inequities and local practices
that foster the spread of HIV?
- How is the media treating HIV prevention and behavior
change?
- What additional issues are impacting the country and its
HIV epidemic (e.g. war, famine, refugees, other diseases)?
- How are local experts engaged in assessing the supporting
environment, including women and PLWHA?
|
| These diagnostic questions are all critical
for empowering a grassroots/community-level response to the
epidemic. U.S. missions should collaborate with local experts
to foster a local perspective that is culturally appropriate
and sensitive. Creating a strong community-level response will
aid rapid scale-up and ensure long-term sustainability. |
| |
| Does 'CNN' (Condoms, Needles, Negotiation)
Work Better than 'ABC' (Abstinence, Being Faithful and Condom
Use) in Attacking the AIDS Epidemic? |
| By Steven W. Sinding |
| |
| After more than two decades of HIV/AIDS,
we have learned a great deal about how it is transmitted, care
and treatment options, its global impact, its developmental
roots, and what preventive measures are most feasible and effective.
Yet it sometimes seems as if these science-based lessons are
lost in the cacophony of ideological, religious and political
rhetoric that surrounds discussion of HIV/AIDS today. The uproar
about ABC (abstinence, being faithful, condom use) is an excellent
case in point, for the narrow manner in which this model of
prevention is being interpreted may be undermining the global
response. |
| |
| On the face of it, few would argue with
the basic premise of ABC. It is epidemiologically and programmatically
sound-a tiered approach to prevention that is appropriately
calibrated to levels of risk. Indeed, as implemented in Uganda
and other places, the ABC approach has been successful and effective
in reducing the rate of new infection and deserves the support
and the praise it has received. |
| |
| But it's not that simple. |
| |
| The reality of AIDS in Sub-Saharan Africa-still
the region bearing the overwhelming share of the global AIDS
burden-is that marriage (and the illusion of fidelity among
supposedly HIV-negative couples) is increasingly seen as a risk
factor. As health providers, we see that married, monogamous
women are highly vulnerable to HIV infection due to their lack
of rights within marriage, difficulties negotiating safer sex,
extended partner absence and domestic violence. |
| |
| In Sub-Saharan Africa, the majority of
newly HIV-positive women are contracting the virus within marriage
from their husbands.(1)
This pattern is reflected around the world.
In Cambodia, prevalence is falling among sex workers but rising
rapidly in married women: Fifty percent of all married women
who contracted the virus in 2002 were infected by their husbands.(2)
Furthermore, in one recent study, more than 80% of HIV-positive
women were monogamous,(3)
and in a study in Rwanda, 25% of women who were HIV-positive
said they had had only one sexual partner in their lifetime.
|
| |
| (4)
These women had complied with the prevention
messages they were given, and yet doing so failed to protect
them. Promoting abstinence or faithfulness as the only ways
to prevent HIV transmission will leave millions of people without
the ability to protect themselves from infection. Improving
women's status and negotiating skills are thus key areas for
any prevention strategy. |
| |
| Women are increasingly vulnerable to HIV
infection.(5)
In 1997, women made up 41% of people living with HIV; by 2002,
this figure had risen to almost 50%. In 2003, UNAIDS estimated
that five million people were newly infected and 40 million
people were living with HIV/AIDS. Half of those infected were
women. |
| |
| Another critical issue is condom stigma-the
association in many people's minds between condoms and illicit
sex. Many women and men feel shame about using-and frequently
refuse to use-condoms within marriage. A tremendously important
goal must be the desensitization of condom use, the removal
of the taboo on this method and, indeed, on communication between
partners about condom use. |
| |
| The genius of Senator Mechai in Thailand
and, early on, President Museveni of Uganda was their ability,
as political leaders, to create an environment in which open
discussion of HIV transmission permitted discussions about sexuality-at
the community, family and couple levels. Once options were discussed,
real behavior change occurred. In Thailand, this resulted in
phenomenal changes in condom use, and in Uganda it resulted
in a more multidimensional, but nonetheless highly effective,
behavioral response. |
| |
| Indeed, effective condom use is real behavior
change. It has been said that past programs were primarily focused
simply on providing condoms and hoping people would use them
correctly. But for many years, IPPF has been teaching people
how to use condoms correctly and serious efforts have been under
way for several years to help young people understand how to
use condoms properly. By promoting condoms as part of a standard
package of prevention measures, we can help to destigmatize
and normalize their use. |
| |
| It comes down to this: Serious efforts
at behavior change communication may succeed in delaying sexual
debut and limiting the numbers of partners. But among HIV-positive
people-the majority of whom may be unaware of their status-sex
is an undeniable reality and, in the absence of any other technology
to protect sexually active people from the risk of infection,
prevention messages must stress correct and consistent use of
condoms. |
| |
| What is the evidence that condoms are an
essential part of the battle against AIDS? First, a recent position
statement from WHO, UNAIDS and UNFPA reads, in part: |
| |
| (6)
"The male latex condom is the single most efficient available
technology to reduce the sexual transmission of HIV and other
sexually transmitted infections. …Condoms will remain the key
preventive tool for many, many years to come…." |
| |
| According to a meta-analysis commissioned
by UNAIDS, condom use is 90% effective in preventing transmission,
and condom use has been a key element in reductions in HIV prevalence
in many countries.(7)
In Thailand and Brazil, for example, where transmission has
primarily been within the commercial sex trade, condom promotion
has been especially effective. |
| |
| But, where the epidemic is largely heterosexual
and widespread, evidence on the effectiveness of condom programs
has been more mixed and less clear. In Uganda, while it is clear
that condoms have played a role in lowering infection rates,
reducing the number of sex partners appears to have played at
least as large a role. In other words, condoms should not be
seen as distinct from other strategies but as an integral part
of comprehensive strategies that also counsel abstinence and
reducing the number of sexual partners. |
| |
| This view is also expressed in the 2004
UNAIDS Report on the Global AIDS Epidemic (8).
Furthermore, the effectiveness of condoms in preventing disease
transmission (and unwanted pregnancy, for that matter) lies
not in the inherent quality of the product but in its effective
use. Evidence from family planning programs over many years
makes it abundantly clear that the condom is a safe and relatively
effective method, but that compliance in its use is difficult
to achieve with consistency over extended periods of time. |
| |
| For this reason, family planning fieldworkers
often recommended other methods of birth control over condom
use, although condoms were always known to be the best and,
indeed, one of the only forms of prevention of STIs. |
| |
| There is a good analogy between moralizing
against condoms and moralizing against needle exchange programs.
In both cases, the moralizers wish to deny human nature and
behavior. A 2004 evidence assessment by the Cochrane Collaborative
Review Group on HIV Infection and AIDS shows that clean needles,
methadone substitution for injecting drug use, and condom use
by injecting drug users are effective in reducing the spread
of HIV (9). |
| |
| Of course, rehabilitation and detoxification
efforts must continue, and we must search for ways to make them
better. One way to do this is by providing not just one, but
a suite of care services that recognize the reality of injecting
drug users' lives. Just as abstinence and fidelity are not substitutes
for condom use, so rehabilitation and detoxification are not
substitutes for clean needles. |
| |
| Abstinence for younger adolescents, faithfulness
in marriage and condom promotion have a place in international
HIV/AIDS programs. Unfortunately, by twisting the ABC concept
important international voices-the U.S. government and the Vatican,
in particular-have made ABC controversial. The actions of these
major political actors are not only regrettable; given their
influence over millions of people around the world, they represent
a serious setback to efforts to bring HIV/AIDS under control.
|
| |
| Conservative U.S. government officials
have made clear the Bush administration's preference for abstinence-only
approaches and have registered strong misgivings about the moral
and ethical advisability of providing condoms as part of AIDS
prevention programs, arguing-incorrectly-that condoms may encourage
early sex and sexual promiscuity. In addition, U.S. officials
have removed scientifically accurate information about condom
use effectiveness from the Web sites of several federal agencies
and have questioned whether or not condoms provide protection
against STIs, including HIV. |
| |
| This issue of abstinence-only programming
needs to be addressed head on. Not only are there question marks
over exactly what defines abstinence and what makes it sustainable;
there is no clear evidence that it works. |
| |
| As the largest international funder of
HIV/AIDS programs, the attitude and recommendations of the U.S.
government have far-reaching consequences for the health of
people across the world. The "ABC" approach is a central prevention
component of the new U.S. Global AIDS Strategy, yet the government
channels one-third of all HIV prevention funding to abstinence
programs, particularly those that counsel abstinence until marriage
(10).
|
| |
| To date, however, there is no conclusive
proof that abstinence-only programs have been successful in
any country in the world in reducing HIV transmission. (11)
In a recent review of abstinence programs
in the United States by DiCenso and colleagues, pregnancy rates
among the partners of the young male participants were no lower
than those among the partners of nonparticipants. (12) |
| |
| Similarly, the effectiveness of abstinence
as a long-term strategy-particularly for young people-was refuted
by a study presented at the annual meeting of the American Psychological
Society that reported that not only was the "virginity pledge"
broken by more than 60% of the pledgers, but 55% who reported
keeping their virginity admitted to engaging in risky forms
of nonvaginal sex.(13) |
| |
| For its part, the Vatican has conducted
a global campaign of disinformation about condoms. Not only
has the Vatican echoed the Bush administration's concerns about
the effect of condoms on Christian morality, but many in the
church hierarchy have denigrated condoms as flawed products.
(14)
In 2003, the president of the Vatican's Pontifical Council for
the Family, Cardinal Alfonso López Trujillo, told a BBC Panorama
program, "the AIDS virus is roughly 450 times smaller than the
spermatozoon. |
| |
| The virus can easily pass through the 'net'
that is formed by the condom." (15)
In countering the Vatican's claims, WHO and
IPPF were supported by research from the U.S. National Institutes
of Health, which concluded that "intact condoms are essentially
impermeable to particles the size of STD pathogens, including
the smallest sexually transmitted virus." (16)
In other words, the HIV prevention approach we are talking about
here is not ABC in its pure form but rather ABC as it has been
perverted by the religious conservatives who wield such strong
influence within the Bush administration and the Vatican. |
| |
| We live in a world that is complex and
diverse. Many things in addition to the ABC approach are necessary
to control the epidemic: Voluntary counseling and testing-a
cornerstone of the WHO "3 by 5" initiative-needs to be linked
to treatment access; destigmatization campaigns are required
to promote a better environment for those seeking prevention
and treatment; and increased efforts need to be made to improve
the status of women and young girls. |
| |
| The UNAIDS Global Coalition on Women and
AIDS provides an excellent platform to revitalize our global
prevention agenda. And while the ABC approach will form part
of the response, it should be firmly grounded in science, not
ideology. |
| |
| Instead of debating CNN vs. ABC, we must
recognize the complexity of sexual relations, which embrace
every facet of our lives, including issues of culture, tradition,
power and status. We must acknowledge the unequal power relationships
between men and women, especially older men and younger women,
and we must design interventions that provide realistic choices.
Above all, we must resist efforts to impose a particular morality
on individuals. |
| |
| We must respect the individual and find
ways of giving people realistic and effective options. We must
not deny men and women access to information or technologies
that enable them to protect their health and even their lives.
Forty years of experience in family planning and reproductive
health has shown us that empowering individuals to make informed
choices is the only approach that really works. |
| |
| 1. |
Stanecki K, The AIDS pandemic
in the 21st century, U.S. Bureau of the Census, July 2002,
, accessed June 2004. |
| 2. |
Nakamura S et al.,
Projections for HIV/AIDS in Cambodia: 2000-2010, Phnom
Pen, Cambodia: National Centre for HIV/AIDS, Dermatology
and STDs, 2002. |
| 3. |
Newman S et al., Marriage,
monogamy and HIV: a profile of HIV-infected women in South
India, International Journal of STD and AIDS, 2000, 11(4):250-253.
|
| 4. |
Allen S et al., Human
immunodeficiency virus infection in urban Rwanda: demographic
and behavioral correlates in a representative sample of
childbearing women, Journal of the American Medical Association,
1991, 266(12):1657-1663. |
| 5. |
UNAIDS, 2004 UNAIDS
Report on the Global AIDS Epidemic, Geneva: UNAIDS, 2004.
|
| 6. |
World Health Organization,
UNAIDS and United Nations Population Fund (UNFPA), Position
statement on condoms and HIV prevention, July 2004, ,
accessed July 2004. |
| 7. |
Hearst N and Chen
S, Condom promotion for AIDS prevention in the developing
world: is it working? Studies in Family Planning, 2004,
35(1):39-47. |
| 8. |
UNAIDS, 2004, op.
cit. (see reference 5). |
| 9. |
Cochrane Collaborative
Review Group on HIV Infection and AIDS, Evidence assessment:
strategies for HIV/AIDS prevention, treatment and care,
July 2004, , accessed July 2004. |
| 10. |
Sexuality Information
and Education Council of the United States (SIECUS), Bush
visits Uganda and praises "ABC" approach in spite of administration's
preference for abstinence-only-until-marriage, Policy
Update, July 2003, , accessed Feb. 11, 2004. |
| 11. |
Dailard C, Understanding
'abstinence': implications for individuals, programs and
policies, Guttmacher Report on Public Policy, 2003, Vol.
6, No. 5, pp. 4-6. |
| 12. |
Di Censo A et al.,
Interventions to reduce unintended pregnancies among adolescents:
systematic review of randomized controlled trials, BMJ,
2002, 324(7351): 1426 |
| 13. |
Lipsitz A, Bishop
PD and Robinson C, Virginity pledges: who takes them and
how well do they work? presentation at the annual convention
of the American Psychological Society, Atlanta, GA, USA,
May 31, 2003. |
| 14. |
Bradshaw S, Vatican:
condoms don't stop AIDS, Guardian, Oct. 9, 2003, , accessed
Oct. 10, 2003. |
| 15. |
Ibid. |
| 16. |
National Institutes
of Health, Workshop Summary: Scientific Evidence on Condom
Effectiveness for Sexually Transmitted Disease Infection,
July 20, 2001, , accessed Mar. 30, 2004. |
|
| |
| This viewpoint is based on a panel debate
at the 15th International AIDS Conference, Bangkok, July 11-16,
2004. |
|
|
