The ABC Approach to HIV Prevention: Answers to Common Questions

1. The ABC Approach to HIV Prevention: Answers to Common Questions Edward C Green, PhD Allison Herling, MSPH CCIH Annual Conference May 28, 2006

2. What is the ABC Approach? • A= Abstain B= Be faithful C= use Condoms • Population specific approach, emphasizing different options for different populations depending on level of risk (risk avoidance as well as risk reduction)

3. Two approaches to disease prevention 1. Risk avoidance (abstinence or delay of age of first sex; mutual monogamy. Not injecting drugs, or stopping if already started). 2. Risk- reduction or “remedies” interventions (condoms, treating STIs with drugs, providing clean needles) Some refer to the latter as “Primary Prevention” or “Primary Behavior Change”

4. Sex. Trans. AIDS IDU Trans. AIDS RISK AVOIDANCE Abstinence, mutual monogamy Not injecting, stopping IDU RISK REDUCTION Condoms, STI Rx Sterile syringes risk avoidance & risk reduction

5. HIV/AIDS Epidemic HIV/AIDS Epidemic Condom use (STI Rx), VCT Evidence shows: Condoms Alone are insufficient for a Generalized Epidemic (or general population in any epidemic) source: Nantulya 2004

6. Delayed Age at First Sex Fidelity, Partner Reduction Secondary abstinence HIV/AIDS Epidemic HIV/AIDS Epidemic Condom use (STI Rx), VCT ABC—all 3 types of behavior change needed Primary behavior change HIV/AIDS Decline source: Nantulya 2004

7. All 3 behavior types of changes neededSays who? USAID ABC Study 2003 (not just Green, but Doug Kirby, Ruth Bessinger, etc) UNAIDS Multi-Side Study 2001 (esp. Auvert re-analysis) UNAIDS Condom review (Hearst & Chen 2003, 2004) PEPFAR, Okware et al 2005, etc. (“Abstinence, being faithful, and condom use are complementary, synergistic, and inseparable components in the country’s HIV/AIDS national prevention and control programmes…)

8. What is the evidence for ABC? • Proven effectiveness of ABC approach in generalized epidemics, such as those in Africa • Uganda provides the clearest example • HIV prevalence decreased from 15% to 5%, 1991 to 2001 • Increases in C and A but especially in B behaviors

9. A Never married ages 15-24 who had sex in the past year1 B Multiple partners in the past year, ages 15-492 C Condom use last higher-risk sex, ages 15-492 Source: 1 Global Programme on AIDS (GPA), 2 Demographic Health Surveys (DHS) ABC Behaviors in Uganda, 1989 to 2005

10. ABC behaviors in Uganda (cont.) Compared to other countries in Africa, Uganda in the mid-1990s had much lower levels of B behaviors similar levels of C behaviors

11. Condom use at last sex: Percent of sexually active men and women ages 15 to 49 who used a condom at last sex with anyone C behaviors in Uganda compared to other countries Source: Demographic Health Surveys (DHS)

12. Multiple Sexual Partnerships: Percent of sexually active men and women ages 15 to 49 who have had sexual intercourse with more than one partner in the last 12 months B behaviors in Uganda compared to other countries Source: Demographic Health Surveys (DHS)

13. Other evidence for the ABC approach • Other countries in which an ABC approach has led to a reduction in HIV prevalence include Senegal, Jamaica, Thailand, Zambia, the Dominican Republic, and most recently Kenya and Zimbabwe • Kenya: HIV prevalence declined from 10% in late 1990s to 7% by 2003 (UNAIDS) • Zimbabwe: HIV prevalence among pregnant women declined from 26% in 2001 to 21% in 2004 (UNAIDS)

14. A Never married ages 15-24 who had sex in the past year1 B Multiple partners in the past year, ages 15-492 C Condom use last higher-risk sex, ages 15-492 Source: Demographic Health Surveys (DHS) ABC Behaviors in Kenya

15. ABC Behaviors in Zimbabwe In Manicaland(Gregson et al, 2006): • Decline in HIV prevalence, 1998 to 2003 • Population-wide decline from 23.0% to 20.5% • 23% decline in young men • 49% decline in young women • Increase in AB behaviors • Little change in C

16. Behavior Change among males in Manicaland, Zimbabwe Source: Gregson et al, 2006

17. Has ABC been superceded by SAVE? ANERELA+ (the African Network of Religious Leaders Living with or personally affected by HIV and AIDS) has developed a new model for a comprehensive HIV response, called SAVE. • Safer practices • Available medications • Voluntary counseling and testing (VCT) • Empowerment through education Translation: condoms, pills, testing and “empowerment” (Notice removal of A&B)

18. Has ABC been superceded by SAVE? SAVE was not supposed to be a prevention approach, like ABC. It was a support network for HIV+ clergy. But critics of ABC immediately heralded SAVED as “replacing ABC.” Note the use of an evangelical acronym, the suggestion of salvation…the implication that FBOS would be behind something with this name

19. The ABC Approach to Preventing the Sexual Transmission of HIV: Common Questions and AnswersA few comments on this project and why the CCIH HIV Prevention and Health Behavior Working Group undertook it…

20. Aren’t all parts of the ABC approach equally important? Why does the ABC approach emphasize abstinence and fidelity?

21. Aren’t all parts of the ABC approach important? • The “Consensus Statement” published in The Lancet in 2004 and signed by over 150 public health experts stated the following: • For youth, the first priority should be to encourage abstinence or delay of sexual debut. • For adults, the first priority should be to promote mutual fidelity with an uninfected partner. • For people at high risk of exposure to HIV, the first priority should be to promote consistent condom use.

22. Aren’t all parts of the ABC approach important? (cont.) • “All three elements of this approach are essential to reducing HIV incidence, although the emphasis placed on individual elements needs to vary according to the target population. Although the overall programmatic mix should include an appropriate balance of A, B, and C interventions, it is not essential that every organisation promote all three elements: each can focus on the part(s) they are most comfortable supporting. However, all people should have accurate and complete information about different prevention options, including all three elements of the ABC approach.” (Halperin et al., The Lancet 2004)

23. Aren’t all parts of the ABC approach important? (cont.) • However… Evidence has shown that A and especially B behavior changes are necessary for HIV prevalence to fall– C by itself has not had this effect • To paraphrase Norman Hearst: If I am foolish enough to engage in risky sex, I should use a condom. But as a public health strategy, promotion of condoms has had a poor record of producing lower HIV infection rates, especially in generalized epidemics.

24. Aren’t all parts of the ABC approach important? (cont.) Another way to put it: It depends on whether the group we are targeting is engaged in high-risk behavior, or not. In this sense, both sides of ABC are right; it depends on which population segment is being targeted. (those not-at-current-risk always comprise the majority of any country, usually the great majority)

25. Are condoms effective against HIV/AIDS?

26. Are condoms effective against HIV/AIDS? • Condoms are 80-90% effective in reducing risk of HIV transmission (compared to non-use) when used consistently and correctly • Inconsistent condom use produces little or no reduced risk • Inconsistent use IRR = 0.96 • Consistent use IRR = 0.37 (Ahmed et al., AIDS 2001) (also Hearst & Chen ‘03)

27. Are condoms effective against HIV/AIDS? (cont.) • Few people outside high-risk groups use condoms consistently– no country in Africa has ever had rates of consistent condom usage above 5%, with regular sexual partners • Condom use at high-risk sex has increased in countries in which the ABC approach has been successful (e.g. Uganda, Kenya)

28. Are condoms effective against HIV/AIDS? (cont.) • Condom promotion alone has not proven effective and may lead to disinhibition • Hearst and Chen, 2003: “Especially in the setting of generalized heterosexual transmission, it is unknown what level of condom use in the population is necessary to have a substantial impact on HIV transmission. Indeed, there are no definite examples yet of generalized epidemics that have been turned back by prevention programs based primarily on condom promotion.”

29. Average Annual Number of Condoms per Male in sub-Saharan Africa

30. Does the ABC approach demand an unrealistic standard of behavior?

31. Does the ABC approach demand an unrealistic standard of behavior? • Typical statements: • “The behavioral bias of the ABC approach is based on the assumption that individuals all have an innate and equal power to make perfectly correct decisions about every issue in their sexual and reproductive lives.” • “We all know that abstinence and couples being mutually faithful would be great if they were applicable to everybody’s lives, but they’re not.”

32. Does the ABC approach demand an unrealistic standard of behavior? (cont.) • Typical assumptions: • African culture is polygamous– therefore B messages won’t work • Africans start to engage in sex at an early age– therefore A messages won’t work • Women have no power over their sexual lives Therefore AB messages are not realistic

33. Does the ABC approach demand an unrealistic standard of behavior? (cont.) • In fact… Data show that the vast majority of Africans are already practicing A and B behaviors

34. Does the ABC approach demand an unrealistic standard of behavior? (cont.) • 23% of African men and 3% of African women reported multiple sexual partners in the last year • Among unmarried youth 15-24, 41% of young men and 32% of young women reported pre-marital sex in the past year • The trend in Africa is towards higher levels of A and B behaviors and towards slightly lower HIV prevalence (7.2% in 2005 compared to 7.5% in 2003)

35. Is the ABC approach unrealistic for women?

36. Is the ABC approach unrealistic for women? • Some women who practice premarital abstinence and marital fidelity are infected by unfaithful spouses or partners • Women may be victims of rape and sexual violence, including within marriage • Women may be made vulnerable by poverty or other circumstances

37. Many assume that “ABC misses the point” Nancy Padian, presentation to NIH, 2005

38. Support women: reject ABC! Notice the slide’s conclusion. If we care about women we will reject ABC. Yet B messages to men as well as women, along with “structural” measures to empower women, give them the best chance of avoiding HIV infection. Recommended reading: Murphy, Elaine,  Margaret E. Greene and Trang Duong, "Defending the ABCs: A Feminist Perspective on AIDS Prevention." George Washington University School of Public Health. Public Library of Science (in press, and online).

39. Support women: reject ABC? • We see in the country that has done the most to promote fidelity or zero-grazing, Uganda, that women are more empowered to say no to unwanted sex compared with women from any other African country, according to DHS (next slide)

40. Percentage of women who believe that a wife is justified in refusing to have sex with her husband for specific reasons, by country (from DHS data) • ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– • Wife is justified in refusing • sex with her husband if she: • –––––––––––––––––––––––––––––––––––––––––––– • Knows Knows • husband has husband Is tired a sexually has sex Has or not • transmitted with other recently in the • Country disease women given birth mood • ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– • Malawi 2000 73.3 68.2 77.7 60.5 • Rwanda 2000 87 68.6 72.1 55 • Zambia 2001-02 85.6 72.9 87.9 67.0 • Uganda 2000-01 91.2 76.4 89.1 79.5 • Zimbabwe 1999 71.2 63.5 81 52.6

41. Women in Africa: the good news • The good news is that African women have more control over their sexual lives than is often assumed • 2/3 of unmarried women ages 15-24 practiced abstinence last year • A majority of women in Africa say they can refuse sex, or sex without a condom, with their husband

42. Women and HIV: conclusions • The ABC approach must go hand-in-hand with empowering women and addressing gender inequity • No part of the ABC approach will work if women are not empowered (Is a woman who is forced to have sex really able to insist on condom use?) • The B of the ABC approach is urgently needed– the solution is for more men to be faithful • Rape, sexual coercion, and cross-generational sex must also be addressed

43. www.ccih.org/resources/ab

44. Is the ABC approach overly simplistic? What about realities such as gender and social inequalities, poverty, and cultural impediments to behavior change?

45. Is the ABC approach overly simplistic? • The ABC approach is an individual behavioral approach that focuses on what an individual can do to change or maintain behavior • It should be complemented by larger community and societal responses, to address factors such as poverty and gender inequity that can fuel the AIDS epidemic

46. A Avoid exposure Abstinence Mutual faithfulness B Reduce exposure Be faithful (Partner reduction) C Block exposure efficiency Condom use And D for Drugs, for treating STDs, another prevention method ABC Strategy

47. Is the ABC approach overly simplistic? (cont.) • In countries such as Uganda where the ABC approach was effective, the government and various civil society groups also took action to advance women, increase access to education, and decrease poverty • These measures may contribute to the success of the ABC approach, but we can also find countries where these goals have been pursued and HIV rates have remained high (e.g. Botswana)

48. Is the ABC approach overly simplistic? (cont.) • In Uganda and other countries, HIV prevention has been successful even though broader societal goals (poverty eradication, gender equity, etc.) have not been fully met • Rwanda provides an example of a country that has experienced great poverty, social upheaval, and violence… yet HIV prevalence remains low! (3%) Why? High levels of AB behaviors

49. Is the ABC approach overly simplistic? (cont.) • The ABC approach addresses the proximate determinantsof sexually transmitted HIV infection– sexual behaviors • Other “HIV prevention measures” such as increased access to VCT, treatment for HIV and STIs, fighting stigma, poverty alleviation, effective political leadership and increasing the status of women are indirect factorsthat do not effect HIV transmission directly, and in fact may have not have the expected effect on HIV epidemics

50. Does the ABC approach contribute to stigmatization and marginalization of people living with AIDS (PLWAs)?