Transcript The ABC Approach to HIV Prevention: Answers to Common

The ABC Approach to HIV
Prevention: Answers to
Common Questions
Edward C Green, PhD
Allison Herling, MSPH
CCIH Annual Conference
May 28, 2006
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)
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”
risk avoidance & risk reduction
Sex. Trans.
AIDS
IDU Trans.
AIDS
RISK
AVOIDANCE
Abstinence,
mutual
monogamy
Not
injecting,
stopping
IDU
RISK
REDUCTION
Condoms,
STI Rx
Sterile
syringes
Evidence shows: Condoms Alone are
insufficient for a Generalized Epidemic
(or general population in any epidemic)
HIV/AIDS
Epidemic
HIV/AIDS
Epidemic
Condom
use (STI
Rx), VCT
source: Nantulya 2004
ABC—all 3 types of behavior
change needed
Delayed
Age at
First Sex
Fidelity,
Primary behavior
Secondary
Partner
change
abstinence
Reduction
HIV/AIDS
HIV/AIDS
Epidemic
Decline
HIV/AIDS
Epidemic
Condom
use (STI
Rx), VCT
source: Nantulya 2004
All 3 behavior types of changes needed
Says 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…)
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
percent
ABC Behaviors in Uganda, 1989 to 2005
100%
A
B
C
90%
Never married ages 15-24 Multiple partners in the
Condom use last higher2
80% who had sex in the past
past year, ages 15-49
risk sex, ages 15-492
70% 60% year1
59%
60%
53%
50%
41%
38%
36%
40%
30%
23%
21% 23%
20%
16%
20%
9%
10%
0%
Young
Young
Males Females
Males Females
men
Women
1989
2005
Source: 1 Global Programme on AIDS (GPA), 2 Demographic Health Surveys (DHS)
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
C behaviors in Uganda compared to
other countries
condom used
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
40%
30%
21%
20%
20%
10%
9%
3%
6%
8%
Kenya
1998
Zambia
1996
12%
4%
0%
Uganda
1995
males
females
Source: Demographic Health Surveys (DHS)
Tanzania
1996
B behaviors in Uganda compared to
other countries
condom used
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
40%
30%
20%
10%
32%
29%
27%
10%
1%
4%
5%
Kenya
1998
Zambia
1996
6%
0%
Uganda
1995
males
females
Source: Demographic Health Surveys (DHS)
Tanzania
1996
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)
percent
ABC Behaviors in Kenya
100%
A
B
C
90%
Never married ages 15-24 Multiple partners in the
Condom use last higher2
80% who had sex in the past
past year, ages 15-49
risk sex, ages 15-492
year1
70%
60% 56%
47%
44%
50%
41%
40%
32%
30%
24%
30%
21%
17%
16%
20%
4% 2%
10%
0%
Young
Young
Males Females
Males Females
men
Women
1998
Source: Demographic Health Surveys (DHS)
2003
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
Behavior Change among males in
Manicaland, Zimbabwe
1998-2000
2001-2003
50
40
30
20
10
0
17-19 yr olds who New sexual partner Casual partner have started sex
- last year
last month
Condom use - last
casual partner
Source: Gregson et al, 2006
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)
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
The ABC Approach to Preventing
the Sexual Transmission of HIV:
Common Questions and Answers
A few comments on this project and why the
CCIH HIV Prevention and Health Behavior
Working Group undertook it…
Aren’t all parts of the ABC approach
equally important?
Why does the ABC approach
emphasize abstinence and fidelity?
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.
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)
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.
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)
Are condoms effective against
HIV/AIDS?
Are condoms effective against
HIV/AIDS?

Condoms are 80-90% effective in reducing
risk of HIV transmission (compared to nonuse) 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)
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)
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.”
Average Annual Number of Condoms per
Male in sub-Saharan Africa
Does the ABC approach demand
an unrealistic standard of
behavior?
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.”
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
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
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 premarital 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)
Is the ABC approach
unrealistic for women?
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
Many assume that “ABC misses the point”
Message
Reality
Abstain from sex
Rape & forced sex
Be faithful
Infection by partners
Wear a condom
Coercion & financial
dependency
Defense of women!
for whom ABCs do not
apply
Nancy Padian, presentation to NIH, 2005
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).
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)
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
Rwanda 2000
Zambia 2001-02
Uganda 2000-01
Zimbabwe 1999
73.3
87
85.6
91.2
71.2
68.2
68.6
72.9
76.4
63.5
77.7
72.1
87.9
89.1
81
60.5
55
67.0
79.5
52.6
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
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
 www.ccih.org/resources/ab
Is the ABC approach overly
simplistic? What about realities such
as gender and social inequalities,
poverty,
and cultural impediments to
behavior change?
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
ABC Strategy
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
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)
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
Is the ABC approach overly
simplistic? (cont.)


The ABC approach addresses the proximate
determinants of 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 factors that
do not effect HIV transmission directly, and in
fact may have not have the expected effect
on HIV epidemics
Does the ABC approach
contribute to stigmatization and
marginalization of people living
with AIDS (PLWAs)?
Does the ABC approach contribute to
stigmatization and marginalization of PLWAs?
(cont.)



PLWAs are often leaders in the fight against
HIV/AIDS and leaders in advocating for behavior
change, including an ABC approach
Some people may feel stigmatized or
marginalized for either engaging in or not
engaging in A, B, or C behaviors
Faith communities have at times contributed to
stigma, but have also in many cases addressed
(and reduced) stigma, modeled care and
compassion, and effectively promoted AB
behaviors
Does the ABC approach contribute to
stigmatization and marginalization of PLWAs?

Yet while stigma and discrimination are
real…


The ABC approach has proven success
A successful public health approach may be
justified (for the benefit of the population as a
whole) even if it stigmatizes certain behaviors
and causes some to feel stigmatized
Consider the example of smoking….
Questions? Comments?
 www.ccih.org/resources/ab