Challenging Dogma

...Using social sciences to improve the practice of public health

Monday, April 23, 2007

ABC is Not as Easy as 123: Critiquing the ‘Abstinence, Be Faithful, & Correct and Consistent Condom Use’ Program for HIV Risk Reduction-Laura Campbell

This paper will examine, from a social science perspective, the "A, B, C" campaign for HIV transmission risk reduction. This campaign, developed and mandated by the U.S. government, is based on a model that relies on individual intention to affect behavior and fails to account for critical behavioral, psychosocial, environmental, and cultural factors essential to the success and sustainability of a HIV prevention and control program.

The ABC campaign is based on the health belief model. It relies on the perceived susceptibility of getting HIV via sexual transmission, which leads to AIDS and, ultimately, left untreated leads to death. The campaign organizer assumes that the perception of the severity of the outcome of HIV will lead people to protect themselves against HIV by changing their behavior (not having sex), being monogamous and, as a last resort, using condoms. The problem with using this model for HIV prevention lies in the fact that one’s intention does not completely determine one’s behavior. Additionally, this model dictates that an individual can and will adopt A, B, or C because of their fear of getting AIDS and dying. The reality is that it is not that simple. Defining it solely as an individual problem narrows the scope of possible solutions – namely, A, B or C.
By looking at HIV transmission as an individual issue rather than a societal issue, the ABC campaign ignores key factors that play a role in HIV prevention. Stigma surrounding the disease, communication and access to prevention information and techniques are all important factors that are not considered in the ABC campaign. It also does not consider how the society views the disease in relation to rational decision making. The ABC campaign relies on the notion that people make rational decisions when engaged in relation to sexual behavior; this is often not the case. Promotion of A, B, or C targets an individual’s intention and rational behavior and it fails to take into account key social and culture issues regarding the sexual and reproductive health needs of the target population.

Sexual Independence
Sexuality and sexual roles are dramatically different across cultures in developing nations. The ABC campaign falsely implies that individuals have complete control over their own sexual behavior. For example, in many sub-Saharan African countries marriage is increasingly seen as a risk factor for HIV infection as a result of womens’ ‘lack of rights within marriage, difficulty negotiating safer sex, extended partner absence and domestic violence… 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 (1).” A married woman, in this case, does not have the chance to choose A, B, or C; therefore abstinence and faithfulness are ineffective on HIV prevention. In most marriages, abstinence is not an option for women. Wives can choose to be faithful or she may want to use a condom. However, her husband’s fidelity is typically beyond her control and the ability to negotiation condom use is likely non-existent.
Women are increasingly vulnerable to HIV as a result of their status in society, and yet by Congressional mandate the US Government channels 1/3 of all HIV prevention funding into abstinence only programs, thus making “abstinence-until-marriage advocacy the single most important HIV prevention intervention of the US Government (2).” “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 (1).” The ABC campaign does not address female vulnerability within their culture or long term relationships and does not incorporate key issues into their programs to avoid the continued rise in HIV incidence and prevalence among women.

Cultural stigma surrounding HIV is a powerful force within communities that can drive individuals who intend to adopt A, B or C, to do otherwise. A multi-country study conducted from 2001-2004 in Ethiopia, Tanzania, Vietnam and Zambia found that “more than half of people surveyed among the general population agreed with at least one of three stigmatizing ‘shame’ statements, such as feeling that people with HIV or AIDS should be ashamed of themselves. More than 65 percent agreed with at least one of four stigmatizing ‘blame and judgment’ statements, including HIV and AIDS as punishment for bad behavior.”(3) These findings have a profound effect on prevention interventions: fewer people will be tested, even fewer will go back to receive their results, many will not disclose their status to anyone (including a spouse), and few will go for treatment at an HIV clinic in fear of suspicion by the community of having HIV/AIDS. One study cited a case in which “a woman with HIV who had continued to have sexual relations with her husband without condoms and gave birth to a child without availing herself of prevention of mother-to-child transmission services – all because she feared the social consequences associated with AIDS stigma (3).”
This is a powerful illustration of the force of cultural stigma and how it can drive people to behave irrationally. The ABC approach relies on the idea that people behave in a rational fashion all the time. The premise is that if people know that they have HIV/AIDS they will take steps to avoid infecting others, and it assumes that the non-infected will take steps to stay HIV-free. Unfortunately, as shown in this study, the reality is far different. Like the woman cited in the study above, people do not behave in a rational manner regarding HIV/AIDS because of the fear of the social consequences: isolation, exclusion from social networks, insults and gossip, loss of livelihood, and poor care by providers (3). If the HIV-related stigma is so strong in a community and prevention efforts are silent on the issue, then ABC campaign will have minimal impact and the money that funded it is money wasted. Due to cultural stigma, people often do not behave rationally and, therefore, do not consider what the ABC campaign offers for prevention alternatives.
The final choice in ABC, condom use, also poses a problem for individuals in many developing nations. Condom stigma and the association between condoms and illicit sex is something that often eliminates condoms from the acceptable spectrum of HIV prevention techniques (1). Often men and women feel shame about using condoms within marriage or outside of marriage because of cultural implications regarding their virility, HIV stigma or simply because they are embarrassed to talk about it (4). Therefore, in many cases, using condoms is a cultural issue, not only an individual behavior issue. Stigma around condoms and HIV in the community silences individuals who are at risk. An individual may intend to use a condom, but they are unlikely to do so without the support of their community. The ABC campaign fails to fully promote HIV prevention by focusing solely on the individual instead of addressing both individualn and community issues in to consideration when promoting condom use.

Targeted Audience
As a result of the intense focus on sexual transmission and individual behavioral change, some important groups in communities have been overlooked. There has been a severe lack of prevention of mother to child transmission (PMCT) programs and pediatric HIV/AIDS services as a result of the regulatory mandated focus on ABC, and particularly abstinence, programs. By taking the focus and resources away from the community and directing it towards pre-sexually active or sexually active individuals, the campaign ignores key individuals in the community – women who are already infected and their unborn children. Their needs are disregarded because more time and resources are spent on those that do not yet have the disease. The ABC campaign essentially eliminates the importance of PMCT activities in favor of an individual behavior change approach focused on sexual transmission.
The ABC approach also fails to target other key audiences in the HIV/AIDS prevention spectrum, including: injecting drug users, PLHA (people living with HIV/AIDS), children, men who have sex with men (MSM), transgender peoples and others. On a blog about the recent XVI International AIDS Conference someone posted: “Greater inclusion of all groups at all levels of AIDS programming, as well as continued efforts for diverse regional conference coverage must be given greater attention in the coming years for the most effective prevention, care and treatment programs to be developed (5).” The ABC strategy does cater to some individuals that are at high risk for acquiring and/or transmitting of HIV, but it woefully fails to incorporate key people and groups and their ideas and culture into the program. Their peripheral status undermines the ABCs program objective – to prevent HIV transmission. By ignoring these key players in society and culture, the program weakens its own mandate by failing to support those who play a key role in HIV transmission.

In summary, the ABC campaign is flawed in its individually-focused directive. While the ABC campaign’s mission to reduce HIV/AIDS transmission is an admirable one, it fails to take into account key cultural factors that have significant impact. It fails to acknowledge basic human error and instinct. The results are fatal: cultural factors inhibiting women from playing a part in HIV prevention are being ignored, stigma around HIV is rampant and prevalent, and potential target audience members are ignored by current programs. The very mandate of the ABC campaign is questionable as the following statement asserts, “not only are there question marks over exactly what defines abstinence and what makes it sustainable; there is no clear evidence that it works (2).” This appears to be another example of the “perpetuation of a ‘long standing agenda regarding peoples sexual behavior’ rather than a concerted effort to reduce HIV/AIDS transmission and prevalence (2).”

1. Sinding, Steven W. Does 'CNN' (Condoms, Needles, Negotiation) Work Better than 'ABC' (Abstinence, Being Faithful and Condom Use) in Attacking the AIDS Epidemic? International Family Planning Perspectives Volume 31 , Issue 1, March 2005.
2. Cohen, Susan A. Beyond Slogans: Lessons From Uganda's Experience With ABC and HIV/AIDS. The Guttmacher Report on Public Policy. December 2003, Volume 6, Number 5.
3. HIV/AIDS Stigma: Finding Solutions to Strengthen HIV/AIDS Programs. ICRW Report. August 2006
4. Nyblade, L. et al. Disentangling HIV and AIDS Stigma Ethiopia, Tanzania and Zambia. ICRW. September 2003
5. : AIDS and Rights - A collaborative blog focused on HIV/AIDS and human rights.
6. Bankole, Akinrinola; Singh, Susheela; Woog, Vanessa; Wulf, Deirdre. Risk and Protection: Youth and HIV/AIDS in Sub-Saharan Africa. The Alan Guttmacher Institute. January 2004/
7. Boonstra, Heather Meeting the Sexual and Reproductive Health Needs of People Living with HIV. The Alan Guttmacher Institute. November 2006.
GAO Report: Global AIDS Law's 'Abstinence-Until-Marriage' Earmark Shortchanges Other Key Prevention Strategies. Guttmacher Policy Review. Spring 2006, Volume 9, Number 2
8. Singh, Susheela; Darroch, Jacqueline E; Bankole, Akinrola. A, B and C in Uganda: The Roles of Abstinence, Monogamy and Condom Use in HIV Decline. The Alan Guttmacher Institute. December 2003.

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