Challenging Dogma

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

Friday, April 27, 2007

Don’t Ignore the C in ABC: Using Examples from Effective International Programs to Reframe Safe Sex a Public Health Issue in the US- Maiyu Fernandez

What is the ABC approach:
This is the president’s emergency plan for HIV/AIDS relief. It 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(1).
The Issue with ABC:
This program will only provide funding to country’s that will agree to meet the specific teachings for HIV Prevention. Many countries will do anything to have this funding and in turn will submit to following the ABC’s principles. The funding shapes the focus of the HIV prevention methods. Although the program is termed “ABC”, C is not emphasized nearly as much as A or B. Abstinence and/or be faithful programs that are implemented on a stand alone basis will be funded by the emergency plan (1). However, programs that include the “C” component must include information about abstinence and faithfulness to be funded. Conservatives assert that the availability of condoms had a disinhibiting effect on peoples sexual behavior (1).Marketing campaigns that simply target youth and encourage condom use as a primary prevention will not be funded by the plan (1). The ABC model does however recognize that “certain” young people will engage in sexual activity. According to the Youth Risk Behavioral Surveillance Survey, an estimated 47 percent, or nearly half of adolescents reported having had sexual intercourse (2). For at-risk populations including: youth with risky sexual behavior, sex workers, substance abusers, men who have sex with men an integrated AB and C approach is allowed to be taught.
HIV is a complex, multicultural problem with no simple answer:
HIV affects every continent in the world and can affect any individual. Between 1.2 and 1.3 million people in the US are living with HIV, many are not aware they are infected. In the continent of Africa countries such as Botswana, Lesotho, Zimbabwe and Swaziland have an HIV prevalence of greater than 20 percent (3). In east African countries (Uganda, Kenya) the prevalence of HIV exceeds 6 percent (3). For Latin America, Brazil has the highest HIV prevalence estimated at 0.67 percent. It has more than one third of the total number of HIV cases in South America. HIV is also seen in Asia. The HIV prevalence in Thailand, one of the capitals for commercial sex, is estimated at 1.4 %( 3). It must be known that HIV is not only prevalent in third world countries or in countries where sex is a commodity. HIV can even affect countries that have spent much money and time in safe sex education. Both Sweden and Denmark have a low but still meaningful prevalence rate of .2 percent (3). As seen with the statistics no one country has the solution to the HIV epidemic. With this said, each country can truly stand to learn from each other.
Denmark and Sweden’s Lesson:
Their positive view of sex and early safe sex education is a lesson that could stand to be learned by other nations. Acceptance of sexuality is a healthy and normal part of Danish life (4). Sex in Denmark does not have a stigma as it does in the United States. The stated legislative goal of sex education in Denmark for pupils is “to acquire knowledge of sexual matters as to learn to take responsibility for their own lives and to demonstrate consideration for others” (4). With the ABC program the main responsibility for people is to remain abstinent. In the United States there are moral judgments regarding sex. Thus, even if an individual has protected sex it is still stigmatized. Yet, Swedish educators believe that if young people see sexual matters as secretive or shameful they will soon believe their sexuality is wrong (5). In the ABC program sex is seen as wrong and no sex is seen as right. At the core of Swedish sex education is the sense that sex is seen as a source of joy and happiness shared with another individual and as an integral part of human life (5). Denmark’s openness to sex and sexuality has made it easier to talk about AIDS. Their national campaign conveys the message that sex is good, healthy, and beautiful but requires responsible behavior through safe sex practices (4). In Sweden each age group has a targeted sexual education topic. At 6 years old one learns about social and personal relationships, at 10 years of age one learns about the physiologic and hormonal changes that occur in a body, at 13 years old one learns about STDs, sex hormones, contraception and when one turns 16 the subjects are all repeated in much greater detail. In both Sweden and Denmark contraception and contraception counseling is readily available. All persons born or resident in Denmark are entitled to free contraceptive counseling (4). In Sweden all birth control services are free and parental consent is not required (5). Condoms are made readily available at vending machines, grocery stores and barbershops. In the United States individuals must have certain insurance and go to a specific location to receive contraception and or contraception counseling. Both Swedish and Danish educators focus on being realistic with students. There lies one of the main issues with the ABC program: the program is not realistic. Young people will engage in risky behavior and will at one point in their life have sex. That is why the program should focus on safe sexual behavior. Both Swedish and Denmark educators believe that only with realism will they be able to win over young people’s confidence (5).
A lesson to be learned from Thailand:
A country’s response to the epidemic is influenced to a great extent by the information that is made readily available. As knowledge of the risk behavior grew in Thailand the government’s willingness to alter their strategies and policies were grand. (7). Thailand has had a scientific assessment system with respect to HIV. Since the 1990’s, the Thai government has been extremely committed to the prevention of AIDS/HIV. However, it is not only their commitment that has been crucial; it is the combined commitment of all sectors in society that has made a difference. Modifications of health and social services to cope with the evolving epidemiological trends of the disease are vital to the success of HIV prevention (7). In Thailand, the public health problem quickly became a dual social and economic issue.
In the past 14 years, the spread of HIV has slowed dramatically. In Thailand, the rate of new infections had plummeted from 143,000 in 1991 to 21,000 in 2003 (3). In 1990, after a behavioral study showed the passive risk behavior of Thaïs, policy makers allowed HIV/AIDS warning messages to be publicized though all kinds of media. In 1991 the government sponsored the “100 % condom program” after realizing how large the commercial sex trade in Thailand had expanded to. This program called for cooperation from sex workers and sex establishment owners to promote condom use (7).
Recent data indicate that a large percentage of the new HIV infections are occurring in people (mostly married women) considered to be at low risk for HIV infection (8). It is hypothesized that married men have unprotected sex with commercial sex workers (CSWs) and their wives. They act as bridges between the high-risk CSWs and the general population. (7). The government has taken these numbers very seriously and is now encouraging married couples to be tested for HIV and use condoms regularly. They are also asking CSWs to act more responsibility and always use condoms The Thailand government introduces new prevention activities for HIV as fast as new information becomes available and new scientific studies are published.
Lesson from Brazil:
A combined effort of government ads, messages of empowerment and free antiretroviral medications are combating HIV. This country is home to 620,000 people living with HIV. The country’s emphasis on prevention and treatment has helped to keep its HIV epidemic stable for the past several years (8). Among Brazilians of all ages condom use has increased by almost 50% since 1998 (8).Brazil is best known for its pioneering decision in 1996 to offer free combination antiretroviral therapy to all citizens with AIDS (9). The program has improved the health and extended the survival of tens of thousands of Brazilians, and has saved the country an estimated $2.2 billion in hospital costs between 1996 and 2004 (9). In addition to the free ARV therapy, Brazil has explicitly worded government HIV-prevention message. In 2003, Brazil’s Ministry of Health launched a campaign aimed at promoting the use of condoms by adolescent women (10). One of the messages was to empower the girls and encourage them not to be ashamed to buy condoms and to demand their partners to use them. Just as Denmark and Sweden don’t stigmatize the act of sex, Brazil emphasizes that the act of buying a condom is a normal and healthy activity of daily life. Brazil is now forming a network for technology sharing with Argentina, China, Cuba, Nigeria, Russia, Ukraine, and Thailand to improve each country's capacity to manufacture medicines, condoms, and laboratory reagents needed to fight AIDS.
Can Uganda teach the nations?
In the early 1990’s Uganda achieved an extraordinary feat: it stopped the spread of HIV/AIDS in its tracks and saw the nation’s HIV/AIDS rate plummet. Many attribute its success to the ABC approach. However, it is not possible to make a direct causal link between the changes that took place in Uganda and the policies or programs that may have caused them to happen (11). As a Harvard medical anthropologist noted “ABC is far from all that Uganda has done”, “Uganda reduced the stigma of Aids, brought sex behavior out for discussion, let HIV infected people attend public education, and improved the status of women…” There were many factors involved in Uganda’s success. Abstinence was not the sole solution to the problem. Contrary to assertions from social conservatives there is no evidence that abstinence only educational programs were even a significant factor for Uganda between ‘88 and ‘95 (11).
HIV prevalence in Uganda which has been looked at worldwide as a success story is now beginning to increase (11). The increase in HIV prevalence in Uganda is being fueled by complacency, as well as decreased intensity of prevention programs, funding, and political commitment (11). For many countries gender inequity is a powerful factor in the spread of HIV. Gender norms create inequality between the sexes in power and well being, typically to the disadvantage of women (12). The importance of including gender related interventions is a lesson to be learned from Uganda, where policies to advance women’s status were part of the ABC strategy (12). A main focus besides abstinence in the ABC approach should be deciphering gender norms. To be effective in the long term, programs must work to transform the gender norms that make women subordinate to men and encourage men to take risks in the name of masculinity (12).
There is no one solution to the HIV epidemic. The ABC program is not the only approach and certainly not a solution by itself. However, the examples of successful HIV control programs presented above had one thing in common; a strong government commitment. The spread of HIV has been minimal in Denmark and Sweden where early sex education, access to condoms and a belief that sex is part of health adolescence has helped shaped effective prevention polices for all sexually transmitted diseases. The government of Thailand has decreased the spread of HIV dramatically by showing commitment to fight HIV/AIDS and building its HIV prevention programs based on scientific–evidence. Like Thailand, Brazil too has been successful due to strong government commitment and universal access to condoms as well as care and treatment for people living with AIDS. Finally, Uganda’s success had as much to do with government commitment and gender equality as it did with being faithful.
The ABC campaign assumes abstinence will allow young women to focus on going to school, controlling their relations, and becoming empowered and yet it fails to acknowledge the social circumstances driving sex in the first place (12). Emphasis on abstinence does not help prevent the spread of HIV; it simply may delay first contact. For example, studies show that many young women in Swaziland abstain from sex until their late teens but once they have sex they encounter high risks of becoming HIV positive (8). The effectiveness of abstinence as a long term strategy was also refuted by a study done by the American Psychological Society that reported that the virginity pledge was broken by more than 60 percent of the pledgers, and 55 percent admitted to engaging in risky forms of non vaginal sex (13).
To be effective in the long term, programs must also work to transform gender norms that make women subordinate to men and encourage men to take risks in the name of their masculinity (12).
The lack of emphasis on condom use in the ABC campaign, for all types of individuals, hurts prevention efforts. Condom stigma still exists, and this taboo must be removed. By promoting condoms as part of a standard package of prevention, condoms can begin to be destigmatized and normalized (12). The male latex condom is the single most effective available technology to reduce the sexual transmission of HIV and other STDS (13).
Whatever the difficulties of condom promotion, this approach must be used to best advantage. There are not so many weapons against Aids that we can forgo any, nor is any so effective that it makes the other superfluous (14).
1. Department of State. ABC Guidance #1. Washington D.C.: The President’s Emergency Plan for AIDS Relief, 2005.
2. Centers for Disease Control website.
3. A UK and AIDS Charity.
4. David H. United States and Denmark: Different Approaches to Health care and Family Planning. Studies in Family Planning 1990; 21: 1-19.
5. Boethius C. Sex Education in Swedish Schools: The facts and The fiction. Family Planning Perspectives, 1985; 17: 276-279.
6. Brown P. The Swedish approach to Sex Education and Adolescent Pregnancy: Some Impressions. Family Planning Perspectives, 15; 1983:90-95.
7. Phoolcharoen W. HIV/AIDS Prevention in Thailand: Success and Challenges. Science; 280; 1998:1873-1874.
8. UN AIDS and WHO. AIDS Epidemic Update. Geneva, Switzerland: UN AIDS, 2006.
9. Okie S. Fighting HIV- Lessons from Brazil. The New England Journal of Medicine, 2006; 354:1977-1981.
10. Porto MP. Fighting Aids among adolescent women: effects of a public communication campaign in Brazil. Journal of Health Communication, 1996; 5:100-103.
11. Munnabi G. HIV/AIDS: Uganda Slides Back. Ultimate Media Consult.Nov 27, 2006.
12. Murphy E. Was the “ABC” Approach responsible for Uganda’s Decline in HIV? Plos Medicine 3; 2006:1443-1447.
13. Sinding S. Does CNN work better than ABC in attacking the AIDS epidemic? International Family Planning Perspectives 2007; 31:38-40.
14. Hearst N and Chen S. Condom Promotion for AIDS Prevention in the Developing World: Is it working? Studies in Family Planning 2004; 35:39-47.

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