The ABCs of HIV Prevention

Abstaining from sexual activity, mutual monogamy, and condom use are
three key behaviors that can prevent or reduce the likelihood of
sexual transmission of the AIDS virus. These behaviors are often
included together under a comprehensive "ABC" approach - A for
abstinence (or delayed sexual initiation among youth), B for being
faithful (or reduction in number of sexual partners), and C for
correct and consistent condom use, especially for casual sexual
activity and other high-risk situations.

Understanding and effectively promoting these behaviors are crucial
elements in combating the spread of HIV/AIDS. Based on a growing body
of evidence from a number of developing countries, USAID supports the
ABC approach because it can target and balance A, B, and C
interventions according to the needs of different at-risk populations
and the specific circumstances of a particular country confronting
the epidemic.

Background: The Decline of HIV Prevalence in Uganda
As one of the world's earliest success stories in confronting AIDS -
and probably the most dramatic - Uganda experienced substantial
declines in HIV prevalence during the 1990s. According to estimates
by the U.S. Census Bureau and UNAIDS, national prevalence peaked at
around 15 percent in the early 90's and fell to 5 percent by 2001.
Among pregnant women in Kampala, prevalence declined from a high of
approximately 30 percent to about 10 percent, while among pregnant
women in other areas it fell from more than 10 to less than 5
percent. Uganda's marked decline in HIV prevalence remains unique
worldwide. In other sub-Saharan African countries with epidemics of
comparable severity and longevity, similar declines have yet to
occur. Accordingly, Uganda's success has been the subject of intense
study and analysis.

It appears that Uganda's decline in HIV prevalence was associated
with positive changes in all three ABC behaviors: increased
abstinence, including delayed and considerably reduced levels of
sexual activity by youth since the late 1980s; increased faithfulness
and partner reduction behaviors; and increased condom use by casual
partners. The most significant of these appear to be faithfulness or
partner reduction behaviors by Ugandan men and women, whose reported
casual sex encounters declined by well over 50 percent between 1989
and 1995. This conclusion is supported by comparisons with other
African countries.

Uganda's successful combination of ABC strategies was rooted in a
community-based national response in which both the governmental and
nongovernmental sectors (including faith-based, women's, and other
grassroots organizations) succeeded at reaching different population
groups with different messages and interventions appropriate to their
need and ability to respond. Young persons who had not yet begun to
have sex were cautioned to wait, and if a young person had just begun
to have sex, then he or she should return to abstinence. If a person
was already sexually active, he or she should adopt the practice
referred to locally as "zero grazing" - faithfulness in marriage or
partner reduction outside of marriage. For those who continued to
engage in risky behavior, condom use was urged to reduce their risk.

Evidence From Other Countries
While Uganda provides the most dramatic example of the effect of ABC
behavior changes on slowing the spread of HIV infection, there is
growing evidence from other countries as well. In Thailand, the first
Asian country to face a serious AIDS epidemic, prostitution was the
main source of HIV infection. In the early 1990s, the government
instituted a "100 percent condom use" policy in brothels, which was
widely credited with sharply reducing the spread of HIV infection.
Between 1990 and 1995, the proportion of men reporting paying for sex
declined by more than 50 percent. In this more concentrated epidemic,
therefore, partner reduction along with condom use for commercial sex
undoubtedly had a substantial effect on slowing HIV transmission. As
in Uganda, the government's willingness to address the epidemic
openly was also essential.

Zambia, Cambodia, and the Dominican Republic are other countries in
which various combinations of ABC behavioral changes appear to have
contributed to declines in HIV prevalence. In Zambia, a decline in
prevalence seems to have occurred among urban youth during the 1990s,
during which time national surveys reported clear, positive changes
in all three ABC behaviors. The grassroots involvement of faith-based
and other community-based organizations was crucial in promoting
these changes. As occurred in Uganda, the main reported change was a
large decline in casual sex among both men and women. Cambodia is
replicating Thailand's success in applying a 100 percent condom
policy in brothels. Similar to Thailand, the country has experienced
a steep decline in the number of men paying for sex (from 27 to 11
percent between 1996 and 2000). In the Dominican Republic, partner
reduction by men and increased condom use with prostitutes and other
non-regular sexual partners also appear to have slowed the spread of
HIV.

Balancing and Targeting a Comprehensive ABC Approach
The findings of a recent extensive review of survey data are
consistent with the need for appropriately balanced and targeted ABC
approaches. This study analyzed how ABC behaviors appear to have
affected HIV prevalence in three developing countries where
prevalence declined (Uganda, Zambia, Thailand) compared to three
countries where there had been little evidence of a decline
(Cameroon, Kenya, Zimbabwe). In the case of the five African
countries, it found that significant delays in the onset of sexual
activity, declines in premarital sex, and large declines in
extramarital sex and multiple sexual partnerships occurred in Uganda
and Zambia during the 1990s, while comparable changes did not occur
in Cameroon, Kenya, or Zimbabwe. Condom use increased substantially
in all of the countries.

In September 2002, USAID hosted a meeting of technical experts from
HIV/AIDS programs and research institutions to consider the evidence
regarding ABC behavior change approaches to HIV prevention. The
meeting identified areas of consensus that may have important
implications for program planning and decision making:

There is a clear need for a balance of A, B, and C interventions.
Approaches should be combined as appropriate based on the local
cultural context as well as the state of the AIDS epidemic. In
Southeast Asia, HIV is still largely confined to high-risk
populations, in which correct and consistent condom use is relatively
easy to implement. In many African countries, the epidemic is more
generalized and thus requires an appropriate mix of A, B, and C
approaches.

Interventions need to be targeted for efficiency and respond to
crucial differences among target groups. For example, balanced ABC
approaches might be implemented in the form of A interventions
emphasizing sexual deferral to youth; B interventions promoting
fidelity or partner reduction to those not in monogamous
relationships; and C interventions promoting condom use to highly
sexually active groups, especially sex workers and their clients, as
well as people living with HIV/AIDS.
Political leadership and community involvement are key. There is a
critical need for government and community leaders to promote open
communication about the problem of HIV/AIDS, address stigma, help
empower women and girls to avoid sexual coercion, and develop a
multisectoral response to enhance the success of ABC behavior
changes.
Partner reduction is emerging as a key element of successful HIV
prevention. Amid the debate over abstinence versus condoms, partner
reduction and fidelity have been an often neglected component of
behavior change efforts. Yet, as suggested by the experience of the
very different epidemics in Uganda and Thailand, "B" could become the
centerpiece of a unifying, evidence-based ABC approach. As partner
reduction becomes an expected "normative" collective social behavior
(as seems to have occurred in both Uganda and Thailand), the impact
of B could become even more significant in many countries.
Further research is needed. Continuing studies in other countries
will yield more evidence of the most effective balance of ABC
approaches in different settings. Senegal, for example, has achieved
Uganda-like behavior change with a balanced ABC program in a low-
prevalence setting. Further study of such successes is needed to
consider their potential application elsewhere.
The USAID meeting also noted that the ABC approach to HIV prevention
has ample room for the participation of a diverse range of partners
in the global fight against HIV/AIDS. The approach helps clarify the
complementary roles of program partners in overcoming the epidemic,
and all partners - governments, international organizations, donor
agencies, faith-based and other nongovernmental organizations, and
many others - can contribute to ABC programming according to their
particular organizational orientation, capacity, and strengths. This
enhanced collaboration will serve to broaden the ABC strategy and
maximize its impact across a wide spectrum of program and national
needs.


References
Bessinger R, Akwara P, Halperin D. Sexual behavior, HIV and fertility
trends: A comparative analysis of six countries. Phase I of the ABC
Study. Washington, D.C.: Measure Evaluation/USAID, 2003.

Stoneburner R and Low-Beer D. Elements of sexual behavior change
associated with HIV prevalence declines in Uganda: Comparative
analyses of HIV and behavioural data in Uganda, Kenya, Malawi and
Zambia. Proceedings of XIII International Conference on AIDS, Durban,
South Africa, July 9-14, 2000.
Green EC and Conde A. Sexual partner reduction and HIV infection.
Sexually Transmitted Infections, Vol. 76, p. 145, 2000.
Hogle J, Green EC, Nantulya V, Stoneburner R, Stover J. What happened
in Uganda? Declining HIV prevalence, behavior change and the national
response. Washington, D.C.: USAID, 2002.

Low-Beer D and Stoneburner R. In search of the magic bullet:
Evaluating and replicating prevention programs. Leadership Forum on
HIV Prevention, Kaiser Family Health Foundation, Gates Foundation,
New York, 2001.

Shelton JD, Halperin D, Nantulya V, Potts M, Gayle HD, Holmes KK.
Partner reduction in HIV prevention: The neglected middle child
of "ABC." Manuscript in review.
USAID. The "ABCs" of HIV prevention: Report of a USAID technical
meeting on behavior change approaches to primary prevention of
HIV/AIDS. Washington, D.C.: Population, Health and Nutrition
Information Project, 2003.