The ABC Approach

Preventing the Sexual Transmission of HIV

• The ABC Approach to Prevent Sexual Transmission of HIV
• The Decline of HIV Prevalence in Uganda
• Addressing the Context for HIV Infection

	A USAID program in Senegal targets high-risk groups such as, fish sellers, to receive information about HIV/AIDS. Source: Richard Nyberg/ USAID/Senegal

Abstinence from sexual activity, being faithful to a single partner, and correct and consistent condom use are three key behaviors that can prevent or reduce the likelihood of sexual transmission of HIV, the virus that causes AIDS. The balanced promotion of all of these behaviors is commonly known as the “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.

The ABC Approach to Prevent Sexual Transmission of HIV

An increasing number of countries — including Uganda, Thailand, Kenya, Cambodia, Zimbabwe, India, Rwanda, Ethiopia, Dominican Republic, and Haiti — have experienced national or subnational declines in HIV associated with the widespread adoption of “A,” “B,” and/or “C” prevention behaviors.^1–2

In lower-prevalence epidemic settings, where infections are concentrated among high-risk populations, the declines were associated with the implementation of targeted, evidence-based prevention efforts to reduce HIV risk in these populations.^3–5 In high-prevalence epidemics that are primarily sustained by sexual transmission of HIV in the general population, it has been more difficult to assess the contribution of specific program efforts because HIV risk was likely reduced through a wide variety of influences that increased risk perception and produced population-level changes in sexual behavior.⁶

HIV prevention efforts are complicated by the fact that the global pandemic is rooted in different causes in different settings. To prevent the sexual transmission of HIV, the U.S. Government, through the U.S. President’s Emergency Plan for AIDS Relief, supports the ABC approach because it can be used to target the sources of the most new infections in a given population while still being tailored to meet the specific needs of the most at-risk or vulnerable individuals.

Fundamental to this approach is the recognition that different settings will also feature different barriers to the adoption of ABC behaviors. Prevention programs must therefore be developed in collaboration with the communities they serve and must, in addition to promoting individual behavior change, address the social norms, environmental factors, and policies that contribute to new HIV infections.

For instance, in May 2006, the Southern Africa Development Community — an alliance of several countries in Southern Africa — convened an expert think tank meeting to identify and mobilize key regional priorities for HIV prevention. The meeting report characterized multiple and concurrent sexual partnerships as central drivers of the HIV/AIDS epidemic in the Southern Africa region. They recommended that priority be given to interventions that:

• reduce the number of multiple and concurrent partnerships;
• address male involvement;
• increase consistent and correct condom use; and
• continue programming around delayed sexual debut

The Decline of HIV Prevalence in Uganda

As one of the world’s earliest — and probably most dramatic — success stories in confronting AIDS, 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 ‘90s and fell to 6.5 percent by 2004. 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 (figure A).^7–10 Uganda’s marked decline in HIV prevalence remains unique worldwide. In most other sub-Saharan African countries with epidemics of comparable severity and longevity, similar declines have yet to occur (although promising trends have been observed in a small but growing number of other countries). 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 sexual activity 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 and partner reduction behaviors by Ugandan men and women, whose reported casual sex encounters declined by well over 50 percent in World Health Organization surveys conducted in 1989 and 1995 (figure B).^7–10 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 needs and abilities to respond.^{8, 10–11} 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, he or she was urged to return to secondary abstinence. If a person was already sexually active, he or she was urged to 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 encouraged to reduce their risk.

High-Risk Sexual Networks: The Danger of Multiple and Concurrent Partnerships

This image of thousands of overlapping and interconnected tree branches growing outward in every direction visually illustrates what evidence suggests: In high-prevalence epidemics, a substantial portion of new HIV infections are produced by sexual networks — that is, concurrent and multiple sexual partnerships. One reason for this is that the burden of HIV goes up dramatically during the first three to four weeks of infection. It also rises during the late stages of HIV infection and progression to AIDS (although not to the same dramatically high level as during early infection), making transmission of HIV to an uninfected partner 10 to 100 or more times greater during these periods.12–15

Addressing the Context for HIV Infection

The Vulnerability of Women and Girls
Promoting behavior change entails addressing the social norms and environmental characteristics that might prevent individuals from protecting themselves. Therefore, it is important to recognize that the proper implementation of the ABC approach extends far beyond simply advocating for “A,” “B,” and “C.” For example, in many countries, young girls, and women are particularly vulnerable to HIV infection because of existing norms favoring cross-generational sex. Infection rates among young girls are often many times higher than those among their male peers, and infection rates among older men are commonly higher still, making them particularly risky partners. To reduce the infection risks faced by these young girls, programs that attempt to address these norms and particularly target the attitudes and behaviors of their older male partners may help make the promotion of the ABCs of behavior change more feasible and effective.

The ABC Approach Works: Evidence From Other Countries
While Uganda provides one of the most dramatic examples 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 (figure C). In this more concentrated epidemic, therefore, partner reduction along with condom use for commercial sex undoubtedly had a substantial effect on slowing HIV transmission.3–4 As in Uganda, the government’s willingness to address the epidemic openly was also essential. Kenya, 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 Kenya, there has been a marked decline in prevalence in recent years,1 during which time national surveys have reported clear, positive changes in sexual behavior (figure D). Cambodia is replicating Thailand’s success in applying a 100 percent condom policy in brothels. Also similar to Thailand, the country experienced a steep decline in the number of men paying for sex (from 27 to 11 percent between 1996 and 2000).4–5

Growing Consensus Around Partner Reduction
In 2006, USAID co-chaired with UNAIDS an Expert Consultation on Behavior Change in the Prevention of Sexual Transmission of HIV. The consultation was the result of ongoing technical conversations between the Agency and UNAIDS about the need to make behavior change programming a central focus of global efforts to intensify HIV prevention efforts. With the participation of more than 30 global experts on HIV prevention, the consultation highlighted a growing scientific consensus that a comprehensive response — one that includes abstinence, being faithful, and correct and consistent use of condoms as key behavior objectives — is essential to curtail the continued spread of HIV. Participants identified four key priority areas for action and evaluation:

• Addressing the norms of multiple and concurrent sexual partnerships that appear to serve as key drivers of the world’s highest-prevalence HIV epidemics in southern Africa;
  
  
• Addressing the dynamics of gender inequality that sustain high levels of sexual risk for both women and men and impede the adoption of prevention behaviors;
  
  
• Overcoming the role that stigma plays in limiting access to HIV prevention efforts and in causing individuals to treat HIV as “someone else’s problem;” and
  
  
• Intensifying the quality and coverage of HIV prevention efforts in high-risk context and populations in concentrated epidemic settings in which HIV infection risk is limited in the general population but is high in specific and often marginalized subpopulations.

References:

1. Hallett TB, Aberle-Grasse J, Bello G, Boulos LM, Cayemittes MP, Cheluget B, Chipeta J, Dorrington R, Dube S, Ekra AK, Garcia-Calleja JM, Garnett GP, Greby S, Gregson S, Grove JT, Hader S, Hanson J, Hladik W, Ismail S, Kassim S, Kirungi W, Kouassi L, Mahomva A, Marum L, Maurice C, Nolan M, Rehle T, Stover J, Walker N. Declines in HIV prevalence can be associated with changing sexual behaviour in Uganda, urban Kenya, Zimbabwe, and urban Haiti. Sex Transm Infect. 2006 Apr; 82 Suppl 1: i1–8.
2. Shelton JD, Halperin DT, Wilson D. Has global HIV incidence peaked? Lancet. 2006 Apr 8; 367(9517): 1120–2.
3. Celentano DD, Nelson KE, Lyles CM, Beyrer C, Eiumtrakul S, Go VF, Kuntolbutra S, Khamboonruang C. Decreasing incidence of HIV and sexually transmitted diseases in young Thai men: evidence for success of the HIV/AIDS control and prevention program. AIDS. 1998 Mar 26;12(5): F29–36.
4. Cohen J. Two hard-hit countries offer rare success stories. Science 2003 Sept 19; 301(5640): 1659–1662.
5. Saphonn V, Parekh BS, Dobbs T, Mean C, Bun LH, Ly SP, Heng S, Detels R. Trends of HIV-1 seroincidence among HIV-1 sentinel surveillance groups in Cambodia, 1999–2002. J Acquir Immune Defic Syndr. 2005 Aug 15; 39(5): 587–92.
6. USAID. The “ABCs” of HIV prevention: Report of a USAID technical meeting on behavior change approaches to primary prevention of HIV/AIDS. Washington, DC: Population, Health and Nutrition Information Project, 2003.
7. 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, DC: MEASURE Evaluation/USAID, 2003.
8. Stoneburner R, Low-Beer D. Population-level HIV declines and behavioral risk avoidance in Uganda. Science 2004; 304: 714–18.
9. Green EC, Halperin DT, Nantulya V, Hogle, J.A. Uganda’s HIV prevention success: The role of sexual behavior change and the national response. AIDS and Behavior. 2006 July; 10(4): 335–346.
10. Low-Beer D, Stoneburner RL. Behaviour and communication change in reducing HIV: Is Uganda unique? African J AIDS Research, 2003; 2:9–21.
11. Wilson D. Partner reduction and the prevention of HIV/AIDS. BMJ.
    2004 Apr 10; 328(7444): 848–9.
12. Hayes R, Weiss H. Epidemiology. Understanding HIV epidemic trends in Africa. Science 2006 Feb 3; 311(5761): 620–17.
13. Hudson CP. AIDS in rural Africa: a paradigm for HIV-1 prevention. Int J STD AIDS. 1996 Jul; 7(4): 236–43.
14. Koopman JS, Jacquez JA, Welch GW, Simon CP, Foxman B, Pollock SM, Barth-Jones D, Adams AL, Lange K. The role of early HIV infection in the spread of HIV through populations. J Acquir Immune Defic Syndr Hum Retrovirol. 1997 Mar 1; 14(3): 249–58.
15. Galvin SR, Cohen MS. The role of sexually transmitted diseases in HIV transmission. Nat Rev Microbiol. 2004 Jan; 2(1): 33–42.

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November 2008