ABC…if it were only that simple. October 30, 2007

In preparing for my work with AEGY, the past months have been full of reading books, journals, and articles about HIV/AIDS education and prevention. Below is what I’ve learning- so if not interested in healthcare and HIV/AIDS, the following may be a bit drab- consider yourself warned!

If you’re at all familiar with the topic of HIV/AIDS prevention, then the letters ABC should ring as bell as they are the current foundation of many current prevention methods. As I’ve read, I’ve soaked up a bunch of knowledge; here in Kamuli, living and working with people who are HIV+, I’ve seen reality. I will try my best to explain the ABC approach and offer my critiques of it as I go- and of course, I must emphasis that this is strictly my perspective- I am not an expert nor years of experience under my belt- so take all that I say with a grain of salt.

The ABC approach to HIV/AIDS prevention is based upon three core public health teachings- A stands for abstinence (delay of sexual debut- geared towards youth), the B for be faithful (fidelity in relationships- focus on adults), and C is for condoms (correct and consistent use- with message directed at high risk/vulnerable populations). All elements of ABC are necessary, the emphasis of which method of prevention is based upon the targeted population. It is important to mention that this approach encompasses much more than just ABC- if it were this simple to prevent the spread of HIV, there wouldn’t be nearly so many heart wrenching stories of those affected. ABC also includes the following areas: voluntary counseling and testing (VCT), treatment of STDs, opportunistic infections, and HIV (with antiretroviral drugs), destigmatization of people living with AIDS (PLWA), reduction of poverty, increased political openness, effects of gender inequalities (increase in women’s status and education, violence, discrimination in sexual behavior).

The American funded, PEPFAR (President’s Emergency Plan for AIDS Relief) initiative has adopted the ABC method as its prevention focus and has received much criticism worldwide. Those from the religious right are upset that condoms are being encouraged and those on the left claim that there is too much emphasis on abstinence. Each side has their views and their own statistics to back it up and yet, from the general perspective here in Kamuli, ABC seems to be quite sufficient in educating the public, especially youth, on how to protect themselves from infection.

Placing too much emphasis on only one letter is to neglect the needs of the others- for example, if only the C is focused upon, HIV would continue to spread rapidly in Uganda as many of the cases of transmission are a result of infidelity with multiple partners in rural places where accessing condoms is virtually impossible. Besides, culturally speaking, advocating the use of condoms is absurd. For condoms to be effective (mind you, only 80-90% effective) in preventing the transmission of HIV, they must be used consistently and correctly which again, is unlikely due to the environment that is rural Uganda. Also with too much emphasis on C, a community is vulnerable to risk compensation- condom promotion can lead to greater sexual risk taking which is a result of a perception of reduced risk making the risk taking seem more attractive (sort of like wearing a seat belt makes you feel safer when driving a car and therefore you’re more likely to speed). Of course, though, encouraging the use of condoms to those individuals who are at risk is extremely important and mustn’t be ignored. It’s a matter of risk reduction opposed to risk elimination (A and B).

Often in literature, Uganda is praised for its early efforts in combating the AIDS epidemic with this approach. The government was quick to admit that there was a problem and openly addressed sexual behavior (interestingly enough, many Ugandans I’ve encountered believe that their leaders responded so promptly to HIV/AIDS was because that a majority of the military was becoming infected- if the government didn’t act, there would be no army left- just one thought…). Much of Uganda’s success is attributed to letter B- being faithful. Ugandans were bombarded with messages of “zero-grazing” and “love faithfully”- with much focus being upon men. It is quite common to attend an AEGY support group and find it mostly comprised of women. Women are not ashamed to admit their status, as many were infected by their husbands. These women abstained from sex until marriage, were faithful to their spouse and but still were infected- unfortunately by the infidelity of their partners.

As a bit of an aside, I’ve been learning about laws here and thought it appropriate to share a few pertaining to this topic. Interestingly, here in Uganda, homosexuality and underage sex are both illegal. According to Ugandan law, sexual responsibility for males is at age 14 and for women, age 18 (note the difference between genders!). This means if a teenage girl becomes pregnant and is under the age of 18, her partner, if over the age of 14, is arrested, fined, and imprisoned. Abortion is illegal as well, leading to many to seek the procedure in unsafe rural clinics performed by untrained lay people. Clearly, these laws effect the youth of Uganda and need to be considered in prevention efforts.

Factors like poverty, illiteracy, instability, displacement, gender disparities all are present and very real here in Kamuli making any prevention strategy difficult to implement. Nothing is ever as simple as ABC…