What is the ABC model of HIV prevention?The ABC approach to HIV/AIDS prevention in its basic form suggests that public health work in prevention, education, and health promotion around HIV transmission should take a three pronged approach, emphasizing abstinence, monogamy, and condom use.
Definitions of the ABC approach vary. There are at least two different definitions of the ABC approach, and the differences are crucial.
UNAIDS defines ABC as including information on:
- Abstinence or delaying first sex
- Being safer by being faithful to one partner or by reducing the number of sexual partners
- Correct and consistent use of condoms for sexually active young people, couples in which one partner is HIV-positive, sex workers and their clients, and anyone engaging in sexual activity with partners who may have been at risk of HIV exposure.
The President's Emergency Plan for AIDS Relief (PEPFAR) which legally requires adherence to an ABC model, defines ABC as:
- Abstinence for youth, including the delay of sexual debut and abstinence until marriage
- Being tested for HIV and being faithful in marriage and monogamous relationships
- Correct and consistent use of condoms for those who practice high-risk behaviors.
The crucial difference in these definitions is that the US definition does not allow information about condom use for young people, or to anyone who isnt identified as practicing high-risk sexual behaviors.
Do ABC models work to prevent HIV transmission?This is a difficult question to answer with any certainty. ABC is just a catch phrase, and most programs include information on abstinence, monogamy, and condom use. Every ABC program is slightly different.
Those who claim that the ABC model works often point to the success of HIV prevention in Uganda in the 1990s.
As a result of progressive leadership, there was a broad and powerful response to the spread of HIV in Uganda. The government started and supported programs that included public awareness media campaigns, training teachers to provide HIV/AIDS education, and getting community leaders and religious leaders involved in the spread of information and education about HIV/AIDS. They didnt stop there. They encouraged a variety of social initiatives including bettering the status of women, fighting stigma of HIV, improving testing facilities across the country, and providing better care for people already infected. Importantly, there was also a dramatic increase in the distribution and use of condoms. The result was a decrease in HIV transmission rates.
While it is impossible to give the credit to any one of these initiatives, it seems clear that a broad and multi-faceted approach to HIV prevention can have a positive impact on transmission rates.
According to Avert, a UK based HIV/AIDS charity, there is no evidence to suggest that the term ABC was ever used in Uganda, and the current ABC model differs in significant ways from the Ugandan approach.
Why is the PEPFARs ABC program controversial?There is almost unanimous agreement among those who work in public health around HIV/AIDS that individuals should be educated about the range of options to reduce HIV transmission, including abstinence, monogamy, and the correct use of condoms.
However in practice the U.S. approach is fraught with problems, as it seems guided more by political and religious ideology, than by science and experience. Some of the key problems with the PEPFAR program include:
- PEPFAR legally requires countries and organizations to spend specific amounts on abstinence and monogamy programs, which mean that other programs get cut. A recent report by the US Government Accountability Office (GAO) found that important prevention programs, including prevention of mother-to-child transmission of HIV, have been cut to satisfy the requirement to promote abstinence.
- Promoting being faithful and monogamy is misleading and misguided, as being in a monogamous relationship does not protect you from HIV transmission. A 2001 study published in the journal AIDS found that the risk of HIV was actually greater in women who were married compared with those who were unmarried, particularly for women younger than 25. Thomas J. Coates, professor of medicine in the Division of Infectious Diseases at UC Los Angeles, also points out that the majority of young women in sub-Saharan Africa acquire HIV through steady partners or spouses.
- Abstinence programs in the US have been found to be both ineffective, and riddled with factual errors. Abstinence is also of little usefulness in the face of sexual violence. While information about abstinence should be included in HIV prevention programs, placing greater importance on messages of abstinence and monogamy is unrealistic, and simply doesnt help the people these programs are intended to help.
There is no current evidence to suggest that the ABC program the US government has adopted is effective. And a recent GAO report suggests that the program is causing significant problems for public health workers on the ground.
- U.S. State Department, ABC Guidance.
- United States Government Accountability Office, Global Health Spending Requirement Presents Challenges for Allocating Prevention Funding under the Presidents Emergency Plan for AIDS Relief , April 2006.
- Glynn, JR; Caraeel, M; Auvert, et. al. Why do young women have a much higher prevalence of HIV than young men? A study in Kisumu, Kenya and Ndola, Zambia AIDS, 15(4), Aug 2001.
- Thomas J. Coates, San Francisco Chronicle, Science vs. Assumption in Public Health Policy: Abstinence alone not the answer, May 25, 2004.