Commentary: ABC or A through Z?
AIDSLink: Issue 81 | 1 September 2003

contributed by: Edward C. Green, PhD, Harvard Center for Population
and Development Studies

Readers of Global AIDSLink have long known about the ABC approach
to AIDS prevention: Abstain, Be faithful, or use a Condom. Readers
also know that Uganda did not invent this; they only implemented the
ABC approach in an especially effective way. In the past few months,
Uganda's ABC approach has become the model for AIDS prevention for
the Bush administration, at least for the countries where the
President's HIV/AIDS Initiative will be targeted. The House and Senate
AIDS bills make specific reference to Uganda's ABC model, and I am
one of the experts who testified about this model in both houses of
Congress. In my opinion, the main thing Uganda did right was to
implement a balanced program of the ABCs, and to actually include all
three elements.

Still, there is a great deal of controversy surrounding HIV prevalence
decline in Uganda. Few other countries have addressed sexual
behavior directly, preferring instead to follow the prevailing risk
reduction model of condom promotion and STI treatment. Another
sensitive issue is that HIV incidence peaked and began to decline in
Uganda before the programs most of us associate with AIDS
prevention (condom social marketing, VCT, treatment of STIs) had
even begun. For these and other reasons, critics have tried everything
from denying there ever was a prevalence decline in Uganda, to
dismissing the ABC approach as simplistic or inadequate. I will deal
with this latter criticism.

Those who complain that ABC is simplistic or reductionistic suggest
that we ought to be doing everything to prevent AIDS: A, B, C, D (for
Drugs, or De-stigmatizing AIDS), E (for Equal opportunity)...all the
way to Z (for Zero misbehavior?). I have noticed that some of the
proponents of "A through Z" or "let's do everything" have trouble
accepting the first two letters of ABC, so maybe the real idea is to bury
or dilute these in every letter of the alphabet.

It is useful to distinguish between the direct and indirect factors that
determine sexually transmitted HIV infection. While the former have to
do with sexual intercourse itself, the indirect factors include things like
political leadership, reducing AIDS-associated stigma and improving
the status of women. I hear people say that the real reason prevalence
declined in Uganda is because of President Museveni's bold leadership,
or because sex became a topic that could be discussed in public. But
we might find political leadership or open discussion elsewhere, and
still not necessarily find any impact on HIV infection rates. The sexual
transmission of HIV can be directly prevented in three ways: by
avoiding the exposure to risk through sexual abstinence; by reducing
the risk of exposure through partner faithfulness and reduction in
partners; or by blocking the efficiency of transmission risk through a
barrier like a condom. In other words, by practicing A, B or C.

The genius of Uganda's ABC program is that it focuses on what
individuals themselves can do to change (or maintain) behavior, and
thereby avoid or reduce risk of infection. And it provides three types of
behavioral options in a clear, unambiguous and, yes, simple manner.
The ABC message has gone out to the public via every imaginable
channel, and has been appropriately tailored to different groups based
on age, gender and risk categories.

But ABC is far from all that Uganda has done. In fact, the country
pioneered approaches towards reducing stigma, bringing discussion of
sexual behavior out into the open, involving HIV-infected people in
public education, persuading individuals and couples to be tested and
counseled, improving the status of women, involving religious
organizations, enlisting traditional healers, and much more. Ask
yourself, how many countries in Africa -- or anywhere else -- have
tried to raise the status of women as both a political and AIDS
prevention strategy?

If any country could be said to have promoted "A through Z" to
prevent AIDS, it's Uganda. But Uganda's message for the public was
the simple one of ABC, focusing on factors that, for the most part, are
under an individual's control. And unlike most other countries of the
world, there was true balance between ABC: it was not just condom
supply and promotion, with an occasional nod in the direction of
abstinence and mutual fidelity.

The only thing simplistic or reductionistic about Uganda's ABC
approach is how some Westerners have interpreted it.

Edward C. (Ted) Green, a medical anthropologist, is currently senior
researcher at the Harvard Center for Population and Development
Studies. His new book, Rethinking AIDS Prevention, is due out in
November.