Commentary: Are the ABCs Simple?
AIDSLink: Issue 83 | 1 January 2004

contributed by: Various

I have a great deal of respect for the diverse and sensitive articles regularly presented in
Global AIDSLink, but I found the commentary, "The ABCs of HIV: It's Not That Simple"
by Kevin Osborne, both biased and uninformed. For example, he sets up and demolishes
"straw men" that do not correspond to reality, like, "The behavioral bias of the ABCs is
based on the assumption that individuals all have an innate and equal power to make
perfectly correct decisions about every issue in their sexual and reproductive health
lives." Indeed, the ABC building blocks of a comprehensive HIV program are "simple" in
concept, but no scholar or health worker that I know considers ABC as simple in practice.
But it can work both locally and nationally; there is solid documentation from Africa,
Asia and the U.S. that when communities respond to AIDS with fundamental behavioral
changes -- avoiding risk, reducing risk behaviors, and caring for people with AIDS -- the
course of the epidemic can be reversed.

Condoms do play a useful role, but proposing a condom-only strategy is vastly
oversimplifying the problems of HIV control. In the field of family planning, we learned
decades ago that simply saturating populations with contraceptives without strong social
and political support was generally ineffective and even counterproductive. Furthermore,
we learned that condoms require the greatest behavior change on the part of both
partners, and so typically contribute only about 5 to 10 percent towards fertility reduction
in most developing countries. In addition, because of difficulties even married couples
have in using condoms properly and consistently, the average contraceptive use
effectiveness is only around 85 percent. This corresponds to condom effectiveness rates
of 80 to 85 percent in reducing the risks of acquiring HIV among consistent users.

Of greatest concern, however, is the agenda that Kevin Osborne is proposing in his
conclusion: "We should put our global energies behind ensuring that sex -- coercively or
by will -- is safe and that condoms are readily available. If we can win this strategic
battle, we will make one of the most important contributions possible in fighting this
epidemic: an environment free of judgment and prejudice." Based on what he implies
earlier about accepting situations where "women...are not in a position to decide when
and what kind of sex to have," I can only conclude that he means that we are not to
"judge" coercive sex, but just keep it safe; just ensure that condoms are available
('simplistically,' assuming in this context they would be used). It seems the highest value
for Kevin Osborne is safe sexual relations under any conditions.

In reality, the foundation of the ABC strategy is human dignity and rights. As health
professionals, we are obligated to truthfully inform people of all the HIV risk factors and
preventive options, and promote compassionate caring of AIDS cases. Then, working
with the local communities, we should seek to develop societies where all people have
the freedom and security to exercise their individual choices on the basis of their personal
values without fear of coercion or stigmatization

-- W. Henry Mosley, MD, MPH
Professor, Johns Hopkins Bloomberg School of Public Health

The ABC approach is frequently criticized as being overly simplistic (e.g., "The ABCs of
HIV: It's Not That Simple" by Kevin Osborne). What critics fail to acknowledge, or even
admit to themselves usually, is that what is currently funded as AIDS prevention by the
major donors is simpler still: "Condoms, condoms and more condoms." (This, in fact, is
the title of a new paper written by Professor Doug Feldman, a dedicated and vociferous
critic of ABC). What donors currently fund under AIDS prevention are the risk reduction
approaches of condoms, with some treatment of STDs and VCT added. What they do not
fund are parallel programs of risk avoidance, also called primary behavior change, i.e.,
abstinence, delay of debut, and mutual faithfulness to one partner.

Risk reduction alone is far simpler than risk avoidance plus risk reduction.

The truth is, for all our enthusiasm about stigma reduction, empowerment of women,
poverty reduction, political activism and the like, when it comes down to it, what the
donors fund in AIDS prevention is pretty much reduced to condoms. The preventive
target of most VCT programs is to get more people to use condoms, whatever their HIV
status. The only program impact indicator currently proposed for the United Nations
General Assembly Special Session on AIDS for behavior change is condom use during
last intercourse, period. And this is for youth!

Even if the ABCs were simpler than the prevention programs donors currently fund,
simplicity does not necessarily mean ineffective. After centuries of trying everything
imaginable to deal with alcoholism, the program of Alcoholics Anonymous was
accidentally invented by a couple of amateurs in 1939. It's based on simply not drinking.
It has been more successful than all the other programs around the world for centuries. If
the AA program had been a proposal that had to be approved by an academic or
government committee of some sort, no doubt it would have been rejected as being
overly simplistic. Cure alcoholism by stop drinking alcohol? Is this some sort of joke?

AA likes to poke fun of the experts by saying that AA "is a simple program for
complicated people."

Of course there is more to AA than not drinking. But nothing else works if one doesn't
stop drinking, just as prevention of sexually transmitted HIV doesn't work unless there is
change at the level of the proximate determinants of HIV infection (avoiding the
exposure to risk, reducing the risk of exposure, or blocking the efficiency of transmission
risk).

At the end of his essay, Kevin Osborne suggests, "We should put our global energies
behind ensuring that sex -- coercively or by will -- is safe and that condoms are readily
available. If we can win this strategic battle, we will make one of the most important
contributions possible in fighting this epidemic: an environment free of judgment and
prejudice. In this way, we can make choice a concept that has meaning."

This is one of the purest and most naive expressions of Western, urban, post-sexual
revolution values I have come across in months. These values are sure to clash with those
of rural Africans. More importantly, in societies where rape, seduction of minors and
coerced sex is common, the promotion of free sexual expression by outside experts might
well exacerbate these problems.

Does Osborne mean we are not to "judge" coercive sex, even rape? Does he mean if a
man chooses to force an underage girl into sex, its fine so long as the man remembers to
use a condom? Even if we cared nothing about human rights, the dignity of women, legal
ramifications or morals, we would still expect the abused girl to have only an 80%
reduced risk of HIV infection, compared to if a condom was not used, if the latest
Cochrane meta-analysis of condom effectiveness is any guide. An "anything goes"
hedonistic philosophy assisted by latex is not enough to combat AIDS, especially in
developing countries where women have little power.

-- Edward C. Green
Harvard School of Public Health