Challenging Dogma - Fall 2008

Wednesday, December 17, 2008

The ABC Approach to HIV/AIDS Prevention: How Anthropology, Political Science and Sociology Point to Interesting Flaws in the Approach- Kate Mitchell

The ABC approach is well known for its brilliant success in significantly reducing HIV/AIDS in Uganda from 1991 to 2001. The approach consists of three main messages: Abstain from having sex until marriage, be faithful, and if all else fails, use condoms. In a ten-year period under this strategy, HIV infection rates in Uganda fell from 15 percent to 5 percent. Perhaps even more striking was the decline in HIV among pregnant women. “In Kampala, the country’s capital, HIV among pregnant women dropped from 30 percent to 10 percent”(Lopez, 1). Uganda has been widely celebrated for achieving such striking reductions.

With numbers like these, it is no wonder the ABC approach has generated a faithful following of politicians, policy makers, clinicians and public health professionals. With HIV/AIDS prevalence in Africa rising at an alarming rate, many are eager to follow in Uganda’s footsteps and adopt the ABC approach to HIV prevention. Many believe that Uganda’s, “standout results [from the ABC campaign] present a model for attacking the African pandemic”(Lopez, 1).

Not so fast. There is another side to this story. A body of critics, also made up of politicians, policy makers, clinicians and public health professionals, has been very vocal about their opposition to the ABC approach. A quick internet search brings up article after article questioning (if not outright denying) the benefits of the ABC method of HIV prevention. They have bold titles such as, “Abstinence programmes do not reduce HIV prevalence in Uganda,” “Uganda’s HIV rate drops, but not from abstinence” and “Uganda’s war on AIDS: Candor more crucial than abstinence, officials say.” Some critics have argued that reductions in Uganda are clearly attributable to other causes that are not so easily reproduced. Others point out that aspects of the program are effective while others are not. Yet others have bones to pick with how the program has actually been implemented. The critiques go on and on.

With such competing views, and HIV rates climbing, key players in the field of International Health have some interesting and tough decisions to make. The question remains: Should this approach be applied elsewhere? Should ABC serve as the gold standard for HIV/AIDS prevention throughout Africa and beyond? Or, could the critics be right? While ABC seems to have yielded extraordinary results in Uganda, can we even be certain that the drops in HIV prevalence are direct results of ABC programming? If the results are directly related, will the approach work elsewhere? Will it even continue to work in Uganda? Should we also consider if the approach is flawed in very fundamental ways?

Using three separate social science fields to examine the ABC approach and the impact it did (or did not) have on Uganda, provides interesting insight into the shortcomings of an approach focused exclusively on abstinence, fidelity and condoms. By utilizing various social sciences to analyze the ABC method, we go beyond infectious disease epidemiology and biostatistics. We also step beyond the conversation of morality and faith that so often dominates the debate of abstinence focused interventions. Through the frameworks of Sociology, Anthropology and Political Science the discussion shifts to issues of gender roles, culture, leadership, social mobilization, power and influence.

Sociology

Sociology is the study of individual behavior within society. It can also be defined as the “study of companions or associates.” When considering ABC methodology from a sociological perspective, gender issues cannot be ignored. In sociology, human behavior is often predicted by the role the individual plays within their society, their community or even their relationship.

The ABC approach does nothing to address the social inequity between men and women in many parts of Africa and the role that women tend to play within relationships. The approach assumes that abstinence, fidelity, and condom-use can be negotiated equally by men and women when in fact they cannot. The following statement clearly illustrates the lack of negotiating ability women often feel: “Abstinence is not an option for a girl married at 13 in Uganda, for the woman whose husband beats her regularly, or for the girl who is raped on her way to get water in Botswana. Men are the only ones who can abstain in these circumstances”(Marton, 2). This lack of negotiating power that women feel in their relationships is also true in terms of fidelity. Alarmingly, married women have one of the fastest growing HIV rates. Marriage is actually beginning to be thought of as a risk factor for HIV in many parts of the world. While a woman may choose to be faithful, she has little to no say in whether her husband makes the same choice (NPR). Condom-use is also difficult and often impossible for women to negotiate in settings where their roles are subordinate. Simply telling the population to choose abstinence until marriage, be faithful to one partner, or use condoms is inadequate when women do not have the ability to adopt these behaviors (assuming they were convinced to do so) because of the social situations in which the women live. Gender inequities put women at greater risk of HIV/AIDS and from a sociological perspective, consideration of these inequities in society are fundamental to the success of a prevention program.

Anthropology

Anthropology is the study of human behavior within a cultural context. This discipline has a strong focus on, “the role that culture plays in what people, groups and societies do”(Edberg, 73). An analysis of ABC strategies for preventing HIV/AIDS from an anthropological perspective demands consideration of the, “complex whole that includes knowledge, belief, art, morals, law, customs, and any other capabilities and habits acquired by man as a member of society”(E.B Tyler). The idea of using the ABC approach across the board as a universal method for preventing HIV/AIDS fails to consider many aspects of culture and the specific contexts in which people live and make health behavior decisions. In a course on Reproductive Health in Disaster Settings taught at Boston University’s Summer Institute, Monica Onyongo talked about some of the problems with an ABC approach to HIV prevention in relation to culture. She talked about parts of Kenya where polygamy is a cultural norm and posed the question: How do you ask a man with 3 wives to be faithful to any one of them? Monica also talked about the tradition in parts of Kenya for men to marry their sister-in-law if their brother dies. This cultural norm poses a very interesting challenge for Public Health professionals, especially in settings where chances are that the brother died of AIDS. An approach to HIV prevention based on abstinence, fidelity and condoms does not even begin to consider these cultural practices and ignoring these practices in prevention efforts leads to catastrophic consequences.

Political Science

At the core of political science thinking is the study of human behavior in relation to the exercise of power and influence (Fairbanks, 1). An analysis of the HIV/AIDS pandemic and the ABC approach from a political science perspective explores the political climate in which the problem exists. This sort of analysis also relies on the following questions: Who are the political leaders involved? What level of power do they have? What level of influence do they have? In the case of Uganda, 2 political leaders (among others) have played very significant roles.

In the early years of the AIDS epidemic in Uganda, President Museveni played a strong and influential role in creating awareness about HIV/AIDS. “At a time when many African leaders were in denial about AIDS in the 1980s, said Green, Museveni spoke to crowds through a bullhorn, stating point-blank that they would die unless they changed their behaviors” (Cohen,1). President Museveni heavily promoted early sex education, mutual respect in relationships, female autonomy, abstinence before marriage, fidelity and condom-use. He also influenced an open dialogue about the disease even among young children right from the very beginning. Some consider “candor more crucial than abstinence” as a contributing factor to reducing HIV (Wax,1). This candor came directly from the influence of President Museveni. “The entire country, from the president to grandmothers and first-graders, has mobilized over the past 11 years in Africa’s most successful fight against the epidemic” (Wax, 1). Some go as far as to say that, “Uganda has waged a successful fight to reduce its infection rate by enlisting the entire population in a frank discussion about sex” (Wax, 1). From the political science perspective, it is clear that President Museveni’s role in the implementation of the ABC program was essential and that his charisma led to significant behavior change in the population. This sort of analysis leads to the question of whether an ABC approach or a charismatic leader is important to HIV/AIDS prevention.

It should also be noted that further analysis of the ways in which the population actually changed their behavior showed that abstinence and fidelity had little to do with the reductions (Roehr, 27LB). A recent longitudinal study showed that while many Ugandans were inspired to change their behavior by the president, the adoption of condom-use played a significant role—over abstinence and fidelity (Roehr,27LB). Recent rises in HIV/AIDS in Uganda have been directly linked to a shift in focus from an even A, B and C approach to a strong emphasis on A for abstinence. Central to the political analysis of ABC prevention in Uganda is an examination of the role of President Bush. Recent pressure from the Bush administration has lead to a lopsided approach—almost exclusively focused on abstinence. In fact, Bush has directed, “about one-third of new AIDS prevention money for Africa to groups that advocate ‘abstinence-only before marriage’ messages”(Wax, 1). This new focus with the help of conservative religious groups has lead to condom shortages throughout Uganda and a silencing of information about the benefits of condom-use. Uganda, once a place where the entire population mobilized and engaged in “frank discussion about sex” and condom use, now faces a political climate where condom-use is considered “a last resort for the immoral.” President Bush had an, “unprecedented opportunity to provide leadership by talking about men’s behavior, and women’s needs to African leaders and the public” (Marton, 2). However, based on his personal moral beliefs and agenda, he failed to go beyond the A in the ABC approach by allocating such large portions of funding to abstinence only programs.

It is clear that ABC can unfold in very different ways in different political climates. It is also clear that the individuals who prove to be powerful and influential in the political arena have a profound effect on how a program is implemented as well as how it is received by the population.

Further political analyses beg the questions: what about countries like Kenya and South Africa where leaders have at one time or another openly denied the existence of AIDS? With a void of political leadership and support around HIV and AIDS, could ABC even stand a chance? Based on the above arguments, it is clear that the ABC approach to preventing HIV/AIDS is a flawed approach but the numbers remain. Uganda has achieved major successes in fighting the spread of HIV/AIDS. While some aspects of the campaign have contributed to the decline in HIV/AIDS, it is also clear that other aspects are directly linked to increases in HIV/AIDS. The new questions become, what can Uganda’s achievements be attributed to and can they be replicated in different societies, cultures and political climates?

A new and compelling argument against the ABC approach is that it is actually an outcome, not a strategy. “One important point is that abstaining from sex, being faithful, and using condoms—ABC-related behaviors—are outcomes of prevention strategies, not strategies in themselves” (Murhpy,1444). I would have to agree. Abstinence, fidelity and condom use are far more likely to occur when women gain autonomy, cultural nuances are considered and the political climate is conducive to the success of the program. This suggests that perhaps abstinence among young people, fidelity in marriage and condom use should be three of many objectives of a new sort of HIV/AIDS intervention that is based on fostering female autonomy, consideration of cultural contexts, open dialogue, social mobilization and capitalizing on supportive and influential leaders (political or not).

If ABC is not the Silver Bullet For HIV/AIDS Prevention, How Should Public Health Agencies Approach Prevention? Anthropology, Sociology and Political Science Provide a Framework for Success- Kate Mitchell

Some have argued that the ABC (Abstinence, Be faithful, and if all else fails use Condoms) approach to HIV/AIDS prevention is the silver bullet, citing success in Uganda and boasting it to be the one proven tool. Others say that ABC has not worked anywhere and certainly did not work in Uganda, where critics claim that massive reductions in HIV/AIDS prevalence were actually due to a lack of treatment resulting in extraordinary numbers of deaths over the decade marked by ABC rollout.
While it is evident that a great deal of the decrease in HIV/AIDS prevalence in Uganda can be accounted for by deaths, it is also apparent that Uganda has achieved some significant results in preventing new infections. In the first part of this assignment (assignment 3), I called upon three social science frameworks to critique the ABC approach to HIV prevention. Through the lenses of Anthropology, Sociology and Political Science, I concluded that while aspects of this program appeared to work in Uganda, ABC cannot be universally applied throughout the world or even throughout Africa. I did not argue with the epidemiological or scientific soundness of the approach. Instead, I argued with the actual feasibility of using this approach as a universal silver bullet applicable in any setting. Variations in culture, gender equality and political will in different parts of the world demand approaches that are unique to each community. I also concluded that in Uganda several interrelated factors worked together to produce an environment in which ABC could achieve some results—but ultimately ABC was less of an approach and more of an outcome of various factors coming together in the right place at the right time.
There is more to be learned from the factors that yielded Uganda receptive to HIV prevention methods than there is to be learned from the ABC approach itself—mainly cultural considerations, improved female autonomy and the use of political will and influence.

It is clear that HIV is a sexually transmitted disease and therefore, promoting abstinence (or delayed sexual debut), fidelity and condom-use must be integral parts of any HIV/AIDS prevention program. Establishing that populations must adopt these behaviors (either in part or in whole) in order to prevent the spread of HIV is inarguable. The challenge is creating an environment in which populations are able to adopt these behaviors, want to adopt these behaviors and actually choose to adopt these behaviors.

I don’t presume to develop any one silver bullet or gold standard for success. I do propose, however, an adaptable framework for success—a framework based upon Anthropology, Sociology and Political Science that can be modified in various settings to establish environments that are receptive to HIV prevention methods. This framework takes into consideration cultural variations, gender inequalities and the importance of political will and public policy.

Anthropology says, “Do NOT ignore culture!”

In my critique of the ABC approach, I pointed out that the approach cannot be universally applied throughout the world or even throughout Africa. I argued that it does not take into consideration cultural factors that often serve as barriers to abstinence, fidelity and/or condom-use. Is it plausible to ask a man within a polygamous society to be faithful to one woman? The field of Anthropology guides Public Health professionals to realize that culture must be considered in the design and implementation of health interventions. To address this issue of cultural variations that do not allow for one prescriptive tool for success, I propose that Public Health organizations implement community-planning strategies. This means that agencies working towards HIV prevention must provide individual communities with the facts and basic knowledge about HIV transmission, methods of prevention and consequences of not adopting new health practices. The agency must then work collaboratively with the community to develop a plan that is culturally specific and scientifically sound for the particular community. Often when health interventions are introduced into communities without consideration of the culture, one or more aspects of the program is not seen as feasible by the community. When this happens, the community often rejects the entire intervention as unattainable. By utilizing community-planning strategies, communities are given the opportunity to articulate what works for them and what does not work for them—within the context of science and facts. While being faithful to one woman might not be possible in a community where men are expected to have up to three wives, it is possible for a community like this to develop a prevention plan that involves condom-use, regular testing and being faithful to three women. Community-planning is important because it involves men and women. It involves community members and Public Health experts. All are seen as equal players in the prevention process. This leads to community buy-in, a concept essential to the success of any Public Health intervention.

Sociology says, “Do NOT ignore gender inequalities!”

In my critique of the ABC intervention, I pointed out that the ABC approach assumes that girls and women have equal capacity to negotiate abstinence, being faithful and condom-use. This is simply not the truth. Throughout much of Africa and much of the world, girls and women are marginalized. They are forced to marry as early as 12 years of age, they are not allowed to stay in school, and ultimately they become highly dependent on men for survival. According to a recent UNFPA article, “…women and girls face a range of HIV-related risk factors and vulnerabilities that men and boys do not--many of which are embedded in the social relations and economic realities of their societies” (UNFPA). In addition, “Violence against women is highly prevalent throughout the world. Girls and young women acquire HIV an average of 10 years earlier than men of similar ages. This is related to early marriage, rape and being compelled into transactional sex for economic reasons” (Roberts, 1). It is due to this range of factors that, “In sub-Saharan Africa, 76 per cent of the young people (aged 15-24 years) living with HIV are female” (UNFPA).

These inequities cannot be ignored. The field of sociology highlights the importance of considering gender inequities when planning a health intervention. I propose that agencies committed to HIV prevention shift some of their efforts towards creating access to primary and secondary education for girls and reducing the disparity between girls and boys in secondary school. While this will not necessarily yield immediate reductions in HIV/AIDS prevalence, it will improve female autonomy. Many Public Health experts have argued that successes in Uganda have been falsely attributed to the ABC approach—when in reality the successes were largely due to increases in female autonomy. It is clear that women who stay in school longer choose to marry later. They are also equipped with additional skills that make them less economically dependent on men and less likely to engage in transactional sex as a means of survival (strongly associated with HIV/AIDS transmission). “Boosting women’s economic opportunities and social power should be seen as part and parcel of potentially successful and sustainable AIDS strategies” (UNFPA). It has been shown that in societies where women feel a sense of empowerment, they are far more likely to choose to wait longer to have sex, engage in monogamous relationships and feel capable of negotiating condom-use. They are also far more likely and able to demand monogamy of their spouses. A large part of improving female autonomy is dependent not only on increasing access to education for girls but also on reducing violence against girls and women. Violence reduction programs should be an integral component of HIV prevention. The UNFPA goes as far as to say, “If HIV-prevention activities are to succeed, they need to occur alongside other efforts that address and reduce violence against women and girls” (UNFPA).

Political Science says, “Do NOT ignore health policy!”

In assignment three, I demonstrated that achievements in HIV/AIDS reductions in Uganda were in large part due to political will. President Museveni traveled to remote villages with a bullhorn, mobilizing the population to change their behavior. His support early in the campaign of ABC methods (advocating equally for A, B and C) lead to frank conversation among Ugandans of all ages about HIV/AIDS and prevention methods. In time, as his support for condom-use dwindled and the national HIV/AIDS prevention strategy became almost entirely focused on abstinence, the country followed suit and discussion of condom-use became taboo. It did not take long before the country faced a national condom-shortage and HIV rates began to rise again.
By examining HIV/AIDS prevention through the scope of Political Science, the importance of charisma, leadership and political will become very clear. Often Public Health implementers see politics and public policy as beyond the scope of their work. As Mervyn and Ezra Susser have argued that Epidemiology has become too narrow, too focused on individual risk factors and has forgotten it’s role as the basic science of public health—implying that Epidemiology is failing the field of Public Health by neglecting to focus on populations, Public Health professionals working towards HIV prevention have also become too narrow, too focused on the silver bullet (a vaccine, circumcision, microbicides or the ABC approach) and have forgotten that Health Policy is one of the subfields of Public Health. It is essential that Public Health practitioners address health problems at the policy level as well as at the community level. Many Public Health professionals have chosen not to play the political game but hope to enact changes in the health of populations outside the realm of politics. This is a big mistake and the consequence of this mistake is the loss of life for millions. By choosing not to participate in public policy and politics, Public Health professionals are making a challenging battle far more challenging. By enacting change at the policy level, Public Health practitioners have the chance to create health interventions that are supported by charismatic leaders. With this support, these health interventions are likely to be adopted as part of the national healthcare system—thus rendering them far more sustainable and culturally accepted.

This approach does not provide a single prescription to prevent HIV/AIDS transmission on a global scale. It does offer an approach to HIV prevention that considers culture, gender inequality and the power of political influence. In order for populations to accept and adopt behaviors that are critical for HIV prevention, the community must be involved in designing the prevention plan for their specific cultural context, female autonomy must be increased allowing women to negotiate their own sexuality and public health professionals must engage in Health Policy reform. This framework, a framework grounded in Public Health, Anthropology, Sociology and Political Science, has the potential to yield HIV/AIDS prevention programs that are holistic, sustainable and achieve measurable results.

References
Cohen S Beyond Slogans: Lessons From Uganda’s Experience With ABC and HIV/AIDS The Guttmacher Report on Public Policy, December 2003
Hampton T Abstinence Only Programs Under Fire JAMA Volume 299, Issue 17, Pages 2013-2015
Lopez K The ABCs of fighting the spread of AIDS in Africa The Seattle Times, June 2005
Marton K Bush in Africa: Saving women from AIDS International Herald Tribune, July 2003
Murphy E Was the “ABC” Approach (Abstinence, Being Faithful, Using Condoms) Responsible for Uganda’s Decline in HIV? The PLOS Medicine, Volume 3, Issue 9, Pages 1443-1446
NPR Uganda, Abstinence and the Spread of HIV (pod-cast accessed on November 17th, 2009)
Roberts J HIV Prevention: Are We Making Progress? www.Medscape.com Accessed on December 10th, 2008
Russell S Uganda’s HIV rate drops, but not from abstinence San Francisco Chronicle, February 2005
UNFPA The Gender Dimensions of the HIV/AIDS Epidemic United Nations Population Fund www.unfpa.org/gender/aids.htm Accessed on December 10th, 2008
Wax E Uganda’s war on AIDS: Candor more crucial than abstinence, officials say The Washington Post, July 2005

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