The ABCs of HIV Intervention- Bridget Kelleher

Introduction

UNAIDS/WHO estimates that since 1981, 25 million people have died as a result of the HIV/AIDS epidemic (1). Needless to say, it has been a priority for the public health community to develop an effective intervention program to control this virus. Many organizations have developed various approaches to the problem, ranging from education programs to policy changes. One interesting program is called the ABC approach.

ABC was first developed in the early 1980s in Uganda under President Yoweri Museveni (2). After recognizing and acknowledging the potential danger of the disease, the national government implemented a program that encouraged people to ("A") abstain from sexual activity, to ("B") be faithful and maintain monogamous relationships, and to use ("C") condoms if people were not abstaining from sex. This program, which later became known as the ABCs of HIV/AIDS intervention, was successful in significantly lowering the prevalence of HIV/AIDS in Uganda (2). In 2004, citing the achievement in Uganda, President Bush incorporated the ABC approach into his own global AIDS action plan. He stated that the method was successful and a “practical, balanced and moral message” (3).

The U.S. surgeon general and most experts agree that the best way to prevent the spread of HIV/AIDS is through a comprehensive program that is rooted in evidence-based data (15), and the ABC approach meets those requirements. However, despite its public health stamp of approval, the method has major flaws.

Rational Choice

ABC wrongly supposes that individuals “strive to make the most rational choice possible” (14). What does it mean to ‘be rational’ in the first place? To be a rational human being means that a person weighs the options presented to him to make a decision that he feels is best suited for him at the time. Humans who follow rational thinking will apply logic and rules to a situation to develop a course of action.

It does not follow, though, that rational action necessarily means good action. For example, if a man who is married feels that his wife is mean to him and doesn’t engage in wifely activities (however he defines them), then for him it might be a rational choice to find a women who will treat him well and fulfill his needs, since his current wife is not living up to her end of their marriage contract. Stepping out on his wife is not a morally good choice, nor is it a nice one, but it could be considered a rational choice.

Applying rational choice to health means to compare the ‘positive’ and ‘negative’ health outcomes of particular courses of action. An action with the most positive outcome would be the rational choice. The ABC method is centered on the belief in an individual’s rational choice. The Health Belief Model (HBM), a type of public health intervention model, plays a large role in ABC. HBM is a cost-benefit model based on people’s rational behavior in which perceived susceptibility of a disease (in this case HIV/AIDS) is weighed against the likelihood of actually developing the negative outcome in question. “Other factors such as SES, age, and race come into play in mediating whether an individual is able to act on 'cues to action' in exercising sound health care choices” (9).

The idea of a rational mentality that supposedly dictates choice is flawed. Dan Ariely writes in his book, Predictably Irrational, that humans have a deep belief in their ability to make rational decisions for themselves; however, this belief doesn’t automatically translate into perfectly rational thinking. Ariely argues quite the opposite, stating that humans are in fact often irrational; moreover, we are predictably irrational (i.e. “our irrationality happens the same way, again and again”) and thus that there are a number of situations in which we predictably diverge from rational thinking (12).

The assumption that humans are rational beings is a supposition many public health interventions make. The ABC method is no exception. This strategy honestly believes that people will view the threat of AIDS as so great that they will be able to rationally think about the risk from having sex, calm their rampant hormones, and delay first sex. It also honestly believes the converse of that situation—that people who are having sex will not only use a condom every time, but will also use a condom every time correctly. It is not to say that individuals are incapable of weighing the risks of a decision; however, it is easier (and more fun even if for a moment) to throw caution to the wind and engage in the risky behavior than to calculate your personal risk.

Another problem with rational choice theory is that it assumes that intent translates into behavior. From a rational point of view, if an action will yield the best results for a person, it is assumed that he will do the action. For some people this may be true, yet this is not the case for all. A good example of failing to act despite the intention is seen in teenage Abstinence Pledges. An Abstinence Pledge is a pledge to God, family and self to abstain from sexual activity until a person marries. Unfortunately, as one eight year study published in 2005 found, this intention didn’t result in the intended action as “61 percent of the consistent pledgers and 79 percent of the inconsistent pledgers reported having intercourse before marrying or prior to 2002 interviews” (13). This example is one of many where people may have the right intention, but end up failing in the follow through.

Individual-level

A second issue with the ABC program is that it is targeted at the individual level. The logic makes at least prima facie sense: sex happens at the individual level, so if you want to curtail HIV, which is transmitted through sex, then you should have a program at the individual level. Putting programs at the individual level, however, can foster the assumption that choices happen in a vacuum. The idea that people make choices in a vacuum is two-fold: first, that every action takes place as isolated cases, separate from past actions, and second, that every decision is made independent of an individual’s social systems and general beliefs. It is preposterous to think that a person’s past actions, family, friends, and culture don’t play a role in his choices. As John Donne wrote: “No man is an island entire of itself, every man is a piece of the continent, a part of the main” (6). No individual is separate from the world with which he lives. The community and the people within the community are all being influenced and influencing each other.

Making the decision to abstain from sex, to be faithful to your partner, or to use condoms consistently isn’t a decision devoid of outside influences. From government officials to religious leaders to your neighbors down the street everyone is talking about their views on sex. The extent to which an individual internalizes others' opinions varies, but it is an important factor that has to be acknowledged in any successful intervention program.

Public health officials like to think that putting an approach at the individual level places control of health decisions in the hands of the individual, but that assumes that individuals have control over their lives. Setting the ABC strategy at the individual level is supposed to empower individuals, giving them control over their sexual behaviors. Although nice in theory, this idea falls apart in practice. Most women in non-Western countries do not have the power to refuse sex or negotiate safe-sex practices (5). Due to cultural standards women are subjugated to their male partner’s wants and will, and if he doesn’t want to abstain from sex, if he doesn’t want to be faithful to her, and if he doesn’t want to use a condom, then the women is powerless to protect herself. Beatrice Were, a Ugandan woman, said, “the approach places a huge burden on a woman to abstain and, when she's married, to be faithful. Personally, I did all of that, but I still got infected” (5).

Were’s quote touches upon another flaw in ABC. It is a “segmented approach that targets different messages to different groups of people” instead of allowing the possibility that “the same people may need different messages at different stages of life” (4). How does a married woman who wants to become pregnant simultaneously protect herself from infection when her husband in unfaithful? How does ABC plan to assist young girls, who delay first sex, when they decide to become sexually active? These are valid questions pertaining to sexual risk reduction that ABC has yet to answer.

Framing

The ABC method efforts “defining a situation” (11) represent a comfortable view of an unpleasant disease. According to Erving Goffman, frames allow individuals or groups of individuals “to locate, perceive, identify, and label” events (11). As a result, individuals are able to deduce meaning, compile experiences, and direct actions. Framing, in the social behavioral sense, is a social construction of a phenomenon. Typically those with power, such as mass media or specific social movements, can influence how a person perceives meanings attached to rhetoric.

ABC frames sexuality to only apply to heterosexuals. The three risk groups for contracting HIV/AIDS according to UNAIDS are sexually active heterosexuals, men who have sex with men (MSM), and injecting drug users (1). Yet ABC does not discuss or include the last two groups in its program. While MSM are still transmitting the virus through sexual intercourse, it is doubtful that President Bush and like-minded supporters had this particular population in mind when adopting ABC for PREPFAR in 2004. In fact, “in virtually all regions outside sub-Saharan Africa, HIV disproportionately affects injecting drug users, men who have sex with men, and sex workers” (1).

The fact that the ABC approach simply ignores the case of MSM is an example of the public health community favoring the status quo and overlooking the marginalized. As Michael Siegel writes in Marketing Public Health:

Practitioners have respected the value heterosexuals place on long-term relationships, commitment, love, and marriage by acknowledging that heterosexuals do not need to use condoms to prevent AIDS after entering into a faithful marriage or monogamous relationship (8).

Yes, the ABC approach can be applied to self-identified homosexuals, who are free to be open about their sexuality, and not hold their relationships in a different light than heterosexual couples. Homosexuals are just as able to weigh the risk of HIV and choose a type of action (either A, B, and/or C) as heterosexuals are. However, ABC does not take into account MSMs. The MSM label is not just a politically correct term to make people feel less uncomfortable talking about homosexuality, but it is a category to encompass those who engage in homosexual activities but who do not label themselves as “gay.” MSM make up a significant proportion of HIV/AIDS infections and therefore, as a matter of public good, should not be overlooked or excluded in prevention programs.

Furthermore, the ABC method frames the idea that HIV/AIDS is transmitted through sex more than any other mode of transmission. The ABC strategy was designed to lower the risk of contracting HIV through sexual relations. Although sexual transmission of the virus is still a leading problem, it is not the only mode of transmission. Injected drug use is still categorized by UNAIDS as a high-risk behavior strongly associated with the transmission of HIV. It is this particular behavior that threatens the success of any HIV/AIDS intervention because not only will people who use illicit drugs share needles with other users, thus potentially transferring the virus to others, but they will also have unprotected sex while high. ABC has no way of dealing with this problem since it assumes that people will be in a clear mindset when making decisions pertaining to sex.

Conclusion

ABC was successful in Uganda not just because “Abstain, Be faithful, and Condomize” was a novel idea, but because the government was able to tailor the program to their community’s needs and to mobilize community leaders, citizens, and the media to create a new social norm. However, without those extra factors working in conjunction with the message, ABC alone is insufficient. It lacks an acknowledgement of people’s culture, irrationality, and group influence. ABC poorly defined the situation and was not an approach realistically capable of being applied to all groups.

The U.S. Surgeon General, Dr. Satcher, in his Call to Action to Promote Sexual Health and Responsible Sexual Behavior defined sexual health as including the “freedom from sexual abuse and discrimination and the ability of individuals to integrate their sexuality into their lives, derive pleasure from it, and to reproduce if they so choose” (16). By ignoring the reality of two groups at risk for HIV/AIDS, MSM and intravenous drug users, the ABC strategy not only does not contribute to basic sexual health as Dr. Satcher defines it, but it also fails to address other risk factors associated with HIV/AIDS.

A Fresh Look at The ABCs of HIV Intervention

ABC was successful in Uganda during the 1990s not just because “Abstain, Be faithful, and Condomize” was an effective message, but also because the government was able to tailor the program to their community’s needs and to mobilize community leaders, citizens, and the media to create a new social norm. However, without those extra factors working in conjunction with the message, ABC alone is insufficient. It lacks an explicit acknowledgement of the influence of people’s culture, of their ‘predictable irrationality’, and of the strong effect social norms can have on individual behavior. Without these additions, ABC becomes a slogan, not a program, and cannot realistically be capable of being applied effectively to all groups.

This is not to say that the entire message of ABC needs to be discarded. The approach has many merits, one of them being its comprehensive view of sexual choices. However, ABC can be improved by incorporating explicitly a heuristic framework based on the social sciences.

Predictably Irrational

Sexual arousal is a low impulse-control state. When people are sexually aroused, they have even less impulse control than they expected to have (12). This is why safe-sex programs that depend on condom use are less successful than anyone, even the participants, expects.

It is common knowledge that women in general are more cautious about sexual encounters than men. After all, women have much more to lose from a casual sexual encounter; they’re the ones that have the baby. It would seem that an intervention that makes women the gatekeepers would be more effective. However, there is a complication: women hate conflict. In fact, they may be willing to trade almost anything, even their health, for the love and security of a male. Louann Brizendine writes in The Female Brain that the circuitry in a women’s brain prevents her from initially expressing emotions of fear, anger, and aggression. Her circuitry opts instead to force her to process and avoid conflict and anger (17). By interrupting the anger response, the female is able to protect herself and her children from “an extreme response from a trigger-tempered male” (17). Even if the male doesn’t respond with violence, the threat and fear that he would leave her is enough to make a woman bite her tongue. Thus, an intervention that makes women the gatekeepers must also provide them with resources to deal with conflict and their fear of it.

Imagine an advertising campaign that utilizes a modified ABC. Particularly because each intervention must be targeted to a specific group and a specific community, the first step would be to go into the field, find women who are successfully managing this conflict, study what they do, and decide how to present these techniques to other women. The ad should portray a woman using these field-tested techniques and words to convey interest in her partner and her respect for him, thus avoiding undo conflict, while protecting herself from disease. A follow-up ad could show groups of women revealing that they had successfully used these techniques, both reinforcing the behaviors and giving women additional confidence.

Community-Level

The traditional ABC approach also did not explicitly emphasize the important role cultural and societal norms play in modifying and shaping human behavior. No individual is separate from the world in which he lives, devoid of his culture and community beliefs. Individuals, to a certain extent, will follow the rules dictated by the norms of their society. This idea is formalized in social expectations theory, which states that people act en masse based on the social norms of a group (10). Therefore, by combining the message of ABC with social expectations theory, and targeting self-identified hetero- and homosexual individuals, it should be possible to design a more effective ABC-style intervention.

Laws, agenda pushing from social movements, and even endorsements from well-known and respected local figures, do affect human behavior. Therefore, one possible intervention would rely on research conducted in each community to learn who is the leading authority figure, or is otherwise highly influential, within different age groups. Depending on the age group and the community, the person could be a government official, a leading businessman, the local minister, a well-respected doctor – anyone who could not only act as a cultural broker between public health clinicians and the community, but who also commanded sufficient community respect and personal influence to modify or improve what people in the community did and expected, to more closely align that with the ABC message.

Framing

Another big problem with the ABC approach was that it framed the issue of HIV as mainly being transmitted through heterosexual sex. This clearly isn’t the only group at risk for HIV/AIDS. Men who have sex with men (MSM), prostitutes, and drug users also need to be included in any well-rounded HIV intervention.

In the Western world we talk about safe-sex practices with ardent fervor, but what about safe-drug practices? How often do we openly discuss safer ways to do drugs? (The answer is hardly ever.) The topics of illicit drug use and deviant sexual practices are still very taboo even in the “developed” world.

One way to break social taboos is by practicing agenda setting—if you can get your issue on the media’s agenda long enough, people will start to accept your message. Perhaps if “developed” countries put the topics of risk reduction and safe-drug practices in relation to HIV prevention on the agenda, it would not only reduce the incidence of HIV/AIDS in their own areas, but also possibly make other countries start to feel more comfortable talking about the taboo topics surrounding AIDS. Heterosexual acts are not the only vehicles for the transmission of HIV/AIDS. Reframing intervention programs to explicitly include MSM, prostitutes, and drug users may be more effective.

Conclusion

It is easier to critique a faulty intervention than to develop its replacement. The intervention strategies presented in this paper are based on theories that have been proven to be successful in social science and mass communication. It is reasonable to propose that public health programs based on these theories would be equally effective. HIV/AIDS is not a simple disease, and its method of transmission is complex as well, so any intervention program targeting it cannot be simple, either. The best HIV intervention program would appear to be one that utilized a heuristic framework based on the social sciences. Unfortunately, even the best of interventions may not able to eliminate HIV, since at least some people in a community will engage in risky behavior, and that will probably always be the case. However, the hope is that by implementing an evidence-based program founded on a well-developed ecological model, HIV will become rare, if not completely eliminated.

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