Challenging Dogma - Fall 2008

Wednesday, December 17, 2008

It’s Not As Easy As ABC: Abstain, Be Faithful, Use Condoms in Africa – Antoine Longuet

It’s Not As Easy As ABC: Abstain, Be Faithful, Use Condoms in Africa – Antoine Longuet

AIDS is known to be one of the worst pandemics since its discovery in 1981 (1), particularly in Africa, where the spread of its infection has amounted to 24 million in 2007, with over the 33.8 million infected individuals around the globe (2). A number of organizations have launched intervention initiatives to stop its spread, one of them being the ABC program launched worldwide in the 1990’s by governments of affected countries such as Botswana, Uganda, Mozambique and by the UN which has created the UNAIDS department to deal with this crisis (3). The name of the ABC program is an acronym for the messages it wishes to promote: Abstain, Be faithful, and use Condoms. Recently, the United States Bush Administration launched the President’s Emergency Plan for AIDS Relief (PEPFAR), which endorses the ABC program and increased US funds for AIDS relief (4). The ABC initiative has come under considerable criticism since the early 2000’s by scholars for its ineffectiveness in understanding the complex cultural and sociological factors that lie between the program’s objective and its actual intervention. The ABC intervention has also been criticized for its lack of marketing research to promote itself, incapacitating the effectiveness of its message.

ABC And Local Cultural Factors:

ABC has primarily been promoted in Africa in the 1990’s, where it was believed to have a great success in Uganda (the number of infections dropped from 15% in 1992 to less than 5% in 2006) (5). However, this was often not the case in other countries, where there is still a staggering number of infections, which keep rising.

Misconceptions of the ABC program are based on assumptions about the different ways through which the disease is spread. This intervention focuses primarily on heterosexual transmission via conventional intercourse. However, the program ignores the many other ways through which the disease spreads. Surprisingly very little research has been done on homosexual transmission in Africa, while it is an important debate topic within the First World to prevent the spread of AIDS. Also, the program ignores local cultural factors, which often move against the efforts made by the ABC program. Sociological factors, particularly polygamy and sexual violence, are another larger issue, which truly affect the success of the ABC program. In this sense, it can be said that the ABC program is based on analysis of individuals within a vacuum, without taking into account socio-cultural factors.

Local cultural practices involving sexual relations and defining socially acceptable sexual activities have often hindered the efforts of the ABC program. Just as “Ethnographic research […] often reveals how deeply sexual intercourse is enmeshed in meaning and social experience”. It is only recently that “researchers are […] turning their attention to little-known sexual practices”, as Erik Eckholm noted (6), which “might also raise transmission odds” (6). Such practices include female circumcision, which is often forcefully done upon women in South Africa, and usually in a non-sterile environment with tools used on women who have been previously infected. Other such practices include anal intercourse, particularly between men, which often leads to HIV transmission. A more obscure practice involves sexual intercourse with monkeys (6), which are known to be HIV carriers and is believed to be the origin of the virus. However, the ABC program is primarily directed towards regular heterosexual intercourse, and surprisingly contains very little research on homosexual activity or other kinds of sexual activities in which the HIV virus can be transmitted. The fact that the ABC program targets conventional sexual relations, through which the disease is most spread leaves “gaps” through which the virus can continue to infect the African population and proliferate within it.

Another cultural issue, to which the ABC program is confronted, is myths about the HIV virus as a whole. Alma Gottlieb documented “rumors connecting AIDS to vampires” (6). Such myths distort the definition of HIV transmission that needs to be assessed on a local basis where the myth is present. Other less obscure myths involve misunderstandings of the inner-functioning of AIDS and its transmission. Older seropositive men often believe that sexual intercourse with virgins or minors, which are considered “AIDS-free” would “wash-out” HIV from the body (5). This particularly poses a problem to the ABC program in terms of abstinence and condom use as many of the older seropositive men either rape their victims, or provide food, clothes and education to women and girls of poor backgrounds in exchange for sexual favors. The men who demand sexual favors in exchange for economic support are often termed as “sugar-daddies” (5). In such as case, not only do these young women not abstain, but also due to the “body-cleansing” myth that is involved, condom use is inexistent. This is particularly threatening for virgins where the rupture of the hymen, at any age, is involved with vaginal-bleeding, and causes automatic HIV transmission if the sexual intercourse involves a seropositive mate while not using a condom (6). It has also been noted that within a couple in which both partners are seropositive, men tend to die before females do. Locals have addressed this by assuming that women are more resistant to the virus because they eliminate the infected blood through the menstrual cycle, another reason why virgins are considered to be “virus-cleaners”. The true explanation to this is earlier male extra-marital affairs than for females (6), which poses a serious challenge to the ABC program.

The main cultural problem that ABC faces in Africa is the widespread belief that condoms actually spread AIDS, and therefore a general male resistance to use condoms. Other males are against the use of condoms because they consider this to diminish the sexual pleasure that is involved in sex, and the simply do not consider the practicality of its use. African males have often been noted to believe that condoms are “like taking a shower with a raincoat”, or “eating a candy with the wrapper” (6). Conferences in which AIDS is discussed are often met by male responses, which involve little interest about why such phenomena occur, and “the production of knowledge and ability to distinguish [the use] of condoms as correct or incorrect in this sense [is] taken for granted” (6).

ABC And Local Social Factors:

The ABC program is proven to be inefficient when facing cultural problem due to the fact that it gives narrow alternatives to prevent the transmission of AIDS, which are culturally unfeasible. Furthermore, this intervention is inflexible because of its inadaptability to local cultural-conditions. The ABC intervention also faces many social challenges on a variety of levels going from the simple one-on-one sexual interaction to post-colonial stereotypes that apply to the African population as whole.

First of all, heterosexual relations within a couple are often stricken with sexual violence and marital rape in Africa. Thirty three percent of women in Uganda suffer from sexual marital violence, while eighteen percent of married women experience sexual violence with seropositive men who blame them for their condition (7). Studies have shown that men are twice as likely to die before their spouse due to AIDS due to extensive extra-marital sex (5). Women in poorer areas of Uganda and Africa as a whole claim to marry men who travel extensively along trading routes, and very often have sexual relations with other women (6). This particularly becomes difficult for ABC when such marriage conditions involve men who not only have affairs, but also are also polygamous. African countries in which the Islamic tradition of polygamy is widely socially accepted and permitted by authorities, such as Ethiopia and Nigeria, are a haven for HIV transmission (5). Within such conditions, not only do married women not abstain, but do not use condoms during intercourse because of the taboo involved with its use in a married couple, even polygamous. The use of the condom is often looked down upon, and when suggested in a couple, this often leads to suspicions of infidelity (5).

Cases of marital rape and violence clearly show that there is a gender inequality within certain regions of Africa where women not only are marginalized for their gender, but are even more so if they are seropositive. South Africa is known to be one of the countries in Africa in which gender marginalization occurs to the extent that it has the highest reported rape rate in the world (7). Not only does gender inequality push women on the margins of social and economic life, thus increases their dependence on their husbands, but it makes the ABC program entirely ineffective. Marginalized women, particularly in South Africa, are submitted to the will of their husbands or mates by socio-economic, even cultural factors, which render the discussion on condom use inexistent due to the fact that the ABC initiative is directed towards the male condom, ultimately giving the male gender the choice of its use. The fact that the ABC program specifically targets the male use of the condom, as opposed to the female one, undermines its effectiveness within regions where women abuse is common. As noted within the Review of Concern on Women & HIV/AIDS study: the “combination of poverty, unequal access to basic needs and resources, oppressive cultures and traditions, the denial of sexual and reproductive choices and the absence adequate heath-care and information” (7) render the ABC program entirely ineffective in region where female discrimination is actively performed.

The Church has also played a controversial role with regards to the ABC program in Africa as it has actively promotes the A and the B of the program (Abstinence and Being faithful) but discredited the use of Condoms, suggesting that it interfered with the natural order of things and that it is an immoral object (8). The Church has actively been opposing the use of the condoms through church sermons, as well as in catholic schools for decades due to its belief that it promotes “immorality and sexual promiscuity” (8). Furthermore, the Islamic community in Kinshasa also condemns the use of the condom, claiming that it “wages sin” (5). Edward Green has actively fought the use of condoms, convinced with the fact that “HIV incidence began to decline [in Uganda], primarily due to reduction in partner numbers” (5). He also claimed that condoms are not 100% effective and that Ugandans dislike the use of the condom. He even coined the use of the condom as a “western, technological solution inappropriately exported to Africa” (5). As a result, women who propose the use of the condom, while not being married, are often considered “free-women” who actively have sex with multiple partners, and are thus considered to be unfaithful, even prostitutes (5). However, Dr. Serwadda, a researcher on AIDS, claims that although abstinence and faithfulness in a relationship, promoted by the church, has played a major role in diminishing the extent of the Ugandan AIDS crisis, “it has not been a magic bullet” (5). He also noted, just as said before, that abstinence is not always an option, and neither is faithfulness in certain conditions, such as in the case or rape and sexual marital violence. Furthermore, while taking into account the discrimination of condom use, women who abstain from having sex till later may only push back to a later time their risk of infection due to the bleeding caused by the rupture of the hymen during loss of virginity if their partners were not to use condoms (5). Until recently, even UNICEF, while intervening in Uganda, made no mention of the use of condoms (5). However, this has changed in the recent years as President Bush made an address in June 2004, backing the use of the condom in the US as well as in Africa, suggesting that the “United States should “learn from the experience” of countries like Uganda”(9). Since, the US and other AIDS program activists have changed their point of view on the use of the condom. President Museveni of Uganda, who had actively opposed the use of the condom for many years, changed his opinion on this issue in an address on Monday, July 12th, to the International AIDS Conference in Bangkok, despite his personal religious beliefs: “Abstain from sex or delay having sex if you are young and not married, Be faithful to your sexual partner (zero-grazing), after testing, or use a condom properly and consistently if you are going to move around. This has now been globally popularized as the ABC strategy” (10).

Post-colonial stereotypes that remain within the African territories are another obstacle that the ABC initiative has come challenged. Most of these revolve around ideas that women are passive, and that “people of color are undependable, uneducated or nonliterate, [and] cannot understand complex messages (6). These stereotypes underline post-colonial racism, which is still prevalent in African countries and work against the ABC initiative as it dilutes and distorts the effect of the messages that are directed towards the African population. On one hand, a similar narrative can be seen within AIDS media coverage, which often leads to conspiracy theories about interventions performed by post-colonialist countries. Eurocentric media is often “biased, [with a] doomsday mode of reporting typical of Western AIDS coverage, [and afflicts] African people [who] appear as the passive recipients of internal and external help, while Africans at large are charged with failing to address the epidemic, even failing to be aware of it” (6). On the other hand, the African press reports constantly new efforts made to fight the epidemic. This discrepancy in media coverage only accentuates stereotyping, and thus not only creates a reticence from the part of the aid recipients who perceive the ABC message as aggressive and imperialist, imposing upon their way of life. This underlines the C of the program, which is one of the western solutions to stop the spread of HIV/AIDS and other STDs.

The final sociological factor that the ABC program faces is based within the legal systems of African countries such as Uganda, which have no definition of what westerners call “prostitutes” (6). Since prostitutes are one of the many ways through which AIDS spreads, the A and the B do not apply, and the C only applies in some cases. In order to effectively apply the A and the B within HIV/AIDS stricken countries, the definition of prostitutes must be put in place within their laws, and therefore either outlawing or the regulating this business. Furthermore, in order to fight the spread of this virus within sexually abused minors by “sugar-daddies”, there needs to be a strengthening of laws against minor defilement. This, however, is now out of reach of the ABC program, which needs to be stretched in order to allow legal enforcement.

ABC and the Health Belief Model:

The issue of culture makes it even more complicated for the ABC program, which promotes itself through a health belief approach, assuming that the population is concerned with its health. The Health Belief Model is an individual based model in which it is assumed that the individual perfectly weighs out the costs and the benefits associated with performing a health related behavior. The outcome of this analysis is an intention, which the model assumes to lead necessarily to the performance, or not, of the behavior depending on the intention. Here, the ABC assumes that the individuals involved in a sexual relation are devoid of social pressures, and that each individual perfectly balances out the health costs and benefits of abstaining, being faithful to their partner, and using condoms. However, as proven in the analysis above, each individual is constantly under immense social and cultural pressures, which ultimately lead to their decision rather than their belief. The health practitioners that have developed the ABC intervention have done so without including socio-cultural factors while basing themselves on the belief that each individual evaluates abstaining, being faithful to their partners and using condoms, according to their health concerns only. Yet cultural and social factors have been proven to drive the decision making process of individuals within these three subjects.

Furthermore, the ABC program focuses primarily on the individual, assuming that his or her decision process occurs without social interaction, in a vacuum. The reality of this is very different, particularly for marginalized and abused women who have no choice with regards to their health decisions. We can therefore say that these decisions are made on a group basis, such is the case for women on whom female circumcision if forced. Finally, the ABC program assumes, just like the HBM model over which it is based, that the intentions of the individual will lead to the action. This is clearly flawed due to the fact that even though men and women have the intention of following the ABC program, they might not due to socio-cultural decisions and inherent impulses. Decisions that involve sexual relations and health are often very delicate due to innate human impulses and socio-cultural factors, particularly in uneducated groups of individuals about the risks of HIV/AID transmission.

Flawed Marketing And Advertising:

In order to be delivered to the population, the ABC program needed to be marketed and tailored to the local crowd of each region within Africa towards which the program was directed. Marketing programs were fragmented into three separate types of projects according to the three objectives of the ABC program: one for abstinence, one for being faithful, and one for condom use. However, the ABC marketing program particularly focused on the condom use. During the 1960’s and 70’s Pentecostalism and the Catholic Church have greatly expanded within Africa, promoting messages that involved abstinence before marriage and faithfulness in relationships (8). However, these religious groups actively opposed the use of condoms, which was in direct opposition to the ABC marketing program focus. One of these programs, called Jeito, was launched in Mozambique in the mid 1980’s promoted the use of condoms through a Condom Social Marketing Program (CSM) (8). This program, like many other CSM programs, did not involve dialogue with the local population on their perception of condom use, and did not analyze in depth the local socio-cultural underpinnings. This was primarily due to the fact that the Jeito program was put in place urgently to quickly address the spread of HIV/AIDS. Furthermore, there was locally a widening gap between the classes, which often translated in the poorer population into survival by prostitution. This was not taken into account when the program was designed. The result of this program was not only strong clash between the messages of the churches and the Jeito program messages, but also a total misinterpretation of the Jeito program’s messages by the local population. While the program was promoting the use of condoms, the reliance of sex work by the poorer population translated into a perception of the use of condoms reserved to prostitutes, who were often infected by HIV/AIDS. Thus, many associated the use of condoms with HIV/AIDS itself (8). This program developed into a political downplay in which the program was unsuccessful. Once more ABC program, through Jeito, has proven to be ineffective not only because it does not take into account local perceptions on sexual activity, cultural and social factors, but also because it offers no dialogue with the local population in order to tailor its message according to the regional socio-cultural conditions. According to James Pfeiffer, the failure of the Jeito program “reveals the striking dissociation that is produced between the aid world and poor target populations when community participation and dialogue are disregarded” (8).He therefore suggests that there should be a “creation of frameworks for long-term dialogue between health workers and communities to establish trust and channels of communication” (8), which would allow the programs to tailor their intervention to the local population rather than imposing a top-down intervention according to pre-packaged interventions that have been put in place in many affected regions.

The failure of the Jeito program illustrates an overall failure of marketing interventions that have been put in place based on the ABC program, which is not designed to local population dynamics. This also illustrates the lack of data that such programs have collected within their regions of intervention, which have lead to misconceptions of the extent to which AIDS have affected the population. These misconceptions therefore “[obscure the] details of degree and specificity” about the perception and extent of the HIV/AIDS crisis (6). Africa is composed of forty-five countries, where seven of them are affected severely by the virus, and only of these are considered as high-risk countries. However, media coverage and general misconception of AIDS have led to think of Africa as a “Continent of Agony” (6). Conversely, such fallacies can also be seen in the other extreme where half of the new infections in Uganda occur within regular marital relationships, but are entirely ignored by local FBO’s (Faith Based Organizations) (5). To a further extent, African male speakers in HIV/AIDS conferences have made claims about the conditions in Africa while undifferentiating women, prostitutes and mothers, thus distorting definitions over which the ABC is based (6).


The ABC program, which has started in Africa in the 1990’s promoted a message throughout HIV/AIDS stricken African countries of Abstaining, Being faithful in a relationship, and using Condoms in order to fight the spread of the virus. However, this program has been proven to be flawed, particularly on its account of lacking knowledge of the local socio-cultural factors, which have often led to the misunderstanding of the program’s messages. Local cultures, which promote polygamy, have greatly hindered the effectiveness of the ABC intervention. Furthermore, local social factors, such as violent marital sex, rape and the existence of men called “sugar-daddies” have rendered the ABC program ineffective due to the marginalization and submission of women within such conditions. It is therefore evident that this program based on the HBM ignores all socio-cultural factors, putting forth a health based conception of the performance of A, B and C. However, the local conditions illustrated above have made this type of intervention irrelevant. The HBM based ABC program is also an individual founded intervention, while local conditions clearly need a population or group founded intervention. Finally, the marketing programs, such as Jeito in Mozambique, have met serious local resentments due to their lack of knowledge of local conditions, which have perceived ABC messages, particularly the use of Condoms, as manipulations of post-colonialist countries. The use of condoms has predominantly been misunderstood as a western tool to be used by HIV/AIDS carriers and individuals of immoral sexual activities. The ineffectiveness of the ABC based interventions show that a larger approach needs to be put in place within HIV/AIDS stricken African countries, which take into account socio-cultural factors, which play an important role in shaping the perception of such programs, and that demand large scale social reform. Therefore, an ecological approach seems appropriate for such an intervention, which would allow the program to tailor effectively its messages and campaigns to local conditions and thus assess more powerfully the spread of the virus. However, such an intervention will still meet a certain amount of challenge as “conclusions of ethnographers [about] the “risk group” categories produced by epidemiology often have little to do with the lived realities of human experience” (5), and thus will ultimately lead to future misinterpretations of messages sent by public health interventions. Ecological model based interventions will face challenges by the local population due to possible target population misclassification, but will ultimately lead to more effective interventions.

Resolving the ABC Program’s Flaws:

As suggested before, and ecological approach to this issue would certainly allow a program such as ABC to effectively tailor its messages and intervention to the local conditions. This, however, requires the program to change its philosophy with regards to the individuals it wishes to target by assuming that group based intervention in which sociological and cultural factors are key to determining individual’s health related behaviors. The ABC program therefore will need to research the local population on multiple levels in order to create an ecological intervention that effectively reaches the target population on several levels. In order for this program to effectively design interventions to local population conditions, the program needs to stretch out into domains out of Public Health, such as law enforcement, which would effectively back-up this program and thereby provide it policy cushion. This approach will thereby not only use Public Health measures to assess the population internally, but it will also use binding policies in order to enforce certain aspects of the intervention.

The Use Of Surveys:

An ecological approach to this issue not only requires the program to assess the target population in terms of a group rather than in terms of individuals, as dictated by the HBM, but also to intervene upon multiple levels, assessing sociological as well as cultural factors that need to be determined beforehand. An effective intervention would require a certain amount of research to be done within each particular region, especially in terms of the cultural factors, which have constantly impeded the progress of this program. In order to effectively research the population and understand the underlying factors, a series of studies through one-to-one surveys need to be done on multiple levels of the population. In hindsight of the problems the ABC program faced in Mozambique (8), Nigeria (5) and Uganda (6), the three main levels of the population can be surveyed: the population itself, subdivided according to SES background, the local authorities, and the religious groups. In Mozambique, the main issue was the population’s SES conditions, which at the time of the Jeito intervention, had plunged, and therefore forced many members of the lower SES classes into sexual work. Local religious beliefs were in full change the moment of the Jeito intervention, and in coordination with the socio-economic instability, caused the intervention’s message to be entirely misunderstood (8). In Nigeria, the fact that polygamy is legally accepted is one of the most complex issues with regard to the ABC program. Surveying local authorities might be able to suggest solutions to the problem and help shape the ABC program’s intervention with regards to the issues of polygamy and AIDS. This would allow the intervention designers to understand the official stance of local authorities on the HIV/AIDS issue. Finally, as seen in Mozambique (8), local religious groups such as the Pentecostal Church have clearly a different stance on the issue of intervening on HIV/AIDS, and would be worthy to seek an opinion from to understand how its position affects the local population perception of the virus. Also, in order to effectively understand the evolution of local cultural conditions, research needs to be done on a long-term basis, even while an intervention is already in place in order to constantly shape it to the evolution of the population’s cultural condition.

Local myths are particularly problem for ABC and are representations of the misinterpretations about the origins of HIV/AIDS and its inner functioning. Alma Gottlieb acknowledged “rumors connecting AIDS to vampires” vi, while Schoepf showed that older seropositive men believe that sexual relations with young women, and particularly virgins would allow them to clear their blood of impurities. Such misunderstandings can be assessed explicitly by addressing the victims of such abuse through sexual education at a very young age to inform them about the realities of the transmission of this virus. However, the fact that many of them do not attend schools and live in a close knit-community often prevents them from discussing such taboo subjects. The most practical and direct solution would be public campaigns using billboards upon which the “story” of HIV/AIDS transmission can be personified. Furthermore, public speakers need to be recruited in order to publicly inform the people as a whole, and not only these young girls, about this virus.

Approaching The Population:

In order to successfully reach the population, these speakers need to have knowledge about the cultural practices and beliefs of the region in which they are intervening; which is why they should be either from that region, or go through local cultural or religious authorities. In a sense, the origin of the speakers and the appearance of familiar cultural ties between the speakers and the population would lean on framing theory (11). These speakers and billboard ads, while still pushing for an HBM approach, which informs people about the basic health concerns of HIV/AIDS, need to use at the same time a marketing theory based approach (11). This will permit the messages of that the speakers and the billboards are sending to not only give health related information about HIV/AIDS to the population, but also package this information in a way that would appeal to the people’s desire. In a sense, by combining the HBM with marketing theory, the speakers and the billboards will present the issue of health through the use of condoms, faithfulness, and abstinence as a socially and through time, a culturally positive object. However, if the program has enough funds, it may even combine an HBM based approach with Advertising theory through the use of more advanced, and more expensive media, such as radio and television (12). Advertising theory would virtually play the same role as marketing theory in these adds, while appealing to the population’s social and cultural aspiration. The use of the advertising and marketing theory thereby necessitate the use of surveys in order to adequately pinpoint the social and cultural aspiration of the population, which need to take into account the religious and governmental positions on the HIV/AIDS issue in order to further the effectiveness of the intervention.

The Use of Dialogue:

The use of surveys to develop effective interventions based on the ABC program which use speakers may not adequately allow the population to effectively feel addressed about the issue. One the main issues with the Jeito program, as determined by Pfeiffer, was its lack of dialogue with the target population (8). Dialogue, through group speakers or through one-to-one surveys, would not only bring information to the target population, but also to the designers of the intervention who, through dialogue, may constantly monitor the changes in the population comportment and perception of the ABC messages. The use of dialogue with the local population will also allow researchers to be able to “think outside the box” in a way that they are not constrained to ask questions to their audience that is restricted to certain guidelines. Such freedom of expression would permit researchers to acquire more in depth information about the socio-cultural background information about the population, such as obscure sexual practices to which Treicher referred, such as homosexual practices and sexual relations with monkeys (6). Dialogue with the population has particularly become important with regards to the religious factors, which are intertwined with the cultural ones. Religious factors are often very complex and are perceived and explained quite differently by the religious authority and the population that follows it. Surveys and dialogue would therefore be appropriate to target the religious authority and the population of followers as not only is this a very delicate and complex subject, but it is also ever increasingly volatile to events.

From a socio-economical point of view, dialogues are not as important as surveys due to the fact that the raw data, such as the state of the economy and how it affects the population, are more readily transcribed and analyzed using this type of research method. However, from a sociological point of view, the dialogue with the population is just as important as from a cultural point of view. Sociological factors depend on the SES status of the group as well as the its cultural attributes, making it also very volatile. In order to assess the problem of HIV/AIDS in women, which are known to be the target to sexual abuse, particularly in South Africa, which has been reported to have the highest rape of rape in the world, the most effective way to address them is to operate a constant dialogue with them in female social events in which they would be allowed not only to speak up and be heard, but also be educated about such concerns. By directly targeting women, who are the victims of sexual abuse, they will have the opportunity to be educated, and thereby by able to make educated choices about their husbands, or their partners, whichever applies best. However, interventions upon women need to be carefully tailored as they are the segment of the population that have been the most abused due to their often marginalized position within society. Women’s position within society has often pushed them to be the target of sexual abuse (13). One of the many ways, which could help women, is the use of the female condom. Even though women who are sexually abused are often do so with no condoms, the use of the female condom will help those who are not being abused, thus giving them a larger leverage when the issue of the use of the condom is being put in question.

Assessing ABC From A Legal Point Of View:

The very fact that women are the targets of sexual abuse not only reveals sociological underpinnings which need to be addressed through dialogue, surveys, and marketing programs in order to change the perception of women and of HIV/AIDS, but also reveals the lack of enforcement of already binding laws. Policies in countries such as South Africa, which has the largest reported rape count in the world, are often key locations for sexual abuse due to the lack of enforcement of the law. This is often due to either corruption, or lack of governmental funding. However, funding may be able to at the same time eliminate corruption, and help enforce the law if they are adequately managed. Furthermore, in order for these laws to be enforced, new elements need to be added to civilian codes of conduct, and rectifications need to be made. The fact that Uganda does not have the definition of what a prostitute is, in western terms, complicated judicial decisions with regards to rape or sexual abuse. This is also makes it very difficult for governmental organizations to control prostitution and women abuse. Outlawing prostitution, or at the very least require a list of declared prostitutes in the country would help authorities and humanitarian organizations help prevent the spread of HIV/AIDS. Polygamy, however, is a much more delicate situation as not only is outlawing polygamy virtually impossible due to the fact that it is deeply engrained within the population’s cultural identity, but it is not easily enforceable. Therefore, the question of controlled polygamy seems to be a quite delicate situation, which can only be assessed on a local level in coordination with governmental and religious authorities.


The main issue with the ABC program was its lack of analysis of local socio-cultural factors due to the fact that it was an HBM approach, thereby causing its marketing approaches to be flawed. However, an effective research through the use or surveys and dialogue with the different groups of the target population will allow the designers of the ABC program to clearly understand the different social, cultural and economical elements that shape their population’s attitude and perception of health related interventions. Furthermore, dialoguing with different target groups of the population will allow localized interventions rather than a broad and imprecise one. The presentation of the ABC program’s campaign through speakers, adds, billboards, and advertisement appropriately tailored to the local population conditions and target groups would allow the intervention to incorporate the HBM approach into a more appealing message in which the issue of health not only becomes less taboo, but also, for the lack of a better term, “looks good”. Finally, the use of legal and constitutional enforcement of sexual abuse through adequate funding and policy modification would allow authorities to regulate to a larger extent the spread of the virus.


1) Discovery Channel. Sexual Health Center: HIV/AIDS.

2) Anup. S. AIDS in Africa. Global Issues. 2008.

3) United Nations. Acquired Immune Deficiency Syndrome Department. New York, NY: UNAIDS.

4) United States President’s Emergency Plan for AIDS Relief. 2008 Annual Report to Congress. Washington, DC: United States Congress.

5) Schoepf. B. G. Lessons for AIDS Control in Africa in Review of African Political Economy. Taylor & Francis 2003; 30: 553-572.

6) Treicher. P. A. AIDS, Africa, and Cultural Theory. Indiana University Press 1991; 51: 86-103.

7) Statement of Concern on Women & HIV/AIDS in Review of African Political Economy. Taylor & Francis 2000; 27:590-593.

8) Pfeiffer. J. Condom Social Marketing, Pentecostalism, and

Structural Adjustment in Mozambique: A Clash of AIDS Prevention Messages. Case Western Reserve University 2004; 18: 77-103.

9) Sanger. D. E., D. G. Jr. McNeil. Bush backs condom use to prevent spread of AIDS. New York City, NY: New York Times, 2004.

10) Museveni’s ABC. New York City, New York: Wall Street Journal, 2004.

11) Seigel, M. Developing Interventions: The Role of Social and Behavioral Sciences Models of Individual Behavior Change: Are they Helping Us or Constraining Us? – III. Boston University, November 9th, 2008.

12) Seigel, M. Developing Interventions: The Role of Social and Behavioral Sciences Models of Individual Behavior Change: Are they Helping Us or Constraining Us? – IV. Boston University, November 16th, 2008.

13) Why we are failing African girls. London: BBC News, 2004.

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