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Was the “ABC” approach (Abstinence, Being faithful, using Condoms) responsible for Uganda’s decline in HIV?

Elaine M. Murphy, Margaret E. Greene, Alexandra Mihailovic, Peter Olupot-Olupot

PLoS Medicine
Volume 3, Issue 9

September 2006

SARPN acknowledges PLOS Medicine as a source of this document: www.plosmedicine.org
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Background to the debate:

Uganda is one of the few African countries where rates of HIV infection have fallen, from about 15 percent in the early 1990s to about five percent in 2001. At the end of 2005, UNAIDS estimated that 6.7 percent of adults were infected with the virus. The reasons behind Uganda’s success have been intensely studied in the hope that other countries can emulate the strategies that worked. Some researchers credit the success to the Ugandan government’s promotion of “ABC behaviors”—particularly abstinence and fidelity. Uganda receives funds from the United States President’s Emergency Plan for AIDS Relief, which promotes the ABC approach with a focus on abstinence-driven public health campaigns. Other researchers question whether the ABC approach was really responsible for the decline in HIV infection. Critics of the ABC approach also argue that by emphasizing abstinence over condom use, the approach leaves women at risk of infection, because in many parts of the world women are not empowered to insist on abstinence or fidelity.

Policies to Advance Women’s Status Were Crucial to the ABCs’ Success in Uganda
Elaine Murphy and Margaret Greene’s Viewpoint

A debate continues to simmer over the much-publicized “ABC” approach to HIV/AIDS prevention, most narrowly defined as: Abstain, Be faithful or reduce the number of your sex partners, and/or use a Condom. The discussion has become polarized in part because for some, the ABCs are synonymous with the promotion of abstinence-only sex education programs for youth, an area of considerable controversy1 that seems to pit political and religious conservatives against their liberal counterparts.

In addition, although ABC behaviors have been credited with Uganda’s dramatic decline in HIV rates2 - 5, questions remain as to whether the ABC-related behavior changes are attainable in other developing countries, given many women’s relatively limited control over their sexual relationships. Influential AIDS policy makers have expressed doubt that ABC-related behavior changes can take place in settings where women seem to have little control over their sex lives. On the eve of the 2004 International AIDS Conference in Bangkok, for example, the deputy executive director of UNAIDS observed that, “Most of the women and girls, as much in Asia as in Africa, don’t have the option to abstain when they want to. Women who are victims of violence are in no position to negotiate anything, never mind faithfulness and condom use”6. An infl uential woman’s advocate reinforces this view: “Most prevention messages…focus on the ‘ABC’ approach to fi ghting HIV-AIDS....While important messages, these things are often not within women’s power to control”7.


Footnotes:
  1. Halperin D, Steiner M, Cassell M, Green E, Kirby D, et al. (2004) The time has come for common ground on preventing sexual transmission of HIV. Lancet 364: 1913–1915.
  2. Green E (2003) Rethinking AIDS prevention: Learning from successes in developing countries. Westport (Connecticut): Praeger Publishers. 374 p.
  3. Stoneburner R, Low-Beer D (2004) Population-level HIV declines and behavioral risk avoidance in Uganda. Science 302: 714–718.
  4. Shelton J, Halperin D, Nantulya V, Potts M, Gayle H (2004) Partner reduction is crucial for balanced “ABC” approach to HIV prevention. BMJ 328: 891–893.
  5. Hearst N, Chen S (2004) Condom promotion for AIDS prevention in the developing world: Is it working? Stud Fam Plann 35: 39–47.
  6. Cravero K (2004 July 7) Record numbers infected with HIV. Washington Post: A14.
  7. Fleischman J (2004 June 29) Beyond gABCh: Helping women fi ght AIDS. Washington Post. Available: http://www.washingtonpost.com/wp-dyn/articles/A13501-2004Jun28.html. Accessed 2 August 2006.


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