# Presentation: 216419

## A Summary of ABC evidencePresentation to the PACHA                  3/29/04

** **
**Edward C. Green, Harvard Center for Population and Development Studies**

## Most HIV is transmitted through sexual intercourse.

- Having multiple sexual partners drives AIDS epidemics.
- If people did not have multiple sexual partners, epidemics would not develop or, once developed, be sustained.

## Yet...AIDS prevention programs do not address the behavioral pattern of multiple partners, except in oblique ways. 

**Programs funded by major donors do not directly address this crucial factor **

## Two approaches to disease prevention

-  **1. Risk- reduction or “remedies” interventions (condoms, treating STIs with drugs)**
**2. Risk avoidance (abstinence or delay of age of first sex; mutual monogamy). **
**This dichotomy is imperfect because reduction in number of sexual partners would have to be classified as risk reduction, not avoidance.**** **
**“****Primary Behavior Change”**

## ABC Strategy

## Condoms, 

- When HIV infections are concentrated in high risk (or core transmitter) groups (MSM, CSW, IDU), as in America or Thailand, it may make sense to focus interventions on risk reduction, i.e.:

- Condoms,
- Treatment of STIs
- Provision of clean syringes

## Yet perhaps this prevention model should not have been exported to Africa intact, without modifying it for the epidemic pattern found in (Sub-Saharan)                                          Africa 

- Yet perhaps this prevention model should not have been exported to Africa intact, without modifying it for the epidemic pattern found in (Sub-Saharan)                                          Africa

## Condom social marketing;

- The 4 main areas of prevention today are:
**Condom**** ****social marketing**;
**VCT** (leading to drugs and/or condom use)
-  **Treatment **of STIs
**PMTCT** (based on nevirapine)

## Yet these “C and D” risk reduction strategies have not proven very effective in Africa.

**...****or left to religious groups**
- Yet these “C and D” **risk reduction **strategies have not proven very effective in Africa.
- Some examples of recent research follow, showing that the condom solution to AIDS  is not working very well:

- -Hearst and Chen UNAIDS study 2003:
-            “inconsistent condom use does not protect against HIV”
- 	“there are no definite examples yet of generalized epidemics that have been turned back by prevention programs based primarily on condom promotion.”
- -UNAIDS multi-site study (condom levels found to be non-determining of HIV infection levels)
- -Weller and Davis 2002: _consistent_ condom effectiveness provided 80% in rate of HIV infection
- -Shelton and Johnston 2001: there are only 4.6 condoms per male per year in Africa (Uganda is 4.0, below average)
- -Which countries have highest condom rates? See next slide

## Average number of condoms per male 15-49 in African countries for which data are available 

| Country  | Average annual condoms 1989–2000  | Males 15–59
1995
(in thousands)  | Average annual condoms per male 15-59  | HIV
Prevalence
(%)  |
| --- | --- | --- | --- | --- |
| Benin  | 4,065,408  | 1,263  | 3  | 2  |
| Botswana  | 2,436,232  | 356  | 7 | 36 |
| Cameroon  | 10,378,900  | 3,280 | 3 | 8 |
| Ghana | 9,901,068  | 4,424 | 2 | 4 |
| Kenya  | 42,391,034  | 6,666 | 6 | 14 |
| Senegal  | 5,513,517  | 2,091 | 3 | 1 |
| South Africa  | 76,284,892  | 11,645  | 7 | 20 |
| Tanzania  | 27,217,215  | 7,603 | 4 | 16 |
| Uganda  | 16,702,846  | 4,740 | 4 | 6 |
| Zambia  | 12,131,695  | 2,280 | 5 | 20 |
| Zimbabwe  | 29,149,405  | 2,826 | 10 | 25 |

## Kenya: HIV Prevalence & Condom Sales

**Condom Sales**

**HIV Prev**

**Kenya****: HIV Prevalence & Condom Sales**

**Notes:**
These next 4 slides are from a 2002 PSI/AIDSMARK presentation at USAID, which may help illustrate part of the background for the emerging interest in “ABC” over the past couple years (and also demonstrates PSI’s active interest in reexamining their approach to behavior change efforts).

## Botswana: HIV Prevalence & Condom Sales

**Botswana: HIV Prevalence & Condom Sales**

**Notes:**
In other words, in a number of African countries, we unfortunately see condom sales rising along with HIV prevalence (and this trend has been observed similarly when analyzing the association between total condom availability and HIV).  Sadly, those countries with the strongest condom programs have often been those with high HIV rates (i.e., Zimbabwe, Botswana, South Africa, Kenya, Cameroon, etc.)  The University of Zimbabwe researcher David Wilson, now with the World Bank’s GAMET project, discussed this at the USAID-organized ABC Panel at the ICASA Meetings in Nairobi in September 03.

## Cameroon: HIV Prevalence & Condom Sales 

**Cameroon: HIV Prevalence & Condom Sales **

**Urban and Rural Prevalence**

**Condom Sales**

**Notes:**
Neither I nor PSI mean to suggest, however, that one causes the other. Rather, this unfortunate association observed between increased condom availability and HIV prevalence, in several high-prevalence SSA countries, was one of the reasons to cause some experts to question the previous implicit assumption that if we just “get enough condoms out there,” somehow prevention will be covered?... Of course, things are never that simple, but this appears to have been one of the background reasons for the increased interest now in ABC: i.e., that perhaps our main current approaches have not always been quite as effective as we had all hoped. In addition to PSI, a growing number of internationally respected researchers, such as David Wilson, Professor Norman Hearst (University of California, San Francisco) and Doug Kirby (the ABC Study Director) are actively investigating and analyzing the available “ABC” data.  Those of you who know these researchers will, I am sure, vouch that they are not driven by ideological concerns, but rather are sincerely committed to expanding the evidence base for our prevention efforts.

## Conclusions [by PSI]:
Condom sales tend to rise over time - but so does HIV prevalence
condom sales increases alone have not led to reductions in incidence or prevalence in many countries.
(perhaps not in any country-certainly not in any country with a generalized epidemic-TG) 

Other Conclusions: there may not be any causal connection, but 7-8 studies now show association between condom use and greater HIV infection levels than among non-users (probably because inconsistent use, disinhibition, false sense of security...)

- Condom sales tend to rise over time - but so does HIV prevalence
***condom sales increases alone have not led to reductions in incidence or prevalence in many countries***.
- (perhaps not in _any_ country-certainly not in any country with a generalized epidemic-TG)
- Other Conclusions: there may not be any causal connection, but 7-8 studies now show association between condom use and greater HIV infection levels than among non-users (probably because inconsistent use, disinhibition, false sense of security...)

**Notes:**
These were some of the conclusions offered by John Berman, Director of PSI’s AIDSMARK global social marketing program, in his presentation last year. (This and the preceding three slides were directly pasted in by me, with permission from PSI.)

## Uganda in 1993

- Something different was happening, something that the experts had not predicted
- HIV infection rates had started to decline, yet condom rates were too low to have had any significant impact

## Decline in National HIV Seroprevalence in Uganda, Based on 15 Sentinel Surveillance Sites

## The prevention approach that was developed in Africa

**The “ABC” approach**
_**A**_bstain**, **_**B**_e** **faithful, or use** **_**C**_ondoms
**Uganda put strong emphasis on, and resources into, fidelity, abstinence, delay of debut among youth, who were the primary targets in AIDS prevention.**
**In spite of all we hear about raging hormones, behavior changed first, and to the greatest degree among age group 15-19. This group also had the greatest decline in HIV prevalence. **

## Uganda’s Early Response:

- National response began in 1986, with bold leadership by President Museveni.
- The period 1986-91 is important, since HIV incidence & eventually prevalence peaked then.
- Condom social marketing didn’t take off until mid-1990s. There was some condom promotion from the beginning,  but this approach was not favored by the President.

## President Museveni on condoms

- “Just as we were offered the “magic bullet” in the early 1940s, we are now being offered the condom for “safe sex.” We are being told that only a thin piece of rubber stands between us and the death of our continent. I feel that condoms have a role to play as a means of protection, especially in couples who are HIV-positive, but they cannot become the main means of stemming the tide of AIDS.”
- President Museveni, 1991

## Pres. Museveni’s approach 

- He put emphasis on persuading youth to delay sex until they were married, and those already sexually active were urged to be faithful to one partner only (“zero-grazing”).
-  “When I had a chance, I would shout at them," he said. "[I used to say] 'you are going to die if you don't stop this. You are going to die!"

## Distinguishing features of the prevention approach (all beginning 1986-7)                          and in addition to an ABC approach

- Bold leadership at the highest level, open discussion re. AIDS & sexual behavior, “sounded the alarm”
- AIDS preventive education in primary schools, reaching children before they are sexually active
- Involvement of religious leaders
- Involvement of PLWHAs in AIDS prevention
- Fear arousal, meant to engender risk perception and behavioral change
- Face-to-face, open discussion about AIDS, community involvement
- Major involvement and “advancement”  of women and youth
- Fought AIDS-associated Stigma

## Changes in sexual behavior among men in Uganda, WHO/GPA surveys, 1989 &1995

## Changes in sexual behavior among women in Uganda, WHO/GPA surveys, 1989 &1995

## Types of reported behavior change in UgandaDHS 1995

## Types of reported behavior change in UgandaDHS 1995

## Types of reported behavior change, 3 Ugandan Districts, 2000-2001

## Newsweek on Uganda

- A cover story about AIDS in Africa in Newsweek (1/17/00) points out that its not all doom and gloom: there is at least one success story to learn from, Uganda.
- “In Uganda...health workers turned Protector condoms into must-have fashion accessories, simply by introducing a flashy new package and a marketing slogan (“So strong, so smooth”).
- No other method of prevention was even mentioned.

## Actual Condom use in the general population of Uganda

**In 1995, about 6% of sexually active Ugandans, used a condom with some regularity, according to the Demographic and Health Survey.**
**By 2000, this rose to 11% of sexually active Ugandans, or 8% of all Ugandans. However condom use has become quite high among those who need them most, namely those relatively few who are still having multiple partners**** (e.g. among CSW & clients,  >95%)**

## Thailand

**Thailand was the first country in Asia to document HIV epidemics among IDUs, and among sex workers and their clients. **
** **
**Between 1989-90, “shocking” prevalence figures emerged and were allowed to be broadcast to the public, e.g., 1989 findings that 44% of Chiang Mai brothel workers were HIV+**
** **
**Thailand’s national response to AIDS began in 1989. Directed initially by Mechai Viravaidya and the Population and Community Development Association (PDA)**

## Thailand: early national response

**Primary target groups were adolescents, CSWs, clients of CSWs, and wives of men with multiple partners (Pattalung and Bennett 1990:3)**
** **
**Campaign used fear arousal messages to attract attention, to convey the core information that AIDS is fatal but can be prevented**
** **
**Condom use and partner reduction were the primary behavior change messages. Abstinence/delay became part of the message, but not clear when and to what degree.**

## Thai response

**Rapid dissemination of information through leadership structures, down to grassroots **
** **
**AIDS education was incorporated into school curricula in 1990.**
** **
**Religious leaders were mobilized**
** **
**New Prime Minister (1991) became directly involved in AIDS control. Chaired the national AIDS committee, helped develop a 5-year plan.**
**        ****Since HIV prev. declined sharply after mid-1990s, it is useful to look at behavioral changes prior to this decline**

## Early results in Thailand 

- Comparison of national behavioral surveys in 1990 and 1993, just prior to drop in HIV prevalence:
- % of men reporting premarital or extramarital sex in last year fell from 28% to 15%,
- % of men visiting CSW from 22% to 10%, and consistent condom use (reporting always using condoms in commercial sex) rose from 36% to 71%. **(Phoolcharoen et al 1998, AIDS)  **
- By 1996,  condom use rose to 97% in brothels, and to 89% among “indirect” sex workers (e.g. massage parlors) in Bangkok

## Evidence  of  continuing  behavioral  change  (visits  to  female  sex  workers  and  condom  use  at  last  visit)  in  21  year  old  males  in  the  north. 

**Percent  of  sample**

## Slide 35

## Parallels: Thailand & Uganda

**An early and vigorous response **
**An **_**indigenous **_**strategy developed by both **_**governments**_**, before much foreign TA**

**3-4 years after national response began: **
** ***** significant behavior change had occurred, including                  less casual sex  **
**  *****  HIV prevalence had peaked. **
**There was also:  **
**Open discussion       **
**Community mobilization, **
**Strong Political leadership, **
**Explicit messages (no soft-pedaling of messages).**

## Replicability of Uganda’s success

**There seems to be no reason Uganda’s ABC model could not be replicated in other countries with generalized epidemics.**
** **
**(re. the “forcing the model” argument: we donors have already forced a universal risk reduction model everywhere, whatever the culture  or epidemiological pattern)**
** **
**Stoneburner and Low-Beer (2000) say the effect of HIV prevention interventions in Uganda (particularly partner reduction) appears to have had a similar impact as a potential medical vaccine of 80% efficacy.) **

## ARVs and VCT

- The big interest nowadays is in ARVs. VCT is the entry point to treatment and it is also being promoted as an effective tool of prevention. Leading authorities are now saying we can't expect behavior change unless people know their sero-status. Yet there was a great deal of behavior change in Uganda and Senegal and elsewhere in the absence of VCT (and only 10% of Ugandans have been tested in Uganda even today).
**The evidence that VCT leads to behavior change and lower HIV Prevalence is mixed.****   ****If The “C” in VCT is based on ABC, then it could lead to positive behavior change**