# Presentation: 107142

## The ABC Prevention Model and Its Application in the United States

- Alma L. Golden, M.D., F.A.A.P
-  Deputy Assistant Secretary for Population Affairs
- Office of Population Affairs,
- U. S. Department of Health and Human Services
-                         July 17, 2003

## Crisis Management

- CPR
- Crisis demands response
- Address priorities (first – risk of death)
- Airway/breathing/circulation
- Asses and begin to manage immediate and potential threats in situation

## HIV/AIDS Crisis

- HIV/AIDS demanded an immediate response
- First focus on highest risk populations
- Focus on highest risk behaviors
- Initiate reasonable interventions with theoretical validity

## HIV Crisis Interventions Rewarded

- Education and action by those at highest risk
- Rate of infection blunted

## HIV incidence among men who have sex with men in San Francisco

- “Condoms were heavily promoted from the beginning of the epidemic by public health officials and by leaders in the local gay community.  By all accounts, condom use among MSM in San Francisco increased dramatically in the early and mid 1980's and became the norm in this population.  Incidence rates for all STIs fell substantially.  Annual HIV incidence rates fell from double digets in the early 1980's to less than one percent after 1985.”  Hearst

## Success of Crisis Response con’t

- Victims and families learned to advocate for assistance
- $15 billion spent annually on HIV/AIDS research, care and treatment

## Subsequent Interventions

- Focus remains on condom distribution and correct and consistent usage
- Little attention directed toward preventing the development of new high-risk populations
- Few resources and little energy committed to importance of delay of sexual activity, limiting number of partners, or mutual monogamy in long term, committed relationships
- Early stages of HIV interventions may have overestimated the efficacy, acceptance, and willingness of individuals to maintain use of condoms
- Some interventions may have inadvertently conveyed inaccurate expectations of risk

## Twenty Years of Transition: Medical Sciences

- Progress in drug therapies
- Vaccine issues
- Condom studies - condom effectiveness

## “Condoms for AIDS Prevention In the Developing World: A Review of the Scientific Literature” 

- Professor Norman Hearst
- University of California, San Francisco
- January 12, 2003

## Condom Studies

- “Estimates of condom effectiveness range from a low of 46% to a high of 100%” depending on the type of study and variables in the studies.”   Norman Hearst

## Condom Studies

- Meta-analysis studies found condom effectiveness rates between 69% and 90%                                                                                Norman Hearst

## Condom Studies

- “A good simple answer may be...that condoms appear to be about 90% effective when used consistently and correctly.” Norman Hearst

## Condom Studies

- “We need to tell the truth about condoms:  that they are effective but not 100% effective.  This includes referring to sex with condoms as “safer sex” rather than “safe sex.”  Hearst

## Condom Effectiveness

- Sex workers who use condoms consistently are still getting HIV, although it is delayed
- “One cohort study in Northern Thailand...found HIV incidence rates of 1.7% per year among sex workers who reported consistent condom use versus 23.8% for those who did not.”Hearst (49)

## Twenty Years of Transition:Treatment Successes & Challenges

- Vastly improved quality and length of life
- AIDS is no longer a death sentence for most HIV infected people who adhere to appropriate drug regimes
- However, condom use among MSM appears to be on the decline

## Twenty Years of Transition: Social Sciences – The Marriage Movement

- Marriage Movement
- Married people are happier and have less depression
- Married men earn more money than single men
- Married couples build more wealth
- Marriage reduces the risk of involvement in crime and domestic violence
- Married people are healthier, as are their children

## The Marriage Movement

- Married people, particularly men, live longer
- Marriage is associated with a lower risk of infant mortality
- Marriage increases the likelihood that fathers have good relationships with their children
- A Report from Family Scholars:  Why Marriage Matters:  Twenty One Conclusions from the Social Sciences

## Twenty Years of Transition: Social Sciences – The Fatherhood Movement

- “Fatherlessness in America today is an unprecedented reality with profound consequences for children and civil society...  For the first time in our history, the average expectable experience of childhood now includes a significant amount of time living absent one’s own father.”  Wade Horn

## Children of Absent Father

- More likely to:
- Fail or drop out of school
- Exhibit behavioral problems
- Engage in early sexual activity
- Commit suicide
- Engage in crime and violent behaviors
- Abuse substances
- Be abused or neglected
- The Fatherhood Movement:  A Call to Action

- “Controlling for factors such as low income, children growing up in father absent households are at greater risk for experiencing a variety of behavioral and educational problems, including extremes of hyperactivity and withdrawal; lack of attentiveness in the classroom; difficulty in deferring gratification; impaired academic achievement; school misbehavior; absenteeism; dropping out; involvement in socially alienated peer groups and ...... smoking, drinking, early and frequent sexual experience, and in more extreme cases, drugs, suicide, vandalism, violence and criminal acts.”  Urie Bronfenbrenner, “What Do Families Do?”  Family Affairs, Winter/Spring 1991: 1-6

## Twenty Years of Transition:  Epidemiology

- In 1981 there were 329 diagnosed cases of HIV/AIDS and 130 deaths
- In 2001, there were 24,855 reported diagnosed cases of HIV/AIDS and 8,998 deaths
- Transition for white male MSM to women and minority groups
- Half of all new cases occur in people  under age 24

## Slide 23

## Slide 24

## Twenty Years of Transition:  Societal

- Involvement of society has been segmented
- Religious community – emphasis on condom promotion alienated or allowed them to avoid responsibility
- Schools – controversial programs such as condom distribution have shut down school health programs
- Health community – The desire to remain non-judgmental and avoid values has led to non-directive counseling which inadvertently implies that outcomes are equal

## Societal Transitions con’t

- Parents
- Became reluctant to direct children
- Tolerance for adolescent autonomy
- Fear of antagonizing their children
- Fear of adult hypocrisy if guidance given

## Societal Transitions con’tAbstinence Movement

- Parents and others concerned that early HIV/AIDS interventions ignored emotional, social and moral implications of sexual behavior
- Health professions began to worry about early sexual activity, other STIs and number of partners

## Society Transitions con’t:Abstinence Programs

- Curricula focused on values in early abstinence programs
- Major focus currently on health issues, goal setting, decision making, relationship development, and refusal skills
- Abstinence taught collaterally with or substituted for other sexuality courses in schools

## HISTORY OF THE ABCs

- ABC originated in Uganda
- Zambia is now using the ABCs
- ABC is the focus of the $15 billion committed by the U.S. to fighting AIDS in Africa
- Administration is encouraging the use of ABC in domestic programs

## ABC Approach to Prevention in Uganda

- A - ABSTAIN until married or in a long term committed relationship
- B - BE FAITHFUL in marriage and long term committed relationships
- Reducing the number of partners
- C - USE A CONDOM consistently and correctly if neither A nor B is followed

- “...condom promotion has not played a major role in Uganda’s AIDS control efforts until relatively recently.  The evidence clearly indicates that Uganda’s success was due mainly to changes in sexual behavior among the population, especially a large reduction in the number of casual partnerships.”  Hearst

## UGANDA INCIDENCE OF INFECTION (USAID)

- Usaid SLIDE

## UGANDA INCIDENCE OF INFECTION

- 1985 - 10 % of women infected with HIV
- 1990 - 31 % of women infected with HIV
- 2000 – 6% of women infected with HIV
-                                   (USAID DATA)
- AP Africa (July 11, 2003) reports the current incidence as 5%

## Ugandan President Museveni

- “We have made it our highest priority to convince our people to return to their traditional values of chastity and faithfulness, or failing that, to use condoms.  The alternative was decimation.”
-                      (Reported July 11, 2003  by AP Africa)

## What Happened in Uganda?

- A – ABSTAIN
- 1989 – 31% of male teens were virgins
- 1995 – 56% of male teens were virgins
- 1989 – 26% of female teens were virgins
- 1995 – 46% of female teens were virgins
-                                            (USAID Data)

## What Happened in Uganda?

- B – BE FAITHFUL
- 1989 - 39% of males had multiple partners
- 2000 - 11% of males had multiple partners
- 1989 – 19% of females had multiple partners
- 2000 – 2.5% of females had multiple partners
-                                                   (USAID Data)

## What Happened In Uganda?

- C – USE A CONDOM
- Condom distribution increased from less than a million in 1991 to about 22 million in 2000
- Condom use at last sex increased from 24% to 28% of males and from 17% to 21% of females
- Condom use in Uganda is no higher than in most other African countries where the incidence of HIV continues to rise
- South Africa, Botswana & Zimbabwe have higher rates of condom use but have not had similar declines in HIV infection
- 	                                                     (USAID Data)

## Condoms for AIDS Prevention in the Developing World:  A Review of the Scientific Literature

- “A program emphasizing condom use in commercial sex and prevention for injecting drug users would not have worked in Uganda, where these are not the main factors in driving the epidemic.”  Hearst

## ZAMBIA

- Zambian government launched a series of campaigns directed at youth
- Johns Hopkins Center for Communications
- Multi Media Communications Program targeting youth
- “HEART – Helping each Other Act Responsibly Together”
- Focus was on A and C - not B
- Be Faithful was not emphasized because young people’s concept of a long term relationship can be as short as a month

## HIV prevalence among young pregnant women  in Lusaka, Zambia, 1994-1998

## What Happened in Zambia? 

- “In the past 5 years, HIV infections in the 15-19 year old urban girls population have dropped nearly 50%, from 28% to 15%.”  Paul DeLay, USAID July 11, 2002 Press Conference)
- 1996 – 41% of pregnant women between ages of 25 and 29 in Chelstone, Zambia were HIV positive
- 1998 – 32% of pregnant women between the ages of 25 and 29 were HIV positive
-                                       (USAID Data)

## ZAMBIA con’t 

- Premarital sex “among single young women declined from 41% in the early 90’s to 14% in the late 90’s.”  (Paul DeLay, USAID July 11, 2002 Press Conference)

## ABC in Tanzania

- Incidence of infection declined from 4.8% in 1987 to 0.6% between 1993-1996

## HIV Prevalence in Pregnant Women and Condom Sales by Year in Botswana

## Condom Promotion in Other Countries That Have Experienced Declines 

- “As in Uganda, the apparent decline in HIV incidence has more to do with reductions in casual partners than with increased condom use.”  Hearst

## ABC in the United States: How do we translate the success of ABC in Uganda to the U. S.?

## Secondary Benefits of HIV Prevention Activities

- ABC was designed in Uganda to slow the spread of HIV infection, but it also has the potential of helping to prevent the transmission of other STDs and reducing the incidence of unintended pregnancies, including teen pregnancies.

## Secondary Benefits of HIV Interventions:  STDs, Single Parenthood and Teen Pregnancy

- 3 of the 10 most commonly reported infectious diseases are STDS
- 1 in 4 sexually active teens contracts an STD each year
- 45 million women are currently infected with HPV – 14,000 new cases of cervical cancer annually

## Secondary Benefits of HIV Interventions

- Births to single mothers
- In 1960, 5% of births were to single mothers
- In 1999, 33% of births were to single mothers
- Single mothers and children born to single mothers experience multiple health, economic and social problems

## Application in the U.S: Differences Between the U.S. and Uganda 

- High risk populations are different
- In Uganda the infection is spread primarily heterosexually, often within marriage
- In the U.S. high risk populations include MSM and IV drug users
- Minorities are at higher risk in the U.S.
- The gay population in Uganda is small
- No major racial or ethnic differences in Uganda

## Differences Between the U.S. and Uganda con’t

- “A program emphasizing condom use in commercial sex and prevention for injecting drug users would not have worked in Uganda, where these are not the main factors in driving the epidemic.”  Hearst

## Differences Between the U.S. and Uganda con’t: Availability of Health Care

- Access to care, treatment and pharmaceuticals vary
- Condoms are not as readily available in Uganda
- “In a country like ours, where a mother often has to walk twenty miles to get an aspirin for her sick child or five miles to get water at all, the question of getting a constant supply of condoms may never be resolved.”  Ugandan President Yoweri Museveni

## Differences Between the U.S. and Uganda con’t

- Higher levels of poverty in Uganda
- Lower levels of education in Uganda
- Religious patterns are different
- Societal expectations are different

## Similarities Between Uganda and the United States

- Infectious nature of the diseases
- The mechanisms of infection
- Vulnerability of certain populations
- Threat of chronic disease and death

## Similarities con’t

- Concern of families and communities
- Threat of personal and societal losses – estimated that in Zimbabwe, 50% of children will be AIDS orphans by 2020
- Need for positive messages and support systems

## U.S. Implementation

- ABC is not a new public health concept
- The balance among the three interventions and their application to specific populations is new
- “Over the past 5 years, we have gained a better understanding of the delicate balance between these three strategies.”  (Paul DeLay, USAID Press Conference, July 11, 2002, speaking of his experience in Uganda)

## ABC is Population Specific“Abstain”

- “A” is for all individuals who are not in a long-term committed relationship, such as marriage
- “A” applies to nearly all adolescents
- High risk and disadvantaged adolescents should not be singled out with a different message and lower standard of behavior
- Abstain is an appropriate message for sexually active adolescents; previous sexual activity does not preclude future abstinent behavior
- Society needs to provide positive youth development activities

## Abstain con’t

- “A” is for unmarried adults or adults who are not in long term, committed relationships
- AIDS is neither kinder nor gentler to someone in his or her 20’s or 30’s than to someone in his or her teens

- “...men believed that abstinence would likely protect them from acquiring STDs, help them get to know their partners better, and prevent pregnancy...”                Perspectives on Sexual and Reproductive Health, May/June 2003, Heterosexually Active Men’s Beliefs About Methods for Preventing Sexually Transmitted Diseases

## ABC Is Population Specific“Be Faithful”

- “B” is for married people and people in long term, committed relationships when both partners are uninfected
- Committed monogamy between uninfected partners eliminates the risk of sexual exposure to HIV
- The greater the number of partners, the greater the chance of exposure to HIV
- “B” is rarely the appropriate message for teens because of their concept of a long term relationship

## Heterosexually Active Men’s Beliefs About Methods for Preventing STDs 

- Monogamy B Amonogamy would help them build trust and respect with their partner, show their love, avoid STDs and satisfy their partner--both very likely ... and very desirable ...”                                     Perspectives on Sexual and Reproductive Health, May/June 2003

## ABC Is Population Specific“Use a Condom”

- Use a condom consistently and correctly is  the appropriate message for the minority of individuals who choose to neither abstain nor enter into long term, committed relationships with uninfected partners
- Use a condom applies to people who are in a relationship when one or both partners are HIV positive
- Use a condom applies to sex workers and drug abusers

## Application in the U.S.

- “Condom promotion for the general population would also be expected to be beneficial, but so far there is less evidence for this being an effective public health approach.”  Hearst

## Interplay Between A, B and C 

- “Different interventions can interact with each other in ways that are even stronger than shifting money from one program to another or multiple layers of protection.”  Hearst
- “An intervention aimed at reducing one aspect of sexual risk had an unintended impact on another aspect of sexual risk.” ibid
- “A recent effort to model the impact of various AIDS prevention strategies estimated that outreach programs for men who have sex with men would increase their condom use by 33% but also increase their number of high-risk partners by 17% (131) ibid

## U.S. Implementation:  Lessons Learned That Apply to ABC

- Importance of the delivery of a unified message by all segments of society
- In Uganda, the “Emphasis from the beginning was on encouraging involvement and discussion among all sectors of society.  As of 2001, there were reportedly over 700 agencies, governmental and non governmental, working on AIDS prevention in Uganda.  These ranged from religious groups to NGOs to the military.”  Hearst

## Lessons Learned: Unified Message

- Parents and families
- Schools
- Government
- Media
- Churches
- Religious community intervention in 10 districts of Uganda lowered the proportion of respondents reporting two or more partners from 86% among men and 75% among women to 28% among men and 7% for women

## Lessons Learned:  Unified, Consistent Message

- “HIV/AIDS prevention messages aimed at teenagers are best delivered by trusted, known adults in a comfortable setting such as home, church, school or youth groups.”  Metro Council for Teen Potential, Rochester Democrat Chronicle

## U.S. Implementation:  Lessons Learned That Apply to ABC - Changes in social norms and societal expectations

- “ABC....promotes not only individual change, but possibly, more importantly, change in the social norms as they relate to healthy reproductive behaviors.”  (Jane Bertrand, Director of the Johns Hopkins University Center for Communications Programs)

## U.S. Implementation: Lessens Learned That Apply to ABC – AIDS Knowledge

- Learned that knowledge is not a predictor of behavior
- AGI Homepage Question of the Day: “Are people in Cote D’Ivoire who know more about AIDS more likely to use condoms?

## Knowledge as a Predictor of Behavior con’t

- Answer:  “No.  A recent analysis found that among respondents to a 1994 Demographic and Health Survey (DHS) - accuracy of AIDS knowledge did not predict the likelihood of recent condom use.”  (Zellner S., Condom use and accuracy of AIDS knowledge in Cote D’Ivoire, International Family Planning Perspectives 2003, 29(1): 41-47)

## Lessons Learned that Apply to ABC:  Importance of Expectations

- When teens were asked:  “When it comes to your sexual decision-making, which of the following is most influential, the largest percentage said parents (National Campaign:  With One Voice, a National Survey 2001)

## Teen Expectations

- When teens were asked, “How important do you think it is for teens to be given a strong message from society that they should abstain from sex until they are at least out of high school, 93% said it was very important.  (National Campaign Survey)

## U.S. Implementation:Lessens Learned That Apply to ABC: Importance of Support Systems

- Support Systems
- Parents and family
- Schools
- Churches
- Communities
- Need to equip supports systems to promote health

## Adolescent Expectations

- Most kids want to make healthy choices – 63% of sexually active boys and girls ages 12 to 17 say they wish they had waited until they were older.

## Lessons Learned That Apply to ABC: Condoms Play a Role

- “Condom promotion for the general population would also be expected to be beneficial, but so far there is less evidence for this being an effective public health approach.”  Hearst

## Lessons Learned That Apply to ABC:  Intervention Outcomes

- Unforeseen outcomes of interventions negative
- Positive - “...achieved nearly universal use of condoms in Thailand’s large commercial sex industry....In addition to high condom use in commercial sex, the proportion of Thai men patronizing sex workers has fallen sharply.”  Hearst
- Negative - Belief by some that condom promotion programs increase sexual activity by enabling and implying acceptance of sexual activity, particularly among teens.

## Lessons Learned That Apply to ABC:  Intervention Outcomes 

- “Few condom promotion programs collect the data necessary to determine whether their efforts are producing either positive or negative changes in sexual behavior other than condom use.”  Hearst

## Lessons Learned That Apply to ABC: Synergy

- Learned that, despite competition for resources, the ABC message can accomplish more than any of its components individually

## OPA IMPLEMENTATION

- Addition of ABC to Family Planning Clinical Services Grant announcement
- Addition of ABC to Family Planning Training Grant announcement
- 1% Evaluation Project for 2003 – a new scope of work to include ABC