# Presentation: 333829

## ABCABCDEABCDE.........................Zero					    HIV/AIDS 

- Saifuddin Ahmed
- W. Henry Mosley
- Bloomberg School of Public Health
- Johns Hopkins University

## Epidemiological reasoning for ABC strategy  

*reproduction rate of infection* –the average number of susceptible people infected by an infected person over his/her lifetime
- The sexual transmission of HIV can be prevented by blocking the reproduction rate of infection through:
- (a) avoiding the exposure to risk
- (b) reducing the risk of exposure, and
- (c) blocking the efficiency of transmission risk

## ABC Strategy

##               15% in 1991 to 5% in 2001.

**Uganda:** HIV prevalence reduced:
-               15% in 1991 to 5% in 2001.
-                                           - UNAIDS

## Is the implementation of ABC program less challenging for the US, compared to Uganda?

## Sex: voluntary or involuntary?

- Adolescents, even minors, are vulnerable to sexual abuse
- "sugar daddy syndrome", where older men have sex with teenage girls (often for favor or money).
- Favors from teachers in exchange for sex
- Almost no legal protection

- Women are not empowered to control their body and sexuality in Africa.
- In the US, strong legal protection is in place.

## Successes and failures of abstinence programs in the US

- What worked and what didn’t work?
- Why didn’t work?
- Were the programs adequately implemented?
- The urgent needs for continuous monitoring of program implementation adequacy measurements.
- 4 hrs of abstinence education -  during a year
- 4 hrs of TV watching – daily
- Motivation needs evidence,
-    and a sound research provides evidence.

## Slide 8

## "In order to fully understand sexual practices and risk in Rwanda, therefore, one must look beyond numbers to the meaning of sex within the overall constellation of Rwandan values regarding social life and personhood. While statistical models are useful, there is strong tendency in Western medical science to overestimate their  importance." 					Taylor, 1990

## Be faithful  

- In the US:
- Women who became sexually active between the ages of 10 and 14 years were almost 4 times more likely to report having 5 or more sexual partners in the past year
- One in five male high school students and one in seven female students reported having had four or more sexual partners in their lifetime.
- Unmarried people are more likely to have had more than one partner; cohabiting individuals are more likely than married individuals to have had multiple partners
- 17 million women (15-44 years) are at risk of STD and HIV due to multiple partnership – directly or indirectly.

## Condom use does not prevent HIV
[not 100% use-effective]

Condom use reduces HIV risk
[80% use-effective]
		Cochrane Database Syst Rev 

- [not 100% use-effective]
- Condom use ***reduces*** HIV risk
- [80% use-effective]
*	**	**Cochrane Database Syst Rev*

## Consistent versus irregular condom use: effectiveness

- Consistent: RR = 0.37  [95% CI: 0.15 – 0.88]
-                                63% reduction
- Irregular: RR = 0.96    [95% CI: 0.53 – 1.74]
-                               Risk is similar to non-users
-                                        *Ahmed et al. AIDS 1991*

- 73% of individuals use condoms irregularly

- 100% using condoms **irregularly** = 0%                                             .........................................protected
- 50% using condoms **consistently** = 32% ..........................................protected 			95% upper CI:      = 43%                   ..........................................protected

## In US, adolescents who use condoms, consistent use is low; 
35% among the adolescents of age 15-15, and 31% among 18-19 years reported consistent condom use

about 22% teenage males reported condom use consistently in 1995 in the US 

even among the repeatedly counseled HIV sero-discordant couples in Europe, only half used condom consistently, despite knowing the risk

- 35% among the adolescents of age 15-15, and 31% among 18-19 years reported consistent condom use
- about 22% teenage males reported condom use consistently in 1995 in the US
- even among the repeatedly counseled HIV sero-discordant couples in Europe, only half used condom consistently, despite knowing the risk

## Identifying the targets

- Individual

- Peers

- Family

- Society/community

- Do current HIV programs
- target all segments?

## Abstinence

- Individual

- Peers

- Family

- Society/community

- Current approach

- Condom use

## Reproductive 

- Abstinence

- Be faithful

- Family

- Peers

- Social support/ social capital

- Society/Community

- Involvement of social institutions
- (e.g., faith-based organizations,
- PTA, etc)

- Condom use promotion

- Reproductive
- Life-course approach

*Mutual reinforcement*

## Use of religious leaders and organizations in family planning programs

- To reduce societal barriers
- Increase social acceptability
-  Predominately in Islamic countries
- 36% religious leaders discuss family planning in mosque in Jordan
- 70% agree that the mosque is an appropriate venue for family planning lectures and that family planning issues should be discussed in the mass media.
- 91% of male and 98% of female religious leaders say that they encourage couples to discuss contraception.

- Carol Underwood, *IFPP*, 2000

## Slide 19

## Does condom use increase behavioral disinhibition?

- Behavioral disinhibition refers to an increased engagement in high risk sexual practices (casual sex, multiple partnership)  among condom users in response to perceptions of safety conferred by the condoms as a physical barrier against HIV transmission
- The measurement is not possible from cross-sectional data

## Trends in sex outside of marriage/union during 1995-2000 at Rakai, Uganda

- 0

- .1

- .2

- .3

- .4

- .5

- Probability

- 1

- 2

- 3

- 4

- 5

- 6

- 7

- Survey rounds

- Non-users

- Consistent users

- Irregular users

## Behavioral disinhibition effects

- In both men and women :
-  Sex outside of marriage/union reduced significantly among the non-users of condom
- Multiple partnership reduced significantly among the non-users of condom
- But, increased among the condom users significantly

## Where are the messages for consistent condom use?

-             FDA Label requirement:
- "If used properly, latex condoms will help to reduce the risk of transmission of HIV infection (AIDS) and many other sexually transmitted diseases."

- consistently and correctly

- [later specific STDs spelled out]

## Condoms are primarily used with high risk/casual partners

It is unlikely that the high-risk behaviors will be ever at zero level and the needs of condoms for protection with high risk partners are beyond any argument

There is an urgent need to overtly stress consistent condom use through all sorts of communication channels, including on the label;  just promotion may not be enough

 For appropriate informed decision making process, risks and benefits of condom use should be clearly stated [does not provide “safe sex” but “safer sex”] 

- It is unlikely that the high-risk behaviors will be ever at zero level and the needs of condoms for protection with high risk partners are beyond any argument
- There is an urgent need to overtly stress consistent condom use through all sorts of communication channels, including on the label;  just promotion may not be enough
-  For appropriate informed decision making process, risks and benefits of condom use should be clearly stated [does not provide “safe sex” but “safer sex”]

- Summary

## Summary...cont.

- Recognize the significance and address the behavioral disinhibition issues to maximize the effectiveness of HIV prevention programs
- ABC programs – if successful in terms of impact – likely to be more cost-effective
- there is no cost associated with the practice of abstinence and “be faithful”, but condom use incurs costs
- We are tuned to “evidence-based” medicine;  evaluation of the effectiveness of ABC program will be a challenge and will require long-term funding commitments. The process should start now.

## Is condom use promotion enough to prevent HIV?