The New AIDS Fight: A Plan as Simple as ABC
The New York Times
March 1, 2003, Saturday
By Edward C. Green; Edward C. Green, a medical anthropologist at the Harvard
School of Public Health, is author of the forthcoming "Rethinking AIDS
There have been suggestions that President Bush was able to promise $10
billion in new money to fight the AIDS pandemic in part because there is now
a way to spend the prevention part of this sum (about half) in a way that is
acceptable to conservatives. It's true that conservatives favor this
approach, but that doesn't mean it doesn't work.
The initiative is based on what is called the "ABC approach." People might
well wonder what this model is and what evidence supports it. Here is a
summary of Uganda's experience. We now know that the rate of new H.I.V.
infections in Uganda started to decline in the late 1980's. But foreign
experts began showing up in force in Uganda only in the early 1990's.
Moreover, there were very few condoms in Uganda when the epidemic began to
slow; they became widely available only after the experts appeared. Weren't
"we" supposed to teach "them" how to prevent AIDS?
What happened was that beginning in 1986, Uganda tried to bring about
nothing less than fundamental change in sexual behavior. It developed a
low-cost program whose message, delivered by everyone from President Yoweri
Museveni on down, was this: Stop having multiple partners. Be faithful.
Teenagers, wait until you are married before you begin sex.
This is what has become known as the ABC model: Abstain, Be faithful, use
Condoms if A and B fail.
By 1995, according to a survey financed by the United States, 95 percent of
Ugandans were reporting either one or zero sexual partners in the past year.
Moreover, the proportion of sexually active youth declined significantly
from the late 80's to the mid-90's. The greatest percentage decline in
H.I.V. infections and the greatest degree of behavioral change occurred in
those 15 to 19 years old. This was also the group with the fewest AIDS
deaths -- showing that it was most likely behavior and not death rates that
reduced infection rates.
Though only 8 percent of Ugandans aged 15 to 49 reported using condoms
recently -- this according to the 2000 Demographic and Health Survey, which
is conducted for the United States Agency for International Development --
the important thing is that those 8 percent engaged in practices that put
them at the highest risk of H.I.V. infection.
Why wasn't condom use more of a factor in Uganda's success in fighting AIDS?
Partly it was Mr. Museveni's skepticism that in a country where it was
difficult even to find aspirin, condoms could be supplied in adequate
numbers. So the priority in the ABC approach is on A and B. Elsewhere,
prevention typically begins and ends with C, in practice if not design.
But because the ABC approach is starting to be embraced by conservatives in
the United States, some AIDS groups have been reluctant to believe it could
be effective. Too often I've started to explain how the Ugandan H.I.V. rate
began to drop after people started having fewer sexual partners, only to be
met with a look of suspicion or condescension and informed that abstinence
Yet, when Africans are asked how they have changed their behavior in the
face of AIDS, the great majority don't talk a lot about condoms. They talk
about becoming monogamous, says a 2002 United Nations study that summarized
years of research. Furthermore, young people report waiting until they are
older to begin sex.
The ABC approach is not about that great conversation-stopper, "abstinence
only." It is about providing people with more options for preventing AIDS.
Some people cannot or will not change their behavior, and so of course they
need to use condoms. But while condom use was one of the options Uganda has
promoted, faithfulness to one partner is probably the major contributor to
the country's success. We need to develop a balanced approach by recognizing
that Africa and the West have different types of epidemics and going beyond
the fruitless battle between the abstinence and condom camps.