Africa Gives 'ABC' Mixed Grades
AIDS Abstinence Plan Raises Awareness but Has Small Effect on Behavior

By David Brown
Washington Post Staff Writer
Tuesday, August 15, 2006

TORONTO, Aug. 14 -- "ABC," the AIDS-prevention strategy widely promulgated both here and abroad, got a distinctly mixed report card as African countries reported their experiences to delegates at the 16th International AIDS Conference here.

Abstinence until marriage -- the A of ABC -- appears to be well understood by young people. Being faithful -- the B -- is less clear to many. The usefulness of condoms -- C -- varies widely, with some African teenagers aware that they protect against HIV infection most of the time, while others have heard mostly about their rare failures.

More important, the evidence that ABC is changing behavior is quite spotty, with condom use appearing to be the most acceptable of the three forms of advice.

ABC is a centerpiece of the Bush administration's $15 billion, five-year plan to fight AIDS in 15 target countries, most of them in Africa.

Closer to home, a study from Philadelphia found that an "abstinence only" sex-education curriculum was more likely to persuade black junior high school students to put off initiating sex than a more comprehensive curriculum.

The studies' results have something for everyone, and are not likely to end debate over whether ABC represents a balanced message of proven value or heavy-handed moralism out of touch with the reality of youth, Africa and gender inequality.

The Bush program stipulates that one-third of the money spent on preventing sexual transmission of the virus must go for "abstinence until marriage" messages.

Architects of the plan say this recognizes the usefulness of a strategy, devised by Africans, that has allowed a few countries, such as Uganda, to reduce the prevalence of AIDS infection. Critics say the Bush plan's version of ABC focuses too much on the abstinence component while reserving advice about condom use only for high-risk people, such as prostitutes, truckers and migrant laborers.

The interim evaluation of efforts in Botswana, supported by the U.S. Centers for Disease Control and Prevention, found that much of the ABC message was getting through, but that it was not making much of a difference.

A country of 1.6 million people in southern Africa, Botswana has a population-wide HIV prevalence of 17 percent. A program called Total Community Mobilization sent 450 AIDS counselors door-to-door, giving prevention advice, urging HIV testing and referring infected people to treatment. Researchers compared the people's knowledge and behavior in five districts that got this intervention with those in two that did not.

People who had talked to the counselors were twice as likely to mention abstinence and three times as likely to mention condom use when asked to describe ways to avoid infection. However, they were no more likely than the uncounseled to mention being faithful as a good strategy.

The people who had been counseled were also twice as likely to have been tested for HIV in the previous year, and to have discussed that possibility with a sex partner. However, they were just as likely to have a partner outside marriage as the people who had not gotten a visit from a counselor, and they were no more likely to be using a condom in those liaisons.

"People who were exposed to the program had greater knowledge but were no more likely to be practicing ABCs," said Margarett K. Davis, director of the "BOTUSA" collaboration between the two countries.

There was a somewhat different result in a study of young Nigerians, ages 15 to 24, most unmarried, living in the city and working in semiskilled jobs.

People in specific neighborhoods were counseled with an ABC message as part of a seven-year project funded by the U.S. Agency for International Development and its British counterpart. Those people's attitudes and behaviors were measured before and 18 months after the intervention, and compared with those of people who were not counseled.

The uncounseled group showed no increase in condom use -- it stayed about 55 percent. In the counseled group, however, condom use by women in their last nonmarital sexual encounter rose from 54 percent to 69 percent. For men, it rose from 64 percent to 75 percent.

Stigmatizing attitudes appeared to be less common among the counseled group. More of them, for instance, said they would be willing to buy food from someone with HIV compared with those who had not gotten the prevention messages. But those were about the only differences.

"We did not see a reduction in the number of partners," said Godpower Omoregie, the researcher from Abuja who presented the findings.

A survey of 1,400 Kenyan teenagers found a fair amount of confusion about ABC's messages. About 15 percent of the girls and slightly less than half the boys had had intercourse.

Half of the teenagers could correctly define abstinence and explain why it was important. Only 23 percent could explain what being faithful meant and why it was important. Some thought it meant being honest, and some thought it meant having faith in the fidelity of one's partner. Only 13 percent could correctly explain the importance of a condom in preventing HIV infection. About half spontaneously offered negative opinions about condoms, saying they were unreliable, immoral and, in some cases, were designed to let HIV be transmitted.

"This group, at least, had very negative views about condoms," Julie Pulerwitz, who helped conduct the study for the Population Council of Washington, told the delegates.

Some critics of ABC say that some counselors use the strategy as a way to discredit condoms, not simply describe their use. The source of these youths' opinions, however, was not known.

In the Philadelphia study, 662 black students in grades six and seven were randomly assigned to get one of several sex-education messages. One emphasized abstinence only. (At the time, 23 percent had already had intercourse at least once.)

Two years later, 48 percent of the group that got abstinence-only messages had had intercourse at least once, compared with 61 percent of those who had gotten a "comprehensive" message that mentioned condoms, among other things.

John B. Jemmott III, a psychologist at the University of Pennsylvania, said those initiating sex in the abstinence-only group were just as likely to know about condoms, and to use them, as those who got the full ABC message. This curriculum for young students is being adopted for use in Kenya as part of a CDC-sponsored program, he said.

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