African HIV activists want a new model for prevention

For years, the world's largest donors for AIDS research and treatment have funded a simple message for how to prevent the spread of the HIV, the virus that causes AIDS: Abstinence, Be faithful, and Condomize, also known as ABC.

It's a message that has helped reduce the number of people engaging in unsafe sex all over the world, and according to AIDS activists, has saved lives. But in some parts of Africa, this message has been very difficult to sell, and local activists say it should be reviewed or scrapped. 

For some governments, faith groups, non-governmental organizations, and individuals in Africa, ABC is simply not effective. It fails to curb the stigma still associated with AIDS, it pushes the epidemic underground, and it ends up hindering universal access to HIV diagnosis and treatment, they say. 

The ABC message, hatched in the Bush era, would have been up for redesign anyway because of major strides made in scientific understanding of the HIV virus, as well as cultural differences in the way that couples interact in the 54 countries on the African continent, AIDS activists say.

But it is the persistence of mother-to-child transmission of HIV, as well as increasing levels of infection among people in relationships, that a new public message on HIV needs to take into account.

Some faith leaders here have designed a new strategy, called SAVE (Safer practices, Access to treatment, Voluntary counselling and testing, and Empowerment) to replace ABC. With a 2011 UNAIDS report that found that HIV infection rates continued to drop, but that the highest rates remain here in sub-Saharan Africa, secular civil society groups and government leaders are rallying behind the SAVE cause.

Fifteen African countries, including Sierra Leone and the Democratic Republic of Congo, have adopted SAVE, and Malawi is expected to adopt it soon.

It is this lack of progress in Africa, highlighted in that UNAIDS report, that has become the rallying point against ABC.

“Of-course they (UN) wanted to make us 'happy,'" says Canon Gideon Byamugisha, a Ugandan Anglican cleric who is a supporter of SAVE and in 1996 became the first African faith leader to announce his HIV-positive status.

Referring to the UNAIDS 2011 report, which found that HIV infections had dropped by 20 percent, Mr. Byamugisha replies, "What the reports did not acknowledge is that 80 percent is still at-large.”

“Now if we continue the same way, the same messages, same methodologies, and same budgets and for the next 30 years we get another 20 percent, how much is that? A 40 percent reduction. There will still be 60 percent," he says. "Can you imagine that in 2042 you will be here discussing AIDS? That is not tolerable.” 

Morality isn't enough

ABC is not without its supporters. According to UNAIDS, HIV prevention programs are working. The agency says its 2010 report confirmed that new HIV infections have declined in the past 10 years, and this decline is clearly linked with changes in behavior, along with increased knowledge of HIV, both attributable to ABC. 

Even so, UNAIDS admits, "existing prevention efforts suffer from numerous common weaknesses."

“With two new HIV infections occurring for every individual started on antiretroviral treatment, strengthening HIV prevention remains an urgent global health priority,” UNAIDS said in a statement. But the greatest weakness is that national programs are so often unfocused and poorly planned.  

“National prevention programs are too often made up of a collection of disconnected interventions, and these often lack clear milestones, clearly articulated causal pathways and clear connections with other programs that contribute to achieving the same prevention targets," the statement continues. “Weak investments in joined-up planning, monitoring, and evaluation systems reduce decision makers​’ confidence in existing prevention tools and prevent program planners and implementers from improving prevention efforts over time”

In Byagumisha's eyes, achieving the UN goal of zero new infections, zero discrimination, and zero AIDS-related death will require a comprehensive strategy that addresses HIV in its entirety. 

ABC's flaw, the cleric says, is that it takes a moral and sexual approach only – a deadly approach in African cultures where stigma, shame, denial, discrimination and inaction are all too common reactions – and doesn't teach people the multiple strategies that can prevent the spread of HIV. 

“Abstinence, for example, [also] needs condom use, safe blood, safe circumcision, microbicide, vaccines and so forth,” he says.

“ABC is somehow inaccurate because it seems to portray that once you are faithful you don’t get HIV," Byagumish says. "Yet we know there are very faithful people, there are people who are virgins at marriage, who end up being positive. This means that faithfulness is not safeness.”

Combatting the stigma

Mohammed Karama, an epidemiologist at the Kenya Medical Research Institution, says ABC also fails to create incentives for prevention, such as testing; care and treatment for infected people; and empowering the groups working to counteract the epidemic.

“There is a need for a non-stigmatizing approach that includes everyone," says Mr. Karama. "This will strengthen the efforts against the epidemic. That’s why we have been saying we need to reconsider ABC.” 

Because of the stigma – that HIV/AIDS is the disease that one get from “stealing sex" – many have not taken an HIV test, activists say.

“Many people would like not to know their HIV status. We know nearly 60 percent do not know their statuses and that needs to worry us," says Harriet Kongin, head of stakeholders coordination at Kenya’s National AIDS Control Council. "When we talk about prevention, we are saying there are very few of us who have tested and those who have tested are then aware of what needs to be done, but then what happens to that other 60 percent.”