Getting real about HIV/AIDS: ABC does not stop at abstinence.
Most young women in southern Africa, usually at about the age of 16, start having sex with their boyfriends because they are looking for a marriage partner. They are brought up from an early age to believe that marriage is their destiny in life. This is true whatever their social status, but is more urgent if they are poorly educated or come from a disadvantaged family. They often believe the promises their boyfriends make of marriage and homes, even when the boyfriend is much older and possibly even already married because, if the boyfriend has money, the woman could be his second or third wife. Anything is better than being stuck at home looking after younger siblings, cooking and washing and cleaning like a modern-day Cinderella.
In southern Africa, women still expect to be "tested," to prove that they are able to get pregnant before lobola, or a dowry, is paid, since their worth is based on their ability to bear children. Young women often misjudge their boyfriend's intentions, expecting commitment to marriage when he is mainly interested in sex, and will say what he needs to get it. When the man seems to be losing interest, the woman may get desperate and give in to his demands. Negotiating for protection in this situation is unlikely since no woman would want to question a prospective husband on what he has done in the past, what his my status is likely to be, in case he gets threatened by the challenge and leaves. There are plenty more eager young women where this one came from, all looking for the economic security and social status of being a wife. It is also true that most women do not marry the first man they set their sights on, but pass on to the next one in the hope that he will live up to the promise the first one broke. This next person may be someone like Ngoni, and so the chain goes on.
AIDS AND ABC
As Ngoni's story shows, the ABC approach [Abstain, Be faithful, use Condoms] is directed at individual behavior and is of limited application in a society where HIV transmission is already rampant. The driving forces for HIV transmission in southern Africa are linked: poverty, the economic and social dependence of women on men and a fear of discrimination that prevents people from openly discussing their status. Women are not able to disclose to their partners that they may have been exposed to HIV in case they are vilified, deserted and left destitute. Sometimes this may mean being separated from their children. Men cannot disclose their risk of exposure because it contradicts the traditional image of men as responsible leaders and decision-makers, challenges their authority in the home, and shows them up as having exposed the family to risk. Poverty can push women into formal and informal sex work to feed their families, while their men may have to migrate to distant locations to look for work, spending long periods away from home. It is virtually impossible for individuals to change their behavior and either abstain from sex or consistently use condoms in the absence of an enabling and supportive environment.
A supportive and enabling environment has to incorporate a whole range of approaches that support rights and responsibilities in HIV prevention, support and care for those living with HIV and AIDS--including their families--and mitigate the impact of AIDS on families and communities. Removing the stigma that prevents appropriate support for families affected by HIV and AIDS is crucial for successful prevention programs, otherwise silence and fear perpetuate denial, shame, reluctance to seek advice or protection and a stereotyping of those who identify themselves as being at risk as "bad."
The debate about the ABC approach has usually centered on a dichotomy between abstinence and condom use, particularly as focused on young people, and coming from religious versus public health principles. Such polarization is not helpful. There is no single solution for sexually active people: there has to be a choice of methods and different choices may be more appropriate in different circumstances. A woman may successfully delay her first sexual experience, but find she needs to use condoms when faced with a husband returning home after a year's work in the mines of South Africa. Even though the majority of new cases of HIV are in young people, programs cannot focus on their needs to the exclusion of others. Young girls are often infected by men five to 10 years older than themselves, and these men need HIV prevention education through peer education programs in workplaces that reach all ages and that advocate a range of prevention tactics. Young men don't like to go into their first relationship inexperienced and may get initiated by sex workers. Sex workers I have worked with describe how young men refuse to use condoms because they are not used to them and are terrified that using condoms will prevent them from performing. A harm-minimization approach in this context would have sex workers teaching young men how to use condoms and still enable them to feel proud of their manliness. The men would then have better skills to negotiate using condoms in the future.
Programs that encourage young people to delay sexual activity can have positive effects. The recent success in reducing HIV prevalence among young girls in Uganda and Zambia has been attributed to delaying their first sexual experience. However, simply preaching abstinence is not sufficient. The programs have incorporated training in life skills, self-pride and assertiveness. Girls who can say no to early sex are more likely to be able to negotiate for protection during sex in later years.
However, many young people have difficulty coping with the concept of abstinence until marriage. We are often asked, "How will we ever find someone to marry? How can we tell who is trustworthy?" Peer education programs report that men promote abstinence during the day and practice unprotected sex at night because they go out unprepared. Young men in difficult economic situations may not be able to afford to marry for years if they are unemployed or their jobs do not pay enough. When manliness is linked to being a breadwinner and having sex, it is hard to be denied both. Many of these young men end up with sex workers as being cheaper than marriage. If they do not have easy access to condoms, their relative poverty will lead them to HIV infection. And the poorest sex workers, who charge the least money, are the most likely to be HIV positive because they can't afford to turn down sex without a condom.
In Thailand, a "100% condom use" campaign directed at brothels and sex workers and media campaigns persuading men to reduce their number of sexual partners, brought the number of new HIV infections from 143,000 in 1991 to 29,000 in 2001. (1) Both these campaigns convinced men of the seriousness of the epidemic, convinced them of their personal risk and gave them the information and methods to protect themselves. Partner reduction has been similarly attributed as the single most important behavior change in Uganda. (2)
When people get married at a relatively young age, sticking to one partner takes on greater importance than abstinence till marriage. The "Be faithful" message therefore also needs an enabling environment to support it. Concepts of manliness linked to having many partners have to be dispelled by role modeling from influential leaders, family opposition to casual sex, peer support for monogamy and the avoidance of alcohol-fuelled socializing where sex workers become more tempting. Uganda also led the way in providing voluntary counseling and testing so that couples could make informed pre-marital choices, and in making treatment for other sexually transmitted infections accessible. These interventions in concert contributed to the decline in HIV from a 15 percent infection rate to a five percent rate over a decade.
An important element of the campaign in Zimbabwe has clinics advising families on the prevention of parent-to-child transmission of HIV. (This is often called mother-to-child transmission, but in Zimbabwe, women's groups asked for the word "parent" to be used to recognize the role and responsibility shared by men in preventing infection to their children.) This involves the promotion of condom use by men while their partners are pregnant or breastfeeding to avoid transmitting HIV to their partners and thereby to their infants during these times. At present five to 10 percent of HIV negative women become HIV positive over the one to two years of pregnancy and breastfeeding. If women become infected during these vulnerable times, the risk of transmission to their infants is very high--up to 70 percent--because carriers are extremely infectious just after they themselves become infected and before their bodies' immune systems respond.
The reason why so many women become infected at this time is because taboos about sex during late pregnancy and early breastfeeding push men into casual sex and the accompanying risk of HIV. While campaigners try to change behavior towards fidelity and abstinence during this time, and at the same time explain that sex during this time is not dangerous, the interim approach is to promote condom use. The advantage is that men do not need to get tested to use this method, and once condoms have been introduced into the marriage, it is easier to carry on using them--whereas in the past condoms could never be brought into a marriage.
Many faith-based organizations that run support services for HIV positive people promote abstinence, creating an impression that their clients are contaminated and unclean, and deny their need to be fully functioning sexual beings. Many of the women in these groups feel they have to hide the fact that they are still having sex, and by virtue of this are denied access to reproductive health advice and services. The World Health Organization's strategy for the prevention of parent-to-child transmission of HIV involves a three-pronged approach: the primary goal is to use available methods to prevent the spread of my, with subsidiary campaigns preventing unintended pregnancy in HIV positive women and using antiretroviral drugs for mothers and their infants during labor and after delivery. Therefore, the provision of explicit support for HIV positive men and women, allowing them to have safer sex that prevents pregnancy as well as further transmission of HIV, has to be part of comprehensive reproductive health care programs.
Much of the stigma and fear that surrounds my is created by discriminatory attitudes from policymakers and care providers. Many people do not get tested for HIV because of the fear that they will be told to abstain from sex. This denies them the chance of knowing their status and acting on it. Support groups for those with HIV have fought hard to overcome this stigma, emphasizing that HIV positive people need information and acceptance enabling them to have sex that protects their sexual partners. Anything that makes the stigma and fear worse will make it harder for individuals to practice safer sex. We must also do more to acknowledge and combat the stigma that surrounds sex itself and ensure that caregivers do not suggest that a positive test for HIV means an end to sex.
The ABC approach can only work if it is part of a wider strategy that creates an enabling environment for people to work together to prevent the spread of HIV, care for those infected and acknowledge the importance to personal well-being of having a healthy sex life. One element, such as abstinence, cannot be taken in isolation and promoted as the key solution to the epidemic. Thus, the US government's plan to reserve 33 percent of the money set aside for HIV prevention in its welcome $15 billion aid program for abstinence-only programs will be at best a partial solution, and at worst will scare away many of those who need the assistance most. The diversity of people's needs and challenges requires that multifaceted programs are developed to address them. The key challenge is removing the stigma and fear of discrimination. To do this, the shame that has been attached to HIV has to be recognized and overcome, so that people and communities get the information and resources they need to find their own ways of dealing with the epidemic.
(1) UNAIDS, Report on the global HIV/AIDS epidemic, Joint United Nations Programme on AIDS, Geneva, July 2002.
(2) Edward Green, Harvard Center for Population and Development Studies, on AF-AIDS listserv (firstname.lastname@example.org), May 9, 2003.
DR. SUNANDA RAY is the Executive Director of SAfAIDS, the Southern Africa HIV/AIDS Information Dissemination Service in Harare, Zimbabwe--www.safaids.org.zw.
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|Title Annotation:||abstain, be faithful, use condoms|
|Date:||Jun 22, 2003|
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