PCP HIV AIDS Toolkit/HIV Transmission/Handout F: The ABC Approach

Defining the ABC Approach
The “ABC Approach” (Abstinence, Be Faithful, and correct and consistent Condom use) employs population-specific interventions that emphasize abstinence for youth and other unmarried persons, including delay of sexual debut; mutual faithfulness; partner reduction for sexually active adults; and correct and consistent use of condoms. It is important to note that ABC is not a program; it is an approach to infuse throughout prevention programs. The ABC approach is distinctive in its targeting of specific populations, the circumstances they face, and behaviors within those populations for change. This targeted approach results in a comprehensive and effective prevention strategy that helps individuals personalize risk and develop tools to avoid risky behaviors under their control.

Abstinence programs encourage unmarried individuals to abstain from sexual activity as the best and only certain way to protect themselves from exposure to HIV and other sexually transmitted infections. Abstinence until marriage programs are particularly important for young people, as approximately half of all new infections occur in the 15- to 24-year-old age group. Delaying the first sexual encounter can have a significant impact on the health and well-being of adolescents and on the progress of the epidemic in communities. Internationally, a number of programs have proven successful in increasing abstinence until marriage, delaying first sex, and achieving “secondary abstinence” (returning to abstinence) among sexually experienced youth. These programs promote the following:
 * Abstaining from sexual activity as the most effective and only certain way to avoid HIV infection.
 * The development of skills for practicing abstinence.
 * The importance of abstinence in eliminating the risk of HIV transmission among unmarried individuals.
 * The decision of unmarried individuals to delay sexual debut until marriage.
 * The adoption of social and community norms that support delaying sex until marriage and that denounce cross-generational sex, transactional sex and rape, incest, and other forced sexual activity.

Be faithful programs encourage individuals to practice fidelity in marriage and other sexual relationships as a critical way to reduce risk of exposure to HIV. Once a person begins to have sex, the fewer lifetime sexual partners he or she has, the lower the risk of contracting or spreading HIV or another sexually transmitted infection.

Be faithful programs promote the following:
 * The elimination of casual sexual partnerships.
 * The development of skills for sustaining marital fidelity.
 * The importance of mutual faithfulness with an uninfected partner in reducing the transmission of HIV among individuals in long-term sexual partnerships.
 * HIV counseling and testing with their partner for those couples that do not know their HIV status.
 * The endorsement of social and community norms supportive of refraining from sex outside of marriage, partner reduction, and marital fidelity, by using strategies that respect and respond to local cultural customs and norms.
 * The adoption of social and community norms that denounce cross-generational sex and transactional sex, and rape, incest, and other forced sexual activity.

Correct and consistent condom use programs support the provision of full and accurate information about correct and consistent condom use reducing, but not eliminating, the risk of HIV infection; and support access to condoms for those most at risk for transmitting or becoming infected with HIV.

Behaviors that increase risk for HIV transmission include: engaging in casual sexual encounters; engaging in sex in exchange for money or favors; having sex with an HIV-positive partner or one whose status is unknown; using drugs or abusing alcohol in the context of sexual interactions; and using intravenous drugs. Women, even if faithful themselves, can still be at risk of becoming infected by their spouse, regular male partner, or someone using force against them. Other high-risk persons or groups include men who have sex with men and workers who are employed away from home.

To achieve the protective effect of condoms, people must use them correctly and consistently, at every sexual encounter. Failure to do so diminishes the protective effect and increases the risk of acquiring a sexually transmitted infection (STI) because transmission can occur with even a single sexual encounter.

Condom-use programs promote the following:
 * The understanding that abstaining from sexual activity is the most effective and only certain way to avoid HIV infection.
 * The understanding of how different behaviors increase risk of HIV infections.
 * The importance of risk reduction and a consistent risk-reduction strategy when risk elimination is not practiced.
 * The importance of correctly and consistently using condoms during every sexual encounter with partners known to be HIV-positive (discordant couples), or partners whose status is unknown.
 * The critical role of HIV counseling and testing as a risk-reduction strategy.
 * The development of skills for obtaining and correctly and consistently using condoms, including skills for vulnerable persons.
 * The knowledge that condoms do not protect against all STIs.

Implementing the ABC Approach
Effective implementation of the ABC approach requires careful evaluation of risk behaviors that fuel local epidemics. Although prevention interventions are most successful when they are locally driven and responsive to local cultural values, epidemiological evidence can identify risky behaviors within populations and guide specific behavioral messages. For example, in some communities, as many as 20 percent of girls aged 15 to 19 are infected, compared to 5 percent of boys the same age. Coupled with high prevalence among older men, such data can point to transmission that is fueled by cross-generational sex. Prevention approaches must then address the risks of cross-generational and transactional sex through abstinence programs for youth and be faithful programs for men that foster collective social norms that emphasize avoiding risky sexual behavior.

Resources

 * The President’s Plan for Emergency AIDS Relief, Office of the U.S. Global AIDS Coordinator. “ABC Guidance #1 For United States Government In-Country Staff and Implementing Partners Applying the ABC Approach To Preventing Sexually-Transmitted HIV Infections Within The President’s Emergency Plan for AIDS Relief. http://www.state.gov/documents/organization/57241.pdf (accessed May 25, 2007).The United States President’s Emergency Plan for AIDS Relief. “ABC Guidance #1 (Abstinence, Be Faitful and correct and consistent Condom use).” http://www.pepfar.gov/guidance/c19545.htm (accessed May 25, 2007).