Greetings,
Welcome to Week 4 of the Youth Forum on Pregnancy Prevention in a Time of AIDS. I'd like to thank the previous week's guest panelist, Dr. Jim Shelton from the U.S. Agency for International Development, for his participation and thoughtful, provocative comments.
The current week's theme is the ABCs of Pregnancy and HIV Prevention among Youth — Country Perspectives and Lessons Learned. We have invited selected forum participants to share their thoughts, experiences, and research on the subject by addressing questions that I have posed to them. Each digest will begin with one of the questions, followed by these forum participants' responses. We also want to hear others' thoughts and comments on the week's theme, on the comments provided by these respondents, or on past weeks' topics as well.
Let me introduce the week's theme with a brief definition and a couple of helpful Web links for background reading. The "ABC" approach to HIV prevention is commonly understood to mean Abstinence/delay of sexual debut, Being faithful/partner reduction, and Condom use. Three very useful documents on the subject of the ABC approach, which can be discussed in the context of pregnancy prevention as well, are:
- The "ABCs" of HIV Prevention: Report of a USAID Technical Meeting on Behavior Change Approaches to Primary Prevention of HIV/AIDS (PDF, 520K)
- "The time has come for common ground on preventing sexual transmission of HIV" (PDF, 3MB) — a consensus statement appearing in The Lancet, written by several leaders in the field and endorsed by a long list of individuals from around the world
- The "ABC to Z" Approach, by Ward Cates of Family Health International
Best regards,
Ed Scholl, for the Forum Coordinators
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Question: The "ABC" approach to HIV/AIDS prevention is often held up as a model, with some groups advocating a comprehensive ABC approach to young people, while others feel that only A and B should be taught to young people, or A and B with C included in special circumstances, such as youth identified as engaging in risky sexual behaviors. Do you feel that the "ABC" paradigm is a useful one for considering how to help young people prevent HIV/AIDS? Do you favor emphasizing any particular part of the "ABC" approach for youth?
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From Jennifer Nadeau, Director of Communications at The Alan Guttmacher Institute in New York -- In terms of individual behavior, certainly abstaining from sex, having fewer sexual partners, and using condoms are the best ways to protect oneself from sexually transmitted HIV infection. And "ABC" behaviors can have an impact at the societal level as well: some combination of important changes in all three of these behaviors contributed to an extraordinary reduction in HIV/AIDS rates in Uganda, for example.
Beyond that, however, the picture becomes considerably less clear. Ugandan policies and programs aimed at turning back HIV/AIDS went well beyond instructing young people to practice A, B and C. The country reinforced its ABC approach with numerous other societal initiatives, including promoting the status of women and discouraging gender violence and sexual coercion, all backed by political commitment at the highest levels. Uganda's experience must not be taken to mean that adopting an ABC program will allow other countries to replicate its success. Indeed, young people's sexual activity takes place within a complex societal context of beliefs, motivations, attitudes, and opportunities, and is not likely to be determined by an intervention aimed simply at telling them how to behave.
Nevertheless, educating young people on how ABC behaviors can help them protect themselves is clearly important. In this regard, it is critical that programs emphasize all three facets of the ABC paradigm and do not denigrate or stigmatize condom use. Consistent, correct use of condoms remains the only way for sexually active individuals to protect themselves against a range of sexually transmitted infections, including HIV, while also preventing unintended pregnancies. Failing to instruct young people in how to use condoms — or suggesting that condoms are a last resort for those who insist on doing things that are "risky" — endangers their health and their lives.
From Julie Wiltshire, health care provider in Uganda -- As a model, the ABC is a useful tool. I do not favour any particular emphasis on individual sections as I believe an integrated approach is best. From my experience of working in an agency providing reproductive health services to both adolescent and adult populations, to both rural and urban communities, I have noted the following observations about the ABC model in Uganda, indicating that ABC does not always mean the same thing to different people:
- Abstinence: it is not clear what this is. Many people misunderstand the abstinence message to mean "not having sex, most of the time." This will not protect them against HIV/AIDS unless they abstain from sex at all times. This message is inappropriate for married youth. However, for many youth, particularly in rural areas, abstinence may be the only means to stay safe, especially if health services are limited, access to condoms is almost nonexistent, and acceptable to many people as it falls within cultural expectation. The problem then arises; youth get married at 15–16 years because they are not expected to abstain beyond that age.
- Be faithful — this message seems geared for married, monogamous couples. It may not be so suited to young unmarried adolescents. Perhaps it should be changed to "Be Frank" with your partner. Discuss the risk of HIV/AIDS transmission with your partner. Being faithful alone will not protect you from getting HIV/AIDS if your partner is not faithful or already infected from a prior partner. Set the ground rules for having any sexual relationship to stay safe. Stay with one partner, do not have multiple sexual partners. Perhaps "Be tested" could be combined with "Be Frank." Do couple testing before having unprotected sex. If the person really loves you they will have an HIV Test with you before having sex.
- Use condoms — an absolute must if you are having sex and are worried about getting HIV/AIDS. Additionally it is effective for family planning as well. However the downside is that many youth do not know how to use condoms correctly, they do not have access to condoms when they need them, and the church opposition to condoms as being immoral is an additional challenge to be faced by the youth. Also the youth have beliefs that "a sweet tastes better when it is unwrapped" (sex without a condom is better). The condom message is vital to teach to all youth about condoms so they can make informed choices wherever possible. All youth should be taught how to use condoms correctly, and condoms need to be available to them in a non-threatening environment.
- D — I have seen this used to mean "death" if you do not follow ABC. Perhaps you can use D for "diversion," when the urge to have sex is high, engage in sport or other activities to help you control your sexual urges/high risk behaviour. Perhaps also 'Danger' when youth start taking alcohol which reduces safe behaviour or "Destitution" — selling one's body for money does not mean you will get rich if you get HIV/AIDS in the process. It is better to go without and stay alive. Perhaps D can also be used for "delay marriage." Many young people have early marriage, and there is an increasing transmission of HIV/AIDS within married couples having unprotected sex.
Ideally, it would be useful to ask the youth themselves what messages would be the most effective for them.
From Julie Pulerwitz, Research Director, and Ann McCauley, Youth Specialist, both with the Horizons Program at the Population Council (U.S.) -- Different youth have different needs. Youth can be married or unmarried, sex workers or men having sex with men, virgins or sexually active — all of these youth would have different HIV prevention needs. Some, but not all, youth have passed through all the mental, physical, and emotional changes that are associated with puberty. Furthermore, life circumstances for youth change over time. To ensure that different subsets of youth are able to protect themselves from HIV, a balanced approach is needed that provides information and technologies related to AB and C.
With so many different kinds of young people, it is clear that one approach won't serve them all. In fact, one of the conclusions of the 2003 Horizons-hosted technical expert meeting on the ABCs — attended by representatives of over 20 institutions, including government, academic, and NGOs — was that it is important to make available to youth a comprehensive set of messages about delayed sexual initiation or abstinence, faithfulness or partner reduction, and condom use. Thus, those receiving the messages have access to all of the information and can make informed choices. Yet, different combinations of messages are needed for different individuals and groups in different situations. It is vital to appropriately tailor the behavior change messages according to the intended audience of particular programs. For instance, programs for youth who are not yet sexually active may focus on promoting a delay in sexual initiation, while programs for young sex workers may focus on promoting consistent condom use. Programs for young migrant workers might focus on partner reduction when away from home. Good formative assessments are needed to help develop specific messages and activities that are appropriate for varied audiences in varied cultural contexts.
From Michaelle Soliman, volunteer peer educator working for the NGO, FOSREF, in Haiti -- I think the ABC paradigm is very useful because it says in few words the best behaviour to adopt for not getting infected by the HIV virus. I feel we should put emphasis on A to delay the first sexual relation.
From Atanas Kirjakovski, peer educator working for the NGO, Hera, in Macedonia -- On first glance there is a contradiction between A (abstinence) and C (condoms). Which is better to practice? The right answer is: let people choose what is best for them. Why abstinence? — Because it is the safest way of living and behaving. Why condoms? — Because it is the best known way to protect sexually active people.
From Omeire Edward, youth pastor and sociologist with Ceasefire Project in Nigeria -- Teenagers should be given abstinence-only education at least through junior high school and thereafter comprehensive sex education. Now, there is nothing wrong in giving young adults comprehensive sex education, including the use of condoms, but I think there is every thing wrong with an over-emphasis on condom use rather than risk avoidance skills such as how to negotiate difficult situations, refusal skills, assertiveness and delayed sexual initiation. Why do we emphasize C and not A? What we see in many sex education programs is an over-emphasis on using condoms.
From Duanne Punpiputt, External Relations and Project Development Officer for the Planned Parenthood Association of Thailand (PPAT) -- With rapid social changes and the availability of and accessibility to a wide range of media, talking about abstinence only is obviously not sufficient to protect the population and young people in particular from HIV/AIDS/STI infection.
PPAT always talks about ABC through education/edutainment activities. The ABC approach is useful for knowledge dissemination activities for young people in schools, communities, or through special activities such as youth camps as we do not know who has already engaged in sexual intercourse and who has not. Certain part(s) of ABC may be emphasized for specific youth groups such as those living together as couples in dormitories or practicing risky behaviours. In other words, messages and focuses change, depending on the needs of the target audiences and the situations they are in.
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