Greetings,
Our four postings from Kenya, Nigeria, the U.S., and Zambia discuss issues we've raised this week related to the ABC approach.
Fabian Miselo discusses a program that facilitated informed sexual decision-making among Zambian youth. Eugene K.M. Darteh of Kenya urges that ABC campaigns provide more thorough, pragmatic information to youth. Princess Olufemi-Kayode of Nigeria and Matthew Piccolo of the U.S. voice differing opinions on whether condom use should be promoted in sexual and reproductive health efforts.
In addition to these, we continue our approach of posting responses to a question about an ABC issue, which I posed to selected participants. The question for today is: Several participants in our forum have spoken to the fact that many young women in developing countries lack the power to practice A, B or C behaviors. They may be coerced into having sex, they may barter sex for food, and they may be powerless to negotiate condom use with their husband or partner. How can we address their needs if we only talk about "ABC"?
Below are five responses to the question I posed. Following those comments are the four digest postings.
Best regards,
Ed Scholl, Forum Moderator
On behalf of YouthNet, The INFO Project, and the Implementing Best Practices in Reproductive Health Initiative/World Health Organization
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From Michaelle Soliman, volunteer peer educator working for the NGO, FOSREF, in Haiti -- Let's be realistic. If we only talk about ABCs, we can't address their needs, because AIDS is also a social problem. Women must be empowered, which means: give them education, work...all the means to become more independent to be able to make their own choices.
From Jennifer Nadeau, Director of Communications at The Alan Guttmacher Institute in New York -- A broad, culturally sensitive approach is needed to address the sexual health needs of young women in unequal sexual relationships, burdened by the pressures of early marriage and/or unable to negotiate contraceptive use.
In its collaborative project "Protecting the Next Generation: Understanding HIV Risk Among Youth," The Alan Guttmacher Institute is investigating young people's sexual risk and protective behaviors within the broader context of societal opportunities and constraints, including constraints imposed upon young women as a result of gender inequality. So far, research in Burkina Faso, Ghana, Malawi, and Uganda confirms that sexual coercion does occur among adolescents. For example, in a colleague's study among secondary school students in the Kabale district of Uganda, 31% of females and 15% of males reported having been forced to have sex. Young women coerced into having sex do not always have the choice to abstain, be faithful, or use a condom.
In addition to addressing concerns about sexual coercion and inequality within sexual partnerships, policymakers, donors, service providers, activists, and academics need to give more consideration to integrating HIV prevention into reproductive health services as appropriate — and to integrating reproductive health services into HIV-related programs. Brazil and Jamaica, to name just two countries, have linked HIV prevention strategies with the prevention of unintended pregnancy, which reflects the complex realities of life and sexual relationships. Women, especially, often are trying to prevent both simultaneously. Even if a woman abstains until marriage, for example, she is likely to still want and need "C" — be it Condoms or other Contraception — in order to be able to plan her childbearing. Alternatively, how can a married woman who wants to become pregnant protect herself from the risk of HIV from her husband if he has other sexual partners? And must a young woman who has abstained from sex altogether wait until she becomes sexually active to be entitled to the full and accurate information necessary to protect herself from unplanned pregnancy and disease?
Promoting A, B and C is an important part of the fight against HIV, but it is not enough, especially for disempowered young women. To make changes in ABC behaviors a realistic and effective strategy for all, we need to support young people with comprehensive, accurate information, real access to health care services, and broader social and economic opportunities.
From Julie Wiltshire, health care provider in Uganda -- Unemployed, unmarried women in urban areas certainly have few options when it comes to generating enough funds to live, and women and girls in internally displaced camps and areas of insurgency are regularly subjected to rape and defilement. The key to improving this situation in not to primarily focus on women alone, but to focus on men's behaviour as well. Where social structures are failing women and girls, it is helpful to use a human rights approach to improve sexual and reproductive health. This is a multisectoral approach involving the local police, army, community resources, and of course, educating health workers providing services. The ABC approach can still be used, because you must always hope for a better future where "normal" lives may be achieved, but while the women and girls live in vulnerable situations, different messages are more appropriate to supplement the ABC model. There needs to be more work on this, so that health-care providers can give more appropriate messages to those communities, usually using a human rights approach so that other agencies can reinforce the messages (i.e. rape, defilement is against the law, etc).
From Julie Pulerwitz, Research Director, and Ann McCauley, Youth Specialist, both with the Horizons Program at the Population Council (U.S.) -- There are certainly constraints that young women, and women in general, experience when trying to implement behaviors that would protect them from HIV, such as refusing sex or insisting on condom use. Individual behaviors are enacted in a social, structural, and policy environment that must be taken into account as well. HIV prevention should include multi-faceted approaches that address the needs of young women.
To succeed, an "ABC" approach has to address more than just information about A, B and C. In fact thinking of the approach as only including "abstinence, be faithful, and condoms" has caused widespread confusion. A distinction should be made between the specific behaviors that are among the hoped-for outcomes of HIV risk reduction programs — delayed sexual initiation or abstinence, faithfulness or reduced numbers of sexual partners, and consistent condom use — and a program that has the goal of promoting these behaviors. The behaviors themselves are the intended outcome: engaging in these behaviors will reduce risk of HIV/AIDS. Yet to successfully promote these behaviors, a program needs to include a number of components and activities. These activities may include explicit messages encouraging preventive behaviors but may also include the development of policies to support these behaviors, such as the 100 percent condom use policy that has been used with success in brothels. Other activities may be targeted toward developing youth's self-esteem and skills to refuse or delay sex, or to insist on condom use, so that they have the capacity to implement these behaviors. Issues related to gender — particularly the fact that girls and women often do not have the power to negotiate safer sex or abstinence — need to be taken into account, such as by building the supportive social context required to enable young girls to handle sexual pressure from their peers and adults, or by linking with microfinance programs that provide young women with opportunities to develop a source of income.
From Atanas Kirjakovski, peer educator working for the NGO, Hera, in Macedonia -- It is really difficult to apply the ABC model to these extraordinary situations. Women in these types of situations should develop skills to convince their partners to use condoms. Many sexually active couples believe that use of a condom is a sign of distrust. Some people could find it offensive and will insist on sexual intercourse without condoms. These women should learn how to insist on condom use very carefully, argumentatively, and self-confidently.
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Forum Digest 15
- Empowering Youth to Make Informed Choices
- Youth Need Information, Support
- Condom Use Important to ABC Messages
- C at Odds with A and B
1. Empowering Youth to Make Informed Choices
I am working for CARE International in Zambia in charge of its peer education efforts. First and foremost, I wish to thank you, the initiators of this forum and all who have contributed to this discussion. I wish just to support all the contributors who clearly recognise that the ABC paradigm is the best approach to help youth survive in a time of HIV/AIDS.
It has been mentioned already that these youth come from different backgrounds. Therefore, limiting them to one or two options would not address their needs or favour their position in life. For example, in the seven Zambian districts that we are supporting with IEC materials, we have allowed the youth themselves to determine which is the best choice, after having advised them on the advantages and disadvantages. (Of course, many spiritual leaders will oppose condom use. But, do they stay with the youth throughout the week or it is just on prayer days?)
I would like to hear and learn more from others.
-- Fabian Miselo, CARE International, Zambia
2. Youth Need Information, Support
I have read through the thoughts of the various participants on the theme: the ABCs of Pregnancy and HIV Prevention among Youth. I also think there is a need to provide a comprehensive sex education focusing on the ABC approach to young people. However, I would like to comment on A and C.
My opinion is that the messages should be comprehensive. For instance, when young people are asked to use condoms, they should be taught how to use them properly and consistently. I think there should be a lot of emphasizes on consistent condom use. This is because there is usually the temptation to stop using condoms after some time, usually under the illusion that you trust each other. In the case of abstinence, I believe that youth need a lot support to do this, and, thus, efforts should be made to provide them with information on practical ways of abstaining.
In promoting ABC among young people, we should ensure that they have access to counseling services and products (condoms) in a youth-friendly environment.
--- Eugene K.M. Darteh, African Population and Health Research Center, Nairobi, Kenya
3. Condom Use Important to ABC Messages
The problem with the ABC paradigm is misconceptions and myths associated with condoms. Societal attitudes present a difficulty, in that, before the message is concluded, a negative response is aired about condoms. During the last World Cup, I was privileged to serve on an ad-hoc committee working to formulate the HIV/AIDS prevention message. It was a tug of war before the word, "condom," was permitted to be used on national television.
Whether we like it or not, and as much as we would appreciate their abstaining, there are sexually active adolescents. We need to preserve their lives with whatever means necessary. Condom use provides dual protection for the prevention of unintended and unplanned pregnancy, as well as STIs, including HIV/AIDS.
The ABC approach is ok. Let everyone make their choice — the A message for the faith-based and B and C for others.
-- Princess Olufemi-Kayode, Executive Officer, Media Concern for Women and Children, Nigeria
4. C at Odds with A and B
Thank you for your thoughtful comments and experiences. I realize that countless socio-economic, political, and cultural factors are involved in sex education, but I believe that we can base our programs and policies on basic principles. Here is my personal opinion on each aspect of the ABC approach:
Abstinence/Delay of Sexual Debut:
- Abstinence is the only foolproof method to protect oneself against STDs. I have yet to find a contraceptive method that is 100% effective as in the case of abstinence. Why would we want to counsel youth and/or adults to use any faulty method? If an 80-97% prevention rate is risk-adverse enough for you, then go for it. What if all of our airplanes completed their trips safely only 80-97% of the time or your company paid you only 80-97% of the time? The honest fact is that STDs will never be extinguished with current contraceptive devices. Abstinence, coupled with faithfulness, is the only way to protect yourself 100% of the time.
- Ideally, sex education will be provided by responsible parents in the home. But, if we must do otherwise, I believe that we need to make youth aware of these success/failure rates and counsel them to remain abstinent until they are mature enough to make a long-term commitment. We teach children and adults that drugs will kill them. Why not teach them that unsafe sex, even with a condom, could kill them? I believe that most people will choose abstinence when given all the facts. I attended a university where every year 30,000 students sign a code of honor binding themselves to remain abstinent and/or faithful to their companions. Of those students, 99% remain faithful to that pledge and contract no STDs. With the right approach, abstinence education can be effective.
Being Faithful/Partner Reduction:
- Being faithful rivals abstinence in importance. It doesn't do much good to be abstinent but then not be faithful to one partner after sexual debut. Sex education should include a strong emphasis on remaining faithful to one partner and point out the risks of having multiple partners.
- Also, regardless of cultural or religious beliefs, sexual intimacy is exactly that, intimate. Intimacy should be an expression of deep-rooted love and long-term commitment. To have intercourse without such a commitment is dishonest and imprudent. We have a duty not only to educate the next generation with scientific facts, but also to instill in them principles that will protect them and prepare them to live as responsible citizens in society.
Condom Use:
- Condoms may have a place in some settings, but combining C with A and B is contradictory. Teaching youth to be abstinent or faithful to their partner, and then giving them a condom, is like saying, "Don't jump off a cliff onto a rocky shoreline…but, in case you decide that you want to do that, here is a parachute that will protect you most of the time." We must clarify our teaching in order to avoid confusion and misconceptions. We must teach that safe, responsible sex is a major responsibility that accompanies maturity. Everything we do engenders consequences in the lives of those around us; we must learn to be responsible for our actions.
-- Matthew Piccolo, U.S.
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