Greetings,
With this digest, we wrap up the fourth and final week of the Youth Forum "Pregnancy Prevention in a Time of AIDS." We also have five new postings.
Our focus for week 4 has been on the theme of the "ABC" approach to pregnancy and HIV prevention among youth, and we have been fortunate to have much participation and thoughtful responses, even if they have not always been of one accord (as you would expect from any difficult and challenging subject)! I would like to give a special thanks to the forum participants that I called upon last week to respond to the four questions I posed and that were presented in digests 13-16.
Most forum participants who posted comments liked the "ABC" paradigm overall, for its recognition that there are a variety of behaviors that can either eliminate (A) or reduce (B and C) exposure to the sexual transmission of HIV/AIDS and STIs. Most also favored a comprehensive ABC message, while recognizing the need to tailor the message to the individual or group being targeted. To recap the week briefly, below I have repeated several statements made by forum participants that I think are particularly worth remembering:
"We MUST get away from thinking that because not everyone can abstain or remain monogamous, that no one can." — Edward (Ted) Green, Harvard Center for Population Studies, U.S.
"…it is critical that programs emphasize all three facets of the ABC paradigm and do not denigrate or stigmatize condom use." — Jennifer Nadeau, Alan Guttmacher Institute, U.S.
"Different youth have different needs…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 A, B and C. With so many different kinds of young people, it is clear that one approach won't serve them all." — Julie Pulerwitz and Ann McCauley, Population Council, U.S.
"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." — Michaelle Soliman, Haiti
"The weight of evidence suggests that an informed youth does not mean a more promiscuous youth." — Mark Blackett, Uganda
We also learned from Julie Wiltshire, in Uganda, some additional meanings for the ABC paradigm. She suggested "B" might be used for "Be tested" and "Be Frank" (i.e. communicate with your partner). She also proposed using the letter "D" for "Diversion" (engaging young people in sports or other activities) and "Delay marriage," reminding us of the increased risk of HIV transmission faced by many young brides, particularly those who marry older men.
Finally, Julie Pulerwitz and Ann McCauley pointed out the important distinction "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," which could include a number of components and activities and the development of policies. Examples include the 100 percent condom use policy among commercial sex workers in Thailand, promoting self esteem and teaching refusal skills to help young girls practice abstinence, and linking reproductive health education with microfinance programs to help young people find a source of desperately needed income.
This has been a week of rich discussion and I want to thank all of you for participating. Next, we will ask you to complete an evaluation of the online forum which will help us to better plan events of this kind in the future.
The five new postings follow below, focusing on ABC and related issues. Following up Dada Oluwaseun's post from last week, Edward Green of the U.S. points to the success of ABC in Africa, especially in Uganda. Dr. Subidita Chatterjee discusses the moderated UNFPA forum on condoms and how young people talked about the difficulties in mixing B and C.
Egbune Cheche calls for voluntary testing for HIV to be integrated, as a first step, into ABC design. Effanga Aye Henshaw shares her insights in communicating HIV risk to reduce recidivism among male sexual offenders. Vladimir Encarnación Jáquez also finds merit in Oluwaseun's call for adults to listen to youth, adding that this is a two-way process.
Best regards,
Ed Scholl, for the Forum Coordinators
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Forum Digest 17
- Stay the ABC Course
- B and C, Challenging Together
- Voluntary Testing a First Step
- Communicating HIV Risk to Prevent Sexual Violence
- Adults and Youth — Working Together
1. Stay the ABC Course
I would like to make some comments on recent postings, first being Dada Oluwaseun's comment that ABC provides options for pretty much everyone. I have been interested in ABC since I first saw it at work in Uganda in 1993 (though, it was not necessarily called ABC then). Dada's reaction is characteristic of people in developing countries. ABC makes sense to them. It is better than C alone; it recognizes that a sex worker and a 12 year old may require a different approach to prevention, for example.
Yet, American and European AIDS experts almost always resist the A & B of ABC. They say Africans are polygamous by nature (or culture), that women have no power, that A & B are bad for women, that it's too simple, that it cannot work for everyone, that a woman might abstain and then get married and get infected by her husband (so why bother abstaining?) — the list goes on. Why do Africans like ABC when Western AIDS experts do not?
Part of the genius of Uganda's ABC program is that it focuses on what individuals themselves can do to change (or maintain) behavior, and, thereby, avoid or reduce risk of infection. It is not a panacea for all of society's ills. Neither is the condom. But, many Western critics seem to suggest that if A or B behaviors are not realistic for everyone, we should not promote them to anyone. By this logic, if everyone cannot give up smoking, then we should not promote smoking cessation..
Some of my American colleagues on a board that I serve on have been arguing that we should end poverty instead of promote ABC. Or, end male dominance and homophobia. We need to ask ourselves is whether an AIDS program is able to overcome social ills in the short to medium term. And, even if that were possible, would HIV infection rates necessarily fall? We don't know.
ABC relates to what has been called the "proximate determinant" of sexually-transmitted HIV infection. The sexual transmission of HIV can be directly prevented in three ways: by avoiding the exposure to risk (e,g, through sexual abstinence); by reducing the risk of exposure (e,g, through partner faithfulness and reduction in partners); or by blocking the efficiency of transmission risk (e,g, through a barrier like a condom), or, perhaps, also by male circumcision, which reduces the presence of dendritic leukocyte cells). In other words, by practicing A, B, or C. All of this is to say that African common sense in this matter — that ABC works — is backed up by epidemiology.
Also, I take issue with Mark Blackett's comment that the "be faithful" message has been ineffective in Uganda. Unbiased studies, published in 2004 in Lancet, BMJ, Science, and even in Studies in Family Planning, all agree that "be faithful" is the main thing that worked in Uganda. This cannot be shown in the DHS study mentioned by Blackett because the major behavioral change occurred before the first AIDS-related DHS in Uganda (1995). So comparing the 1995 and 2000 DHS will not show what happened in Uganda; it misses the big story. Even a study in Uganda by Pfizer agrees with the importance of "Be Faithful."
-- Edward Green, Harvard University, U.S.
2. B and C, Challenging Together
Thanks for a very nice structured discussion on young people and contraception in the era of AIDS. I wanted to discuss two issues which could be relevant to the topic.
The first issue pertains to your question about the B in ABC. I happened to be the facilitator cum moderator of a discussion on "Increasing Condom Use among Sexually Active Young People," on behalf of UNFPA in 2003. In that discussion we had active participation from a number of young people and experts alike.
The young people thought that B (being faithful) and C (condom use) were kind of antagonistic to each other in the following sense. Whenever the issue of condoms was raised by one partner of a couple — whether they were married or just partners — the other partner invariably thought that the other person had been unfaithful. So, once the relationship was becoming closer the question of condoms was very detrimental to the issue of trust or faith in the relationship.
There were several suggestions put forth by the participants as to how to overcome this problem. One was to stress the need for condom use — not only to prevent STI or HIV but also to reduce transmission of other diseases like Hepatitis B. A related reason this is important is the unsterile health scenarios in many of the developing countries, where HIV /STIs can still be transmitted through unsterile blood transfusions or IV injections. Thus, it should be stressed that, even if their spouse or partner had been faithful, there were other ways to get these diseases; and using condoms would help protect them or there partners — as in most cases, the HIV/STI status of partners remained unknown.
So, the message could be abstinent till maturity and, when you have sex, always use a condom, to be medically safe. To maximize chances of medical safety, we would have to talk about being faithful and getting tested. If condoms could be promoted as an essential commodity, on medical grounds — which had to be used, as a rule, whenever two people had sex — it could also help married women who have little power to negotiate condom use in marriage.
The other issue that I would like to discuss is the value of branding and social marketing, not only to make sexually active young people accept condoms but also to encourage all young people (both sexually inactive or already sexually active) to visit user-friendly health services or to promote behaviour change communication among them. Many social marketing organizations around the globe could, of course, share knowledge about successes with young people.
Again working for UNFPA, I did some work in China where we conducted focus group interviews with university, college, high school, and middle school students. We found that, when young people were asked to create brands and logos for such services, it appealed to other young people even more. It helped them to identify with the commodity and services. The fact that a little cost was added to obtain these things — as opposed to giving them those services free of charge — only added value in the minds of the young people for them.
-- Dr. Subidita Chatterjee, Consultant in HIV/AIDS and Reproductive Health
3. Voluntary Testing a First Step
The ABC approach to HIV/AIDS issue should strive to cover the D to Z. Voluntary testing to determine one's status should precede the application of this method. There's no point in closing the gate when the horse is gone. Timing is important. Unfortunately, most people are not willing to submit themselves for an HIV test, even with an incentive. Some go into marriage and practise the ABC method only to produce a HIV-positive fine boy!
-- Egbune Cheche, Coordinator, Cartoon Media Outreach, Nigeria
4. Communicating HIV Risk to Prevent Sexual Violence
I have been reading your forum and it has been quite educational. I would like to seize this opportunity to share my experience in the field. I work with young girls whose reproductive health rights have been violated. Most of the young men involved in these acts are usually very selfish and self-centered people. So, our strategy is to use these characteristics to our advantage by emphasizing how they put themselves at risk by committing rape. This makes them also reflect on the fact that they are actually harming themselves.
This will make them careful for the wrong reason, but, at least, we are helping to reduce rape until we can install a good process where young girls can fight for their rights without experiencing discrimination.
-- Effanga Aye Henshaw
5. Adults and Youth — Working Together
This point is very important, and that's why I feel the need to emphasize this. One of the main problems with us and adults is that separate our needs. It's true that we have started a very hard competition between adults and young people. I agree with Dada Oluwaseun, from Nigeria, who said that adults need to listen and help youth with problems. It's very difficult to provide youth with sexual information and education in many of our countries, especially in Latin America, where we're still working under conservative methods. We have to work together: Adults need to understand us, and we need to understand them.
About today's questions, I think the media is very important in HIV/AIDS prevention. Here in the Dominican Republic, since 2003, we've been implementing a project that emphasizes media participation by young people. This advocacy project could potentially make many changes in some spaces.
-- Vladimir Encarnación Jáquez, Youth Activism, PROFAMILIA, Dominican Republic
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