The ABC of HIV Prevention

The ABC approach to preventing the sexual transmission of HIV has been defined and adopted by a variety of organisations, governments and non-governmental organisations ever since the term was first used in 1992. Although it is often associated with Uganda, and is credited with drastically reducing HIV infection in the country in the 1990s, the ABC approach incorporates messages which were used before Uganda's HIV prevention campaigns.

Also, ever since PEPFAR adopted the 'ABC' approach to HIV prevention in 2003, it has been criticised by some for its particular definition of 'ABC'. So what exactly is the ABC approach, why does it cause such controversy, and does it work?

back to top The Origins of the ABC approach

Since the beginning of the response to HIV prevention, it has been known that HIV can be transmitted sexually. Even before the term 'ABC' was conceived, materials provided by WHO, the Global Program on AIDS (later succeeded by UNAIDS) and governments and organisations around the world, contained information on how abstinence, fidelity and condom use could prevent the sexual transmission of HIV.1

Roadside ABC sign in Botswana A roadside sign in Botswana - late 1990s

For example:

  • A USAID programme called 'AIDSCOM' (1987-1993) promoted behaviour change campaigns in various parts of the world, which either promoted abstinence, fidelity or condom use depending on the targeted group.2
  • A 1992 poster from Uganda pictured a couple sheltering under a protective umbrella. On the umbrella were slogans promoting abstinence, marital fidelity and condom use.3
  • A 1991 poster in Senegal declared “stick to one partner; should you have more than one partner, be sure to use condoms correctly and dispose of them after one use”.4
  • In 1992, the GPA promoted delaying sex, marital fidelity and condoms in its Global Strategy but without making any mention of 'ABC'.5

Then in 1992, the Filipino Secretary of Health, seeking a compromise between the Catholic Church and government at the time brought together abstinence, fidelity and condom use to create the 'ABC slogan':6

  • Abstain from sex
  • Be faithful if you do not abstain
  • Use a condom if you are not faithful

The Filipino Secretary of Health then began to promote it widely, within the Philippines and abroad at international conferences.

An HIV prevention sign in Zambia promoting abstinence, fidelity and condom use A 'Fleet of Hope' HIV prevention sign in Zambia promoting abstinence, fidelity and condom use

In 1994, a Tanzanian pastor, Fr Joinet, who was seeking to clearly communicate the HIV prevention message came up with a visual representation of the ABC approach which he termed the 'Fleet of Hope'.7 This presented the AIDS epidemic as a flood, with people drowning. Three boats, representing 'abstinence', 'fidelity' and 'condoms' provided life saving options; each boat was also connected by a bridge which suggested that people could move from one situation to another but that each option was equally viable. The 'Fleet of Hope' was then adapted and used in other countries, particularly in sub-Saharan Africa.

Since the late 1980s in Uganda, the government had begun educating the public about sexual transmission but focused on abstinence for youth and 'zero grazing', or partner fidelity. The term 'zero-grazing' comes from the agricultural practice of tying livestock to a post, restricting them to a zero-shaped section of grass. Then in the early 1990s condom promotion in Uganda became more accepted by the government and condom use increased. However, although President Museveni referred to the ABC approach in 2004 as a 'social weapon' against HIV and AIDS, there is not clear indication that the term 'ABC' was used in public sector HIV prevention programs in Uganda during the 1990s.8

The 'ABC approach' had been used by educators in some schools in the US since the early 1980s, yet it was only in 2003 that it was promoted by the US abroad. That year, the President's Emergency Plan for AIDS Relief or PEPFAR (America's initiative to combat the global HIV/AIDS epidemic), adopted the 'ABC' approach as its primary prevention strategy against the sexual transmission of HIV, claiming that the promotion of abstinence and fidelity of ABC was the reason that the HIV infection rate reduced so dramatically in Uganda in the 1990s.9

back to top UNAIDS definition of ABC

According to UNAID's 2004 Global Report on the AIDS Epidemic, 'ABC' stands for:10

  • Abstinence (not engaging in sex, or delaying first sex)
  • Being safer, by being faithful to one's partner or reducing the number of sexual partners
  • Correct and consistent use of condoms

UNAIDS is clear in the report that this is a 'combination approach' which can be adapted to context, population and stage of the epidemic. It also proposes that each point may be relevant to different people at different stages of their life. However, it is not a 'population specific' approach; therefore condoms are needed by all sexually active people, including young people. Moreover the report states that “faithfulness is only protective when neither partner is infected with HIV and both are consistently faithful” and marriage does not necessarily protect people from HIV infection. UNAIDS points out that the approach is 'of limited value' to many women and girls, as they cannot negotiate safe sex with partners or choose to abstain for sex. Perhaps for these reasons, UNAIDS does not make specific mention to the 'ABC' approach to HIV prevention in subsequent publications.

back to top The PEPFAR definition of ABC

PEPFAR, America's initiative to combat the global HIV/AIDS epidemic, follows an ABC strategy through 'population-specific interventions' that emphasise:11

  • Abstinence for youth, including the delay of sexual debut and abstinence until marriage
  • Being tested for HIV and being faithful in marriage and monogamous relationships
  • Correct and consistent use of condoms for those who practice high-risk behaviours

PEPFAR identifies those who practise 'high-risk behaviours' as ''sex workers and their clients, sexually active discordant couples or couples with unknown HIV status, substance abusers, mobile male populations, and men who have sex with men,” among others.  Notably, the promotion of condoms to young people in general is not supported by PEPFAR. However, PEPFAR does say that its funds may be used to support programmes that deliver age-appropriate “ABC information” for certain high-risk young people, provided they are informed about failure rates of condoms, and the programmes do not appear to present abstinence and condom use as equally viable, alternative choices.

Controversy

Since the adoption of the ABC approach by PEPFAR, there has been criticism of the way that PEPFAR defines 'ABC'. The controversy arises from the fact that PEPFAR does not promote the use of condoms outside the 'high risk groups'. Instead, outside the 'high risk groups' PEPFAR promotes delay of sexual debut and abstinence until marriage.

Poster encouraging sexual abstinence, Zambia Poster encouraging sexual abstinence, Zambia

If young people delay sex in areas with a high HIV prevalence, then this risk avoidance will indeed result in them avoiding infection whilst they are adopting this approach. However, abstinence until marriage does not always ensure safety, because marriage in itself provides no protection from infection. Many people are unsure of the HIV status of their partners, and those who are faithful cannot be certain that their partner is maintaining the same commitment.

Abstinence is not a realistic option for the millions of women and girls who are in abusive relationships, or those who have been taught always to obey men. People who do not abstain should do everything possible to reduce risk, including using condoms.

“Condoms, when distributed with educational materials as part of a comprehensive prevention package, have been shown to significantly lower sexual risk and activity, both among those already sexually active and those who are not." UNAIDS12

AIDS organisations and experts have voiced concern that PEPFAR puts too much emphasis on abstinence until marriage, and is not doing enough to make young people aware that condoms, if used correctly and consistently, are highly effective at preventing HIV infection.13  

PEPFAR claims that its approach is validated by 'what worked in Uganda'. However, on closer examination it is clear that the simple catchphrase 'ABC' cannot sufficiently describe what happened in Uganda in the 1990s.

back to top What happened in Uganda

When HIV was rapidly spreading through the population of Uganda in the late 1980s, President Yoweri Museveni, unlike most other African leaders at the time, recognised the danger and took swift action showing forceful leadership. Uganda's response was powerful and wide-ranging. The government launched an aggressive media campaign involving posters, radio messages and rallies; they trained teachers to begin effective HIV and AIDS education; and - most importantly - they mobilised community leaders, churches and indeed the public in general.14

The government worked alongside many independent organisations, using different messages to address different groups of people according to their needs as well as their ability to respond. Young people were encouraged to wait before first having sex, or to return to abstinence if they were not virgins. All sexually active people were given the message of 'zero grazing', which meant staying with regular partners and not having casual sex. Those who did not abstain were encouraged to use condoms, which were promoted to the population as a whole.

In order to encourage people to take up such strategies - and to make them effective - action was taken to encourage candid discussion of HIV and AIDS, to reduce stigma, to better the status of women, to improve testing facilities, to treat other sexually transmitted infections and to provide better care for those already infected.

What worked in Uganda

Uganda abstinence poster Uganda abstinence poster

What appears to have worked in Uganda was a combination of risk avoidance and risk reduction approaches, including the widespread promotion and distribution of condoms.15 During the 1990s, schemes funded by USAID and other donors increased condom use.16 This combination approach resulted in a fall in the annual number of new infections between the late 1980s and mid 1990s, which in turn led to a reduction in HIV prevalence. In later years, an increase in the death rate probably made a contribution to further declines in prevalence, while the number of new infections remained more or less unchanged. 'Be faithful' or 'zero grazing' was a key element of the prevention campaign of the 1990s.17   

“The evidence, therefore, points to the existence of a range of complementary messages and services delivered by the government and a wide diversity of non-governmental organizations. To be sure, those messages included the importance of both young people delaying sexual initiation and "zero grazing" (monogamy). But contrary to the assertions of social conservatives that the case of Uganda proves that an undiluted "abstinence-only" message is what makes the difference, there is no evidence that abstinence-only educational programs were even a significant factor in Uganda between 1988 and 1995. ” SA Cohen 'Beyond Slogans: Lessons from Uganda's Experience with ABC and HIV/AIDS18

Although Uganda certainly did succeed in reducing its HIV prevalence drastically from a height of 18 percent in 199219 to 4.1 percent in 2003,20 HIV prevalence in the country has since risen (the HIV prevalence in 2009 was 6.5 percent).21 There are a number of reasons why this may be happening, including fewer people dying of AIDS due to an increase in access to antiretroviral therapy. However, there have been suggestions that a shift away from 'be faithful' or 'partner reduction' aspect of the country's HIV prevention approach to a new 'abstinence only' focus as promoted by PEPFAR could be partly responsible for this increase.22 23

In 2011, a senior official at the Ugandan Ministry of Health commented that..."We have concentrated so much on treatment and care yet more Ugandans are getting infected each year and the number of those who need ARVs is increasing. It is time we reviewed the old-fashioned prevention because it has flopped...Few people in Uganda are using the “ABC”- abstain, be faithful and use condoms strategy".24 However the Director of 'CDC-Uganda', an American-Ugandan bilateral organisation, also added that complacency could be a reason why prevention strategies weren't working and why the number of new HIV infections is increasing..."But complacence [sic] could be part of the problem. Young people nowadays no longer see people dying; they see people on ARVs but getting children. We need to re-examine our strategies in the fight against HIV/Aids".25

back to top ABC around the world

The ABC approach has been adapted and promoted around the world. In the 1990s for the example, the government of Botswana adopted the slogan which was seen on billboards around the country.

However, certain countries which have been promoting the ABC strategy as a national strategy have expressed doubt about its effectiveness. For example, Swaziland announced in 2010 that it was going to scrap its ABC prevention strategy because it had not been effective in reducing HIV infection rates. According to the Director of the National Emergency Response Council on HIV/AIDS... “If you look at the increase of HIV in the country while we've been applying the ABC concept all these years, then it is evident that ABC is not the answer”.26 In Namibia, women's groups have criticised the ABC approach, claiming that it does not taken into consideration cultural context, where women's inequality often means that they cannot remain abstinent, practice marital fidelity or demand the use of condoms.27

A billboard promoting the ABC approach to HIV prevention A billboard promoting the ABC approach to HIV prevention

In countries where the ABC approach has been used by the government in the past, it has been found that the ABC message has not always been well communicated. For example, a study which examined understanding of the different components of 'ABC' among 500 adults at flower farms in Kenya found that most could not define the concepts clearly – and many confused 'fidelity' or 'be faithful' with 'being honest'.28 Another study conducted among teenagers in the country exposed a similar lack of understanding.29 In 2006, it was reported at the International AIDS Conference that African countries had had 'mixed experiences' with the ABC prevention method.30

As a result, even those countries which receive a large amount of PEPFAR funding have sought to adopt a more flexible approach. South Africa's 2007-2011 National Strategy maintains that all public 'Information, Education and Communication materials', “disseminate messages around ABC, stigma mitigation and human and legal rights”.31 However, there has been disagreement over the promotion  of condoms in schools, which is allowed under South Africa's Children's Act but which has been resisted by PEPFAR as PEPFAR does not allow for the promotion of condoms outside high risk groups.32   

In 2009, the AIDS Secretariat of Antigua announced that it would promote the ABC approach (focusing mainly on abstinence and 'be faithful) in secondary schools.33  

Generally, in those countries where the majority of new infections are heterosexually transmitted, the ABC approach has been sidelined in national strategies for a more comprehensive approach. However, the ABC slogan continues to be visible on billboards and posters in countries where it has been actively promoted. Moreover, the centrality of the ABC approach to PEPFAR's prevention strategy means that it will continue to play a significant role in HIV prevention campaigns and strategies in those countries which receive a substantial amount of PEPFAR funding. 

back to top Beyond ABC

As early as 2004, UNAIDS called for a move towards a more comprehensive approach to HIV prevention which reflects the inequality between men and women in many of the countries with a high HIV prevalence. Some organisations have recommended expanding on the 'ABC' slogan to include social and economic factors, particularly women's rights. At one point, it was suggested that 'DEF' were also added; representing 'defending against gender-based violence', 'education: improving girls education' and 'fix property and inheritance laws'.34

In 2003, the African Network of Religious Leaders living with HIV and AIDS coined a new prevention approach with the acronym 'SAVE' (Safer practices, Available medication, Voluntary counselling and testing, Empowerment) intended to encompass a far wider range of prevention needs.35 This was later adopted by Christian AIDS for its HIV prevention programmes.36     

However, there are those who believe instead that 'one size fit all' approaches (like the ABC and SAVE models) should be abandoned altogether. Instead, some argue, prevention strategies must be tailored to the local context, and be based on the key drivers of the local epidemic.37 There is now general agreement that where the ABC approach is used, it should be balanced and that it should also been seen as part of a wider prevention strategy that, if appropriate, includes circumcision for men, harm reduction for injecting drug users, and PMTCT for pregnant women.38

References back to top

  1. Population Action International (2008) 'Reclaiming the ABCs - The Creation and Evolution of the ABC Approach'
  2. AIDSCOM 'Lessons Learned: AIDS Prevention in Africa'
  3. Population Action International (2008) 'Reclaiming the ABCs - The Creation and Evolution of the ABC Approach'
  4. Population Action International (2008) 'Reclaiming the ABCs - The Creation and Evolution of the ABC Approach'
  5. Population Action International (2008) 'Reclaiming the ABCs - The Creation and Evolution of the ABC Approach'
  6. Population Action International (2008) 'Reclaiming the ABCs - The Creation and Evolution of the ABC Approach'
  7. Johns Hopkins Bloomberg School of Public Health Center for Communication Programs (2005) 'Journey of Hope Malawi Users Guide: Experiential Learning Activities for Making Positive'
  8. Population Action International (2008) 'Reclaiming the ABCs - The Creation and Evolution of the ABC Approach'
  9. Office of the 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"
  10. UNAIDS (2004) 'Report on the Global AIDS Epidemic'
  11. PEPFAR 'ABC Guidance 1 (Abstinence, Be Faithful, and correct and consistent Condom use'
  12. UNAIDS (2004) 'Report on the Global AIDS Epidemic'
  13. Global Health Council (2005, 10th December), 'More HIV funds to promote abstinence'; Washington Post (2006, 20th May), 'Where AIDS Funding Should Go' ; 'Testimony of Dr. Helene Gayle, President and Chief Executive Officer, CARE USA' (2006, 6th September) ; ActionAid (2008, July 28th) 'New Book says Tens of Millions of Young People Face AIDS Risk Due to Lack of Sex Education'
  14. Putzel, James 'The Politics of Action on AIDS: A Case Study of Uganda' Public Administration and Development 24: 19-30.
  15. Singh S, Darroch J E, Bankole A (2003). 'A, B and C in Uganda: the roles of abstinence, monogamy and condom use in HIV decline.' Washington, The Alan Guttmacher Institute
  16. "Uganda reverses the tide of HIV/AIDS", WHO, accessed April 2005
  17. Shelton J D et al. (2004). 'Partner reduction is crucial for balanced ‘ABC’ approach to HIV prevention' British Medical Journal, 328(10).
  18. Cohen, Susan A. (2003, December) 'Beyond Slogans: Lessons From Uganda's Experience With ABC and HIV/AIDS' The Guttmacher report on Public Policy, 6(5)
  19. Uganda AIDS Commission (2008) 'National Strategic Framework for HIV/AIDS'
  20. UNAIDS (2004) 'Report on the Global AIDS Epidemic 2004'
  21. UNAIDS (2010) 'UNAIDS report on the global AIDS epidemic'
  22. IOM (2007) 'PEPFAR Implementation: Progress and Promise'
  23. American Progress (2010) 'How Ideology Trumped Science'
  24. Daily Monitor (2011, July 17th) '25,000 babies born with HIV/Aids annually'
  25. Daily Monitor (2011, July 17th) '25,000 babies born with HIV/Aids annually'
  26. PlusNews (2010, August 16th) 'SWAZILAND: ABC approach to be shelved'
  27. The Body (2006, December 18th) 'Cultural Practices in Namibia Hinder HIV Prevention, Group Says'
  28. The Population Council (2006) 'ABCs for HIV prevention in Kenya: Messages, beliefs, and barriers'
  29. The Population Council (2006) 'ABC Messages for HIV Prevention in Kenya: Clarity and Confusion, Barriers and Facilitators'
  30. Washington Post (2006) 'Africa Gives 'ABC' Mixed Grades'
  31. SANAC 'HIV and AIDS and STI Strategic Plan for South Africa, 2007-2011'
  32. Han, Juliana and Bennish, Michael L. (2009, January) 'Condom Access in South African Schools: Law, Policy and Practice'
  33. Caribarena Antigua (2009, March) 'The ABC's of HIV Prevention'
  34. Global AIDS Alliance 'Comprehensive HIV Prevention'
  35. World Council of Churches (2005, January) 'Working with people living with HIV/AIDS Organizations'
  36. Christian Aid (2008) 'HIV is a virus.'
  37. Collins, C (2008, August) 'Moving beyond the Alphabet Soup of HIV Prevention' 22 Suppl 2:S5-8
  38. Cates, Willard (2003) 'The ABC to Z approach' Network 22(4)