Reclaiming the ABCs: The Creation and Evolution of the ABC Approach

"An important aspect of a supportive environment is that influential people are willing to take a stance in favor of change. The experiences of Uganda, Tanzania, and the Philippines illustrate the roles of such leaders in creating a supportive environment for HIV prevention."

This 18-page paper explores the HIV prevention strategy that focuses on sexual transmission and draws on the "ABC" (Abstain, Be Faithful, use Condoms) approach, with strong emphasis on abstinence for youth and fidelity in marriage (accompanied by testing). On this approach, consistent use of condoms is promoted for those most at risk for transmission of HIV. In contrast to assumptions that the ABC approach originated in Uganda, this paper demonstrates that the building blocks of ABC have existed for many years and were implemented in independent ways in various countries. Programmes aiming to prevent the sexual transmission of HIV quickly promoted these 3 behaviours in different combinations and using different messages, as this report illustrates.

The report was developed through review of the early literature on HIV/AIDS policies and programmes in non-industrialised countries and of media material promoting prevention of heterosexual transmission of HIV in those countries. While the report focuses on the experiences of 3 countries, it also examines the early responses of international organisations to HIV in many other developing countries. Additional data were obtained using a snowball sampling technique through which the authors contacted people who had worked in HIV/AIDS programmes in the 1980s and early 1990s.

From the beginning, the authors argue, the international response addressed A, B, and C (without so terming them) as separate elements - all important behaviours to stem the spread of HIV/AIDS. While early responses recognised the modes of transmission and the importance of prevention strategies, activities and messages reflected the lack of a systematic, comprehensive approach; instead, organisations tended to focus on one or two strategies.

As detailed here, in the mid-1980s, United States Agency for International Development (USAID) undertook 2 large-scale projects called the AIDS Public Health Communication Project (AIDSCOM) and the AIDS Technical Support (AIDSTECH) Project. Various iterations of these projects in different country contexts are described. For example, in the early 1990s, AIDSCOM wanted to sponsor a band for the Carnival celebration in St. Lucia. Working with the Catholic Church, the project had 3 bands - one for abstinence, one for be faithful, and one for condoms. The patois word for condom was "cock-a-lock-socks" (a rooster with socks), so the t-shirts for the other 2 bands were 2 chickens hugging ("You're the one for me") and two chicks ("I'm not ready for that yet"). Such a compromise represents the context from which an integrated ABC approach emerged.

The authors' research finds that "ABC" does not emerge in the international literature until 1992 - in the Philippines. In the early 1990s, Secretary of Health Dr. Juan Flavier, a Catholic physician accustomed to dealing with Church leaders on similar matters related to the Philippines Department of Health (DOH) family planning programme, undertook a nationwide, high-profile campaign. In his dealings with the Church, Flavier was always careful to use scientific evidence as the basis for programmes in order to avoid being pulled into debates of morality. The ABC approach he articulated quickly became known worldwide. Juan Flavier used the media and public speaking opportunities to spread messages about HIV prevention. Dr. Flavier frequently used the phrase "ABC" when making international presentations, including at international AIDS conferences, meetings of health ministers, and at the 1994 International Conference on Population and Development, which helped link the idea of "ABC" with HIV prevention. Also, the Johns Hopkins University Center for Communication Programs (CCP) provided technical advice in the Philippines in the 1980s, and is likely to have contributed to disseminating the term "ABC" though its staff and - by extension - within many countries throughout the world where they worked.

The next portion of the paper looks at Tanzania, where the government established a National AIDS Task Force in 1985; since 1987, Tanzania has mounted a national response through the Tanzania National AIDS Control Programme (NACP). In the late 1980s, Father Bernard Joinet, a Catholic priest who taught clinical psychology at the University of Dar-es-Salaam, was inspired by the biblical story of Noah's Ark to came up with the idea of representing HIV/AIDS as a flood in which people were drowning and the only way to escape the flood is to board one of three boats: "Abstinence," "Fidelity," or "Rubber Lifeboat" (condom). The approach sought to encourage people to board whichever boat fit their life situation; when life situations changed, people could move from one boat to another. The boats operationalised the prevention behaviours in a way that focused on safe sexual behaviours and without moralising. Over time, the graphic representations of the Fleet used in Tanzania have changed, but it continues to be used.

According to the authors, the Fleet of Hope has been adapted for use throughout the world, including Uganda, Burkina Faso, Ghana, Zimbabwe, Nigeria, Kenya, and Haiti. It also served as the basis for other HIV prevention programmes, including "Stop AIDS. Love Life" in Ghana; the "Bridges of Hope" programme in Zimbabwe; and "Fleet of Hope with Future Islands," which has been used in many countries in Africa. The Fleet of Hope theme appeared in folk art, religious services, and media presentations. The United Nations Development Program (UNDP) and the United Nations Joint Programme on HIV/AIDS (UNAIDS) have also incorporated the Fleet of Hope into programme activities.

After reviewing some other uses of ABC in Tanzania, the paper turns to Uganda as a case study, exploring the historical evolution of communication approaches - from an initial narrow focus on instilling fear, to a widening of the range of prevention options (condom use and avoidance of casual sexual contacts). As detailed here, in the late 1980s, one Ugandan religious leader took a stand in favour of openly supporting condom use for HIV prevention. The late Bishop Karuma of the Anglican Church of Uganda, whose son had died of AIDS, was reportedly the first religious leader to link the B and C messages, saying "If you are foolish enough to have sex outside, don't be stupid enough not to use a condom." As the authors' research revealed, however, in the early 1990s, "ABC" still did not appear in public sector HIV prevention programmes. One reason: Ministry of Health (MOH) staff were hesitant to talk about condoms. However, during community-based HIV education sessions, the public was eager to learn and not afraid to talk about condoms, although they were not commonly available through the MOH. President Yoweri Museveni, who had started talking openly about AIDS as early as 1985-1986, "played an enormous role in publicizing and de-stigmatizing AIDS and in promoting a program that includes a wide range of organizations..."

Following a look at different definitions of ABC, the authors offer a discussion section. One salient point presented there: "Research on HIV prevention has found that comprehensive prevention programs, directed at both the individual and the community, and addressing structural factors - such as laws, policies, and social norms - have the greatest effect". Policy recommendations offered include:

• Restore A, B, and C to their public health roots, broadly defining them to include delaying first sex and partner reduction.
• Promote the whole alphabet of HIV prevention approaches, including, among other interventions, access to safe circumcision for men, legal protection for vulnerable populations, promotion of human rights and gender equity, access to livelihoods, and availability of comprehensive evidence-based information and services.
• Give people - without judgment - the complete and comprehensive information they need to decide for themselves which prevention behaviour is most appropriate in the context of their lives. (The authors explain that narrow messages that focus on abstaining until marriage, being faithful in marriage, and only resorting to using condoms for high-risk sex have had unfortunate results).