The ABC’s of HIV/AIDS Intervention Programs - Laura Pinheiro

Since the beginning of the global AIDS epidemic, nearly 30 years ago, it is estimated that 60 million people have become infected with this virus and approximately 25 million have died from it (UNAIDS 3). In the U.S, some control over this epidemic has been gained, and currently, about 1% of the country’s population is living with HIV/AIDS even though about 56,300 Americans continue to become infected each year (CDC). Despite the U.S’s ability to decrease domestic HIV incidence, the global alarm for this epidemic has not subsided. In 2008, there were estimated to be 2.7 million new HIV infections and 2 million HIV related deaths in the world (UNAIDS 2). According to the UNAIDS 2009 report, there are up to 36 million people currently living with HIV and 67% of those reside in Sub-Saharan Africa, home to 91% of all new infections among children (UNAIDS 3). Since Sub-Saharan Africa is an area of large concern relating to this epidemic, there have been several initiatives aimed by national governments and international organizations to help those countries combat HIV/AIDS. Among these, is former President George W. Bush’s public health intervention, the President’s Emergency Plan for AIDS Relief (PEPFAR).

The original PEPFAR was launched in 2003 as part of the United States Leadership Against Global HIV/AIDS, Tuberculosis and Malaria Act (AVERT 1). The Act approved $48 billion to go towards fighting these three diseases: $39 billion towards HIV/AIDS, $4 billion for tuberculosis and $5 billion for malaria (AVERT 1). Under PEPFAR, the money would be allocated over 5 years where 55% went to treatment of those living with HIV/AIDS (ART therapy), 15% to palliative care (care to alleviate symptoms and improve quality of life to those diseased), 20% to HIV/AIDS prevention, and finally, 10% of the money would go to aiding children made orphans because of HIV/AIDS (ALERT 1). The US Global AIDS coordinator, Dr. Mark Dybul, is responsible for coordinating PEPFAR initiatives (ALERT 1). Although there are fifteen “focus” countries (mainly Sub-Saharan African countries among them, but Vietnam is also included), PEPFAR technically refers to, “any HIV/AIDS expenditures and activities that the US government provides to all countries outside of the U.S.” (ALERT 1) An example of a, “non-focus country PEPFAR expenditure is the substantial funding that is being provided for HIV/AIDS work in India.” (ALERT 1) The HIV/AIDS prevention intervention compromises 20% of PEPFAR and is often referred to, as the “ABC’s” meaning abstinence until marriage, be faithful and condom use. While this ABC approach has merits and is a valiant attempt towards combating the HIV/AIDS epidemic, it is also made up of various flaws, hindering it from having the impacts on this global issue that it set out to make. This paper will attempt to illustrate some of the major flaws in the ABC approach from a social and behavioral science perspective and to suggest some changes that could be made in order to increase the effectiveness of this intervention.

The first major flaw in the PEPAR initiative and particularly ABC approach is that it spends an inordinate amount of prevention funding (33%) on promoting abstinence only (ALERT 1). It is true that the only 100% effective way to prevent sexual HIV transmission is not having sexual intercourse with an HIV-infected person, and therefore, abstaining from sexual intercourse, would eliminate the risk of sexually contracting HIV. This idea is flawed, however, because it assumes that people make the decision to engage in sexual intercourse entirely rationally and that is frequently not the case. The Health Relief Model assumes that every health decision is a balancing act where an individual weighs perceived susceptibility to a disease with the perceived severity of the disease and they then make a planned, rational decision based on weighing these two factors (Edberg). Theoretically, a person should weigh the idea that if they engage in sexual intercourse at all, they will increase their risk of contracting HIV and that if they do contract HIV they are likely to become very sick from this disease and eventually die as there is no cure. However, due to optimistic bias, that is, the idea that individuals understand the actual, absolute risk of their behavior, but they perceive their personal risk being much lower, people may not always follow through with their initial intentions stemming from the Health Relief Model (Weinstein). A person may be educated about the ways to sexually contract HIV, they may be fully aware that by abstaining they will eliminate the risk of sexually contracting the disease, they may even have the intention to abstain in order to prevent infection, but when they meet someone that they love and are sexually attracted to and want to have sex with, they may think that their personal chance of contracting the disease is not really as great. Therefore, focusing such a large portion of an intervention to combat the growing HIV/AIDS epidemic on abstinence only is severely flawed, as it treats individuals as completely rational and levelheaded, when in reality, people are frequently governed by their emotions and desires. Rather than telling people not to engage in sexual intercourse, which may also induce psychological reactance, the theory that, “when people think that a freedom is threatened, they experience reactance, a motivational state aimed at restoring the threatened freedom,” more funds should be allocated to educating people on ways to protect themselves when having sex (Silvia, 409). Being more realistic about people’s sexual behavior, especially those who are young, as well as framing the ways to protect oneself in a less restrictive manner, would truly improve the reduction of HIV/AIDS transmission.

The second major PEPFAR flaw is its failure to recognize societal constructs and inequalities in the countries it is attempting to aid. In many of these Sub-Saharan Africa “focus” countries that PEPFAR aims to target, sexual abuse such as rape is a major issue, and a frequent mechanism in which women become infected with this terrible disease. The Theory of Gender and Power discusses how through the sexual division of power, women can be more susceptible to HIV infection due to inequalities: “As the power inequity between men and women increases and favors men, women’s sexual choices and behavior may be constrained, thereby increasing their risk for HIV.” (Wingwood, 564) Women may have the desire to be abstinent in order to protect themselves, but when they are raped or sexually abused, that choice and decision is taken away from them. The abstinence only component of the ABC approach is not tailored towards the societies of the Sub-Saharan African nations who devalue women and do not view men and women as equal members of society, reflecting yet another flaw in this intervention. An intervention that focuses more of its efforts on educating women about the disease, that teach them ways that they can protect themselves (vaginal microbicide gels, females condoms) would be more effective than simply encouraging them to abstain, when often that choice is not even in their power to make. In a region that harbors 67% of the current HIV infections, an intervention that better recognizes and comprehends societal constructs is likely to prove more beneficial in the attempt to reduce HIV/AIDS incidence. By ignoring societal constructs and gender-power roles between women and men, the PEPFAR intervention is not an effective public health intervention to combat the HIV/AIDS epidemic.

A third major flaw in PEPFAR is the “B” in the ABC approach: be faithful. President Bush’s Emergency Plan promotes being faithful by, “supporting counseling, peer education, and community-based interventions to address social norms that increase vulnerability to HIV, such as the acceptance of men having multiple sexual partners outside of marriage, cross-generational sex, and transactional sex.” (State) Being faithful is an individual-level behavior that is very difficult for an intervention to monitor, promote or control. Like the abstinence component, the being faithful component is unrealistic in regards to an individual’s behavior. While a person may have every intention of being faithful and to honor their commitment to their sexual partner, emotions and passion may intervene. The construct of marriage, for instance, may make people feel constricted and unable to exercise their freedoms, and in turn, due to psychological reactance previously described, they choose to stray from their marriage and pursue other sexual partners. There are many complex issues surrounding people’s decisions to not be faithful to their sexual partners: they do not feel satisfied in their relationship, they are sexually attracted to another person, they are unable to control themselves, they do not feel that being faithful is important…etc. It is impossible to approach the control or modification of this individual behavior from an angle that will target every person or even the majority of people because the reasons why people are not faithful vary immensely. For instance, the Theory of Reasoned Action stipulates that individuals balance individual decisions with outcome expectancies such as their personal attitude towards a behavior with subjective norms such as what do other people think about the behavior and how they will you be perceived by engaging in this behavior. (Edberg). While this model is more realistic than the Health Relief Model in that in takes into account societal influences on an individual’s choices, it still cannot explain individuals’ behaviors regarding being faithful. Cheating on a partner or committing adultery in a marriage is considered a terrible thing to do in nearly every society. A woman who commits adultery in some Islamic countries can even be stoned to death for her behavior. Why then, do people continue to betray their sexual partners? This behavior is not a simple one to explain and relying on it in order to combat the HIV/AIDS epidemic is foolish. Simply encouraging people to be faithful in their sexual relationships does not suffice and will not make a considerable impact in reducing the spread of HIV/AIDS as infidelity is not a rational, planned behavior.

The promotion of being faithful is yet another example of PEPFAR’s second major flaw of failing to account for societal constructs of the Sub-Saharan African countries, specifically gender inequality. For instance, in Botswana, the country with the second highest HIV prevalence, 25%, and a life expectancy below 40 years, the number of women living with HIV compared to men is more than twice as great (UNAIDS, 2). Botswana relies on PEPFAR’s aid more than any other foreign contribution to help fight the overwhelming HIV/AIDS epidemic (AVERT, 2). PEPFAR’s ABC policy focuses primarily on male-controlled forms of prevention, and this does not appear to address the overarching percentage of females infected with the disease. In a country where women are barely educated and are marginalized, by not employing HIV/AIDS prevention methods that empower females (who are at a higher risk of sexually contracting the disease), PEPFAR is not proving an effective intervention. According to the Theory of Gender and Power, “women are biologically more likely to become infected if they are exposed to a sexually transmitted pathogen,” so, “biologically, women are at a higher risk for HIV.” (Wingwood, 580) In terms of the “be faithful” approach, if a husband or boyfriend is not faithful to his partner, she may become infected by no fault of her own. A female may not even be aware that her partner was not faithful, and even if she is aware, she may rely so heavily upon this male for financial support and food, that she is not able to do anything about his infidelity. Therefore, if a woman is faithful in her relationship, complying with the ABC approach, but her male partner is not, the woman’s risk of contracting HIV is not significantly reduced, meaning that PEPFAR is not achieving its goal. An intervention that accounts for these societal issues and gender-power inequalities would be much more effective and unfortunately, PEPFAR fails to do this.

The PEPFAR prevention of HIV/AIDS is an intervention that has very good intentions, but does not seem to be approaching the global epidemic, especially in Sub-Saharan Africa in the most effective way. The plan claims that, “Past and current prevention messages have often failed to achieve the widespread behavior change that is necessary to end the pandemic,” and, “prevention efforts are further hampered by the stigma surrounding HIV/AIDS and gender inequality that increases the vulnerability of women and girls,” but it does not seem to adequately address these issues (State). By promoting the ABC’s, which stress the unrealistic and often uncontrollable pillars of abstinence and being faithful, and then telling people to use condoms is proving not to be the best approach. Signs on Botswana highways advertise, “Avoiding AIDS is as easy as: ABSTAIN, BE FAITHFUL, condomise.” (ALERT 2) Indicating that the first two components are more important, but if all else fails, people should use condoms. This ad is confusing; as PEPFAR is not maintaining consistency with the messages it is relaying and is contradicting itself. In addition, the PEPFAR intervention does not take into account gender-power roles, specifically those that marginalize women and increase their susceptibility to acquiring HIV/AIDS. Societal constructs that incorporate these gender discrepancies and inequalities must be considered when developing an adequate and appropriate intervention that will achieve success in reducing HIV/AIDS transmission and controlling this global epidemic. An optimal intervention needs to be more realistic about individual (especially those who are young) behaviors and educate people about ways to protect themselves without prohibiting the risky behavior entirely. The intervention should not use an authoritative voice, which might invoke resistance. Furthermore, it should not attempt to rationally control a behavior that is so strongly affected by emotions and impulses. Finally, a more appropriate intervention that accounts for societal constructs, gender roles and inequalities, will be much more successful in combating the HIV/AIDS global epidemic plaguing 36 million individuals worldwide.

Although there is no intervention that will perfectly address all of the PEPFAR issues previously discussed, there are interventions that would improve upon some of the PEPFAR flaws and thus create more effective HIV/AIDS prevention policies. First, rather than taking the approach of “abstinence only”, an intervention that is more sexually comprehensive, and realistic, will better serve the needs of the population suffering from this epidemic. According to an article published about abstinence programs in the U.S, “Abstinence-only education has had little demonstrable impact on teenagers' sexual behaviors, despite significant policy and funding efforts.” (Harper) Since abstinence only programs have proved to fail in the past, a comprehensive sexual health education program should be instituted in these focus countries either at the local health clinics or perhaps through the schools. If people (especially when they are young) are able to become educated about the risks of sexually transmitted infections (STIs), and ways to prevent, test and treat for them, the general population will be better equipped to handle this epidemic. By sheltering people and telling them that the only way to avoid getting HIV is to avoid having sex, interventions are essentially handicapping individuals who decide to have sex, but still want to remain HIV-free. According to the American Psychological Association (Rotheram), “Only comprehensive sex education is effective in protecting adolescents from pregnancy and sexually transmitted illnesses.” (Rotheram) These comprehensive programs have proven that they work better in efforts to protect youth from contracting STIS and, “scientifically sound studies of abstinence only programs show an unintended consequence of unprotected sex,” so, “in this way, abstinence only programs increase the risk of these adolescents for sexually transmitted illnesses, including HIV/AIDS." (Rotheram) Therefore, it is essential for HIV/AIDS intervention programs to increase funding and emphasis on sexual health education as a means to decrease HIV/AIDS incidence. The cliché “knowledge is power” is quite applicable in this situation: without proper knowledge of risks, symptoms and treatments, people cannot adequately protect themselves. Perhaps if people understood the actual consequences of HIV/AIDS and other STIs they would be able to take precautions in order to prevent their own infection. Realistically, understanding the consequences may not make people more likely to necessarily abstain from sexual intercourse all together, but it hopes to make people more likely to choose their partners carefully, get tested more frequently and use condoms more often, thus reducing the overall rate of HIV infection.

Furthermore, when creating these sexual health education programs in the focus countries local people, not foreigners, should deliver the information about STIs. According to Paul Silvia, a way to deflect psychological reactance is to present information through, “interpersonal similarity.” (Silvia, 278) That is, people are less likely to have reactance to information that is relayed to them by people they feel similarities to and can identify with, therefore deflecting reactance (Silvia). According to this theory, if sexual health messages were delivered by white, English-speaking Americans in Uganda, a much higher level of resistance will be met than if these messages were delivered by an individual that grew up in one of the local villages and speaks the people’s language (Silvia). Taking steps towards creating an environment that the population will not resist these HIV/AIDS messages will prove essential to the acceptance of safer sexual practices and therefore the reduction of HIV/AIDS incidence.

The PEPFAR plan only promotes consistent condom use among “high-risk” populations, which they identify as, “prostitutes, sexually active discordant couples, and substance abusers, “ but assures that, “the general population receives a clear message that the best means of preventing HIV/AIDS is to avoid risk all together,” meaning abstinence (State). This approach is ignoring the fact that many people who are not deemed “high risk” are also interested in having sex and rather than simply authoritatively telling them that they should abstain to be protected, facilitating protection if they choose to have sex would be more effective. Free condom distribution needs to be much more widespread and targeted to all populations (not just ones PEPFAR deems “high risk”), as condoms are the biologically most effective way to prevent HIV-transmission if you engage in sexual activity. Rather than focusing PEPFAR efforts to encourage people to “be faithful” and isolating “consistent condom use” to high-risk populations, if condoms were readily dispensed for free, more people would use them. Brazil’s HIV/AIDS efforts are internationally recognized as successful and condom use is one of the largest pillars of their interventions (ALERT 3). During carnival of 2009, Brazil distributed, “65 million free prophylactics to partiers,” across the country (Daily News). According to Mariangele Simao, the director of the national HIV/AIDS program in Brazil, the country spends nearly $40 million each year buying condoms, making it, “the world's No. 1 government buyer.” (Daily News) Brazil has achieved great success with its HIV/AIDS campaign and, “the number of deaths from the disease has dropped by 80% in recent years in Brazil.” (Costa) In addition, Brazilian media campaigns encourage condom use with messages relayed by celebrities saying slogans like, “Show how you’ve grown up. This carnival, use condoms!” (ALERT 3) These messages not only use an idolized, well-liked voice to spread the word (which has been proven to make the message more appealing), but they also use a technique, which empowers the individual by emphasizing that by using condoms they are smart and exercising control. Brazil is interesting because it is a country, which has been well-developed areas, but the urban and rural slums are overwhelming. Brazil, like many of the target African focus countries, serves a large population of poor, uneducated people without the financial means to adequately prevent themselves from contracting HIV/AIDS. Therefore, the following Brazil’s intervention policies of widespread condom distribution and having popular celebrity figures encourage the responsible behavior might appeal to a large audience (especially the youth) and prove to be effective in these focus nations that PEPFAR aims to help.

Finally, addressing the societal constructs of the particular nation that the HIV/AIDS intervention aims to target is absolutely essential to its success. If the intervention does not acknowledge that the particular country they are implementing a policy in may not value the same things or may not work in the same way, it will not be successful. Of course, molding to societal constructs will vary from country to country. For African nations, programs that target women specifically, such as educating them about the ways that they can protect themselves are instrumental. Women can use vaginal microbicide gels such as Tenofovir 12 hours prior to and 12 hours after sex in order to reduce the risk of HIV infections without their partners even knowing. According to the Caprisa Study done in South Africa, “Women who used the gel in more than 80% of their sex acts had a 54% reduction in HIV infections, a 38% reduction if they used it 50% to 80% of the times they had sex, and a 28% reduction if they used it in less than half of their sex acts.” (Keller) This gel can make a large impact on the fight to combat the HIV/AIDS epidemic. If women are able to use this gel independently of what their partners want, they will be protecting themselves from acquiring the HIV virus within the constraints of their society. It is not the job of PEPFAR or any other HIV/AIDS intervention program to change a different country’s societal constructs because this is a nearly impossible task. However, if foreign intervention programs work within the constructs of these societies in order to help empower and protect those most susceptible to infection, they will be more successful in their attempts to reduce HIV/AIDS. Gender inequality exists in these focus countries and although HIV/AIDS interventions will not eliminate this inequality, it can certainly work to lessen the severity of the impact it has on HIV/AIDS by empowering women and promoting prevention methods that give women rather than men more control.

A reformed HIV/AIDS intervention needs to be created in order to make a larger and better impact on the focus countries defined by PEPFAR. This new intervention should account for individual’s irrational, impulsive and unplanned behavior and societal constructs that fuel gender inequality. A HIV/AIDS intervention that increases sexual health education as a form to protect those who choose to be sexually active rather than simply promoting abstinence will be a more effective way to reduce the spread of the disease. Rather than telling couples to be faithful to one another, an ambition that is noble yet not frequently practical, realistic or controllable (especially by the partner being cheated on), the intervention should promote the widespread use of condoms. Instead of targeting only “high risk” populations with condom use, all populations: even those who are married and in relationships should be targeted in order to reduce the overall spread of the disease. Furthermore, understanding and working within societal constructs of a particular country will only augment the impact of the reformed intervention. Empowering women, often the victims of sexual abuse, rape, and gender inequality in these “focus” countries to protect themselves through female condoms and particularly vaginal microbicide gels, will allow the intervention to effectively impact more people in need. Through these intervention policy changes, plans like PEPFAR can hope to make more efficient use of the billions of dollars that they are spending and impact a much larger population of people afflicted with HIV/AIDS.

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