Wednesday, December 13, 2006

Failure of the ABC campaign to Account for Society, Culture, and Infrastructure in Sub-Saharan Africa - Ibrahim Idakoji

Amid an Epidemic in Sub-Saharan Africa
The most recent Joint United Nations Programme on HIV/AIDS (UNAIDS) data estimates that at the end of 2005, 38.6 million people were living with HIV around the world and an estimated 2.8 million people lost their lives to AIDS. Sub-Saharan Africa appears to be hardest hit by the AIDS epidemic with an estimated 24.5 million people living with HIV at the end of 2005; roughly 63% of all the people infected globally. (1) This pandemic has grave implications for Africa’s economy and productivity, as well as the global economy. Clearly the global effort has failed to thwart the AIDS epidemic in Sub-Saharan Africa and our proposed public health interventions need to take a deeper and broader look at the context in which HIV transmission occurs in this part of the world, and aim to implement interventions that will directly target some of the fundamental causes of this monster disease.

The ABC Approach to HIV Prevention
Many global organizations, AIDS advocacy groups, and recently, President George W. Bush and the United States government, have taken a moral stance on HIV prevention and have made the ABC campaign the focus of its global AIDS prevention strategy. The notion is that simply teaching and promoting the ABCs will lead to behavior change and a subsequent decrease in HIV transmission. Many proponents of the ABC campaign often cite Uganda’s sharp decrease in HIV incidence in the 1990s as a testament to the effectiveness of this approach; however, there still remains much debate as to the true cause of the decline. The letter A denotes abstinence, which is obviously the most effective method of preventing HIV transmission, along with pregnancy and other sexually transmitted infections (STIs). Letter B refers to being faithful, which can be a very effective method if two partners are in a monogamous relationship. The caveat is that both partners must be HIV seronegative before coming into the union, and trust, openness, and honesty are of paramount importance to the effectiveness of this strategy. Lastly, C stands for condom use. Condoms must be used correctly during every sexual encounter for this method to be effective in preventing HIV transmission. One can begin to see that under such rigid conditions, conformity can be difficult and human behavior along with societal context may preclude certain individuals from taking these preventative measures.

A Need to Look Deeper
In this paper I posit that the sole emphasis on the ABC approach in addressing the AIDS epidemic and preventing transmission is shortsighted and does not account for the feasibility of achieving such a goal in the Sub-Saharan African context. There is a pressing need for public health interventions to go beyond promotion of the ABCs and examine societal contexts, cultural norms, infrastructure, and available funding, because as our efforts continue to fail an estimated 930,000 adults and children continue to die yearly in Sub-Saharan Africa.

The Shortcomings of Abstinence Messages
Messages promoting abstinence often fall on deaf ears. Society often tries to ignore the reality that sexual activity is highly prevalent, and increasingly so amongst adolescent populations around the world. One study conducted in a group of 675 male and female adolescents age 10 to 19 years who were attending the adolescent antenatal clinic at the Kenyatta National Hospital and the Special STD and Skin Disease Clinic in Nairobi, Kenya, found the average age of first intercourse to be 15.1 and 16 for males and females respectively. (2) Instead of turning a blind eye to the fact that people are having sex, perhaps we should aim to understand why people are engaging in sexual behavior at a young age, or why people are engaging in sexual activity with many different partners, and the context in which sexual activity is occurring. The “out of sight, out of mind” approach to the issue does nothing more than make sexual activity a taboo subject, and the lack of candor promotes ignorance and misinformation on the risks of engaging in this behavior. This same study also found that when this population of adolescents was asked about STIs, only some of the respondents were able to identify three: gonorrhea, syphilis, and HIV. This highlights the fact that many adolescents are engaging in sexual behavior, yet many of them are not aware of the associated risk factors.

We would be remiss to not also acknowledge the fact that promoting abstinence also comes across as a moral judgment, and when individuals feel they are being judged for their behavior they are likely to tune out the messages or defy authority by continually engaging in said behavior. Labeling Theory posits that the labels applied to individuals, influences their behavior. The moral position behind abstinence categorizes those who do not follow these messages as deviants. Often when individuals are judged by society or labeled as not conforming to societal norms, it becomes a self-fulfilling prophecy as they consciously or sometimes subconsciously commit to adopting the behavior.

Even more disheartening in this approach to prevention is the fact that it does not even begin account for those without a voice; the young victims of rape and sexual abuse. Data from 1,395 women attending antenatal clinics in Soweto, South Africa estimated the prevalence of physical and sexual partner violence, sexual assault by non-partners, child sexual assault, and forced first intercourse. (3) Within a 5 month period, 55.5% of the clinic attendees reported sexual assault by their partners, and 7.9% reported assault by non-partners. Eight percent of the women reported child sexual assault and 7.3% reported forced first sexual intercourse. How are messages of abstinence expected to be received by these individuals? Truly, what value does an abstinence campaign have for these young women and girls who have been violated, robbed of their innocence, and put at risk of contracting HIV?

Cultural Incongruity in Being Faithful
The current definition of being faithful only accounts for one man and one woman in a committed relationship, which may seem obvious and logical from a Western perspective but not necessarily the case in other cultures. We must be careful not to make assumptions or apply our societal standards to other parts of the world. This very rigid definition does not account for cultural differences in marriage and relationship views. In many Sub-Saharan African cultures, a man is permitted and sometimes expected to have multiple wives. By promoting monogamy and being faithful to only one woman, we run the risk of appearing to make a moral judgment about cultural polygamy. Perhaps we should consider how to best protect those involved in such a dynamic, and educate them on how partners involved in a polygamous relationship can be faithful and safe. Simply stated, promoting being faithful in the way it is constructed and understood from a Western perspective under the ABCs, may have no meaning to people in some cultures in Sub-Saharan Africa involved in a polygamous relationship. A study on risk factors for extramarital sex among Nigerian men found that men with 3 or more wives were at greatest risk of engaging in extramarital sex. (4) Furthermore, there appeared to be a perceived cultural acceptability of the practice of having multiple wives, in addition to engaging in extramarital sex. Whether right or wrong, it was the reality in this context and a definite risk factor for HIV transmission that needs to be addressed.

A Lack of Condom Availability
Many underdeveloped nations lack the resources or infrastructure to adequately supply contraception to the population. Simply stating that people should use condoms means nothing, when they are often unavailable and people have become accustomed to intercourse without their use. A study conducted in urban Tanzania between 1997 and 1999 aimed to assess the availability of socially-marketed condoms; condoms typically advertised to the general public and sold at a cost in retail outlets. The authors found that the percentage of outlets selling socially-marketed condoms increased from 25% to 32% between 1997 and 1998 and stabilized at this level, in accordance with an increase in wholesalers and marketers promoting the distribution of more condoms. (5) Although there was an increase, this number is still staggeringly low, and it must be noted that this is the percentage of outlets carrying condoms in an urban setting; one could surmise the figures would be much lower in a rural setting.

Another study looked at the degree of equity in access to condoms in urban Zambia in 1999. The results showed that about 39% of outlets in urban Zambia carried socially-marketed condoms, but only a little more than 30% of the outlets commonly found in low-income residential areas carried socially-marketed condoms. Access to condoms was also assessed based on estimated walking time to a condom source, showing a definite relationship between access to resources and being within reasonable walking distance to a source of condoms. (6) Again these percentages are staggering; one is hard pressed to find a grocery store, convenient store, drug store and the like in the United States that does not have condoms readily available for purchase. It is no surprise that in a region of the world that is overwhelmed with poverty and a lack of infrastructure and economic resources, contraceptive availability is difficult to come by.

Moving Forward
To offer some anecdotal evidence that highlights the stance of the foregoing arguments, I turn to my experience working on issues surrounding the AIDS epidemic in Tanzania, East Africa. In the summer of 2003, one day after completing a day of teaching at a secondary school, I stood in the school yard with a few of my Tanzanian teaching counterparts as the students filed out of class and took to activities in the field. One of my colleagues brought to my attention that some of the girls in our class as young as twelve years of age were in situations where they were having sex with grown men in exchange for payment of their school fees, because they could not otherwise afford to attend school. I was immediately taken aback and felt completely helpless in the situation, and at the same time came to realize that the nature of what we were dealing with went beyond preaching the ABCs. In managing a condom distribution project, I also came to realize through surveying all the outlets and vendors in the rural areas where we worked, that condom availability was sparse and quite costly in relation to the income availability of the majority of Tanzanians. Again, this highlights the fact that in such a context the ABC approach to HIV prevention is shortsighted, and we can do better in implementing more effective HIV prevention interventions.

Conclusion
Addressing the AIDS epidemic in Sub-Saharan Africa requires a multi-faceted approach that goes beyond simply promoting the ABCs. I am not promoting abandonment of the ABCs, but rather an expansion and modification of the ABCs to fit a Sub-Saharan African context, and a consideration of the often overlooked factors that also contribute to HIV transmission. Individuals do not always have the option to practice abstinence, as can be seen in cases of sexual assault or violence committed against women. Simply promoting abstinence in a context where these activities prevail is futile. Being faithful may have different meanings for different people or different communities, and simply applying a definition that others do not ascribe to is also a futile attempt at promoting HIV prevention. It is easy to recommend condom use for every single sexual encounter, but we have seen that condom availability is often sparse in parts of Sub-Saharan Africa, and even more difficult to access by those with a lack of financial resources. The AIDS epidemic is sweeping the continent of Africa virtually unrestrained, and it is time public health take a broader look at the societal structure, gender relations, economics, infrastructure, attitudes and beliefs in each context, and modify our interventions in order to be successful in our fight against HIV/AIDS.

References

1. Unaids.org. 2006 Report on the global AIDS epidemic: 2 Overview of Global AIDS Epidemic [database on the Internet]. Available from http://www.unaids.org/en/HIV_data/2006GlobalReport/default.asp.

2. Lema, V N. Hassan, M A. Knowledge of sexually transmitted diseases, HIV infection and AIDS among sexually active adolescents in Nairobi, Kenya and its relationship to their sexual behaviour and contraception. East African Medical Journal 1994 Feb;71(2):122-8.

3. Dunkle, K L. Jewkes, R K. Brown, H C. Yoshihama, M. Gray, G E. McIntyre, J A. Harlow, S D. Prevalence and patterns of gender-based violence and revictimization among women attending antenatal clinics in Soweto, South Africa. American Journal of Epidemiology 2004 Aug 1; 160(3):230-9.

4. Mitsunaga T M. Powell A M. Heard N J. Larsen U M. Extramarital sex among Nigerian men: polygyny and other risk factors. Journal of Acquired Immune Deficiency Syndrome 2005 Aug 1;39(4):478-88.

5. Agha S. Meekers D. The availability of socially marketed condoms in urban Tanzania, 1997-99. J Biosoc Sci 2004 Mar;36(2):127-40.

6. Agha S. Kusanthan T. Equity in access to condoms in urban Zambia. Health Policy Plan 2003 Sep;18(3):299-305.

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