Defining the ABC Approach

Approach The ABC approach employs population-specific interventions that emphasize abstinence for youth and other unmarried persons, including delay of sexual debut; mutual faithfulness and partner reduction for sexually active adults; and correct and consistent use of condoms by those whose behavior places them at risk for transmitting or becoming infected with HIV. It is important to note that ABC is not a program; it is an approach to infuse throughout prevention programs. The ABC approach is distinctive in its targeting of specific populations, the circumstances they face, and behaviors within those populations for change. This targeted approach results in a comprehensive and effective prevention strategy that helps individuals personalize risk and develop tools to avoid risky behaviors under their control.

Abstinence programs encourage unmarried individuals to abstain from sexual activity as the best and only certain way to protect themselves from exposure to HIV and other sexually transmitted infections. Abstinence until marriage programs are particularly important for young people, as approximately half of all new infections occur in the 15- to 24-year-old age group.³ Delaying first sexual encounter can have a significant impact on the health and well-being of adolescents and on the progress of the epidemic in communities.⁴ In many of the countries hardest hit by HIV/AIDS, sexual activity begins early and prior to marriage. Surveys show that, on average, slightly more than 40 percent of women in sub-Saharan Africa have had premarital sex before age 20; among young men, sex before marriage is even more common.⁵ A significant minority of youth experience first sex before age 15. Internationally, a number of programs have proven successful in increasing abstinence until marriage, delaying first sex, and achieving "secondary abstinence"-returning to abstinence-among sexually experienced youth. These programs promote the following:

• Abstaining from sexual activity as the most effective and only certain way to avoid HIV infection;
• The development of skills for practicing abstinence;
• The importance of abstinence in eliminating the risk of HIV transmission among unmarried individuals;
• The decision of unmarried individuals to delay sexual debut until marriage; and
• The adoption of social and community norms that support delaying sex until marriage and that denounce cross-generational sex; transactional sex; and rape, incest, and other forced sexual activity.

Be faithful programs encourage individuals to practice fidelity in marriage and other sexual relationships as a critical way to reduce risk of exposure to HIV. Once a person begins to have sex, the fewer lifetime sexual partners he or she has, the lower the risk of contracting or spreading HIV or another sexually transmitted infection. Some of the most significant gains in Uganda's fight against HIV are a result of specific emphasis on, and funding of, programs to promote changes in behavior related to fidelity in marriage, monogamous relationships, and reducing the number of sexual partners among sexually active unmarried persons.^6,7 Uganda's President Museveni, along with local religious groups and other NGOs, promoted a consistent message of partner reduction and fidelity, which contributed to a significant decline in the number of sexual partners among both men and women in Uganda. Between 1989 and 1995 the proportion of men who reported one or more "casual" partners in the past year fell from 35 percent to 15 percent; the proportion of women with one or more casual partners in the past year fell from 16 percent to 6 percent, and the proportion of men reporting 3 or more "non-regular" partners in past year fell from 15 percent to 3 percent. This significant level of behavior change contributed to a reduction in estimated adult HIV prevalence in Uganda from 15 percent in the early 1990s to about 4 percent today.⁸ Be faithful programs promote the following:

• The elimination of casual sexual partnerships;
• The development of skills for sustaining marital fidelity;
• The importance of mutual faithfulness with an uninfected partner in reducing transmission of HIV among individuals in long-term sexual partnerships;
• HIV counseling and testing with their partner for those couples that do HIV status;
• The endorsement of social and community norms supportive of refraining outside of marriage, partner reduction, and marital fidelity, by using strategies respect and respond to local cultural customs and norms; and
• The adoption of social and community norms that denounce cross-generational transactional sex; and rape, incest, and other forced sexual activity.

Correct and consistent Condom use programs support the provision of full and accurate information about correct and consistent condom use reducing, but not eliminating, the risk of HIV infection; and support access to condoms for those most at risk for transmitting or becoming infected with HIV. Behaviors that increase risk for HIV transmission include engaging in casual sexual encounters, engaging in sex in exchange for money or favors, having sex with an HIV-positive partner or one whose status is unknown, using drugs or abusing alcohol in the context of sexual interactions, and using intravenous drugs. Women, even if faithful themselves, can still be at risk of becoming infected by their spouse, regular male partner, or someone using force against them. Other high-risk persons or groups include men who have sex with men and workers who are employed away from home. Existing research demonstrates that the correct and consistent use of condoms significantly reduces, but does not eliminate, risk of HIV infection. Studies of sexually active couples for example, in which one partner is infected with HIV and the other partner is not, demonstrate that latex condoms provide approximately 80-90 percent protection, when used consistently.^9,10,11 To achieve the protective effect of condoms, people must use them correctly and consistently, at every sexual encounter. Failure to do so diminishes the protective effect and increases the risk of acquiring a sexually transmitted infection (STI) because transmission can occur with even a single sexual encounter. Latex condoms, when used consistently and correctly, are highly effective in preventing transmission of HIV. In addition, correct and consistent use of latex condoms can reduce the risk of other sexually transmitted diseases (STDs), including gonorrhea, chlamydia, and genital ulcer diseases.¹² While the effect of condoms in preventing human papillomavirus (HPV) infection is unknown, condom use has been associated with a lower rate of cervical cancer. Persistent infection with "high-risk" types of HPV is the main risk factor for cervical cancer. Condom use programs promote the following:

•  The understanding that abstaining from sexual activity is the most effective and only certain way to avoid HIV infection;
• The understanding of how different behaviors increase risk of HIV infections;
• The importance of risk reduction and a consistent risk-reduction strategy when risk elimination is not practiced;
• The importance of correctly and consistently using condoms during every sexual encounter with partners known to be HIV-positive (discordant couples), or partners whose status is unknown;
• The critical role of HIV counseling and testing as a risk-reduction strategy;
• The development of skills for obtaining and correctly and consistently using condoms, including skills for vulnerable persons; and
• The knowledge that condoms do not protect against all STIs.

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