Appendix: Determining the Appropriate Mix of ABC Interventions

To identify the most strategic prevention interventions, countries must first gain an understanding of the types and degrees of risk behavior that fuel the epidemic locally. It is recommended that countries develop their prevention strategies through a two-step situation analysis that addresses questions of "who is doing what, with whom, where, and why."

In the first step, available epidemiological data should be applied to estimate the proportion of new infections that are associated with specific behaviors such as prostitution, early onset of sexual activity among youth, transmission through sexual networks, etc. Efforts should be made to review prevalence data available through national serosurveys, antenatal clinic surveillance, and/or voluntary counseling and testing clinics, to assess different infection burdens by age and by gender. For example, high HIV prevalence among young women, and among older men, may point to transmission that is fueled by cross-generational sex. Population-level surveys featuring behavioral indicators, such as demographic health surveys and behavioral surveillance surveys should also be carefully reviewed to assess the extent to which certain types of behaviors represent important opportunities for preventing new infections. In Botswana, for example, reported levels of condom use are quite high, but so are reported numbers of concurrent sex partners, suggesting that approaches emphasizing partner reduction could have strategic benefits over those that prioritize additional condom promotion.

It is recommended that this first step produce information relevant to each of the following considerations:

• Who are the core transmitters?
• What are the specific behaviors through which HIV is transmitted?
• What are the specific behaviors that represent the most strategic targets for averting new infections?
• What are some of the specific prevention/intervention needs of women, youth, and "vulnerable" populations?
• What are some of the specific prevention/intervention needs of people living with HIV/AIDS (PLWHAs)?
• How can the "ABCs" be applied appropriately? (Note: ABC must be balanced at the portfolio level, i.e. all three components must be represented in the country's prevention strategy, but individual programs must be appropriately designed to meet the needs of the target audience.)
• What are the priorities for abstinence?
• Partner reduction is a critical behavioral determinant in many cases; how is it being addressed?
• In what circumstances are condoms critical?

Having identified these behavior change priorities, the second step should seek to understand more specifically who is engaging in risk-related activities, where to reach these people, and what individual and structural factors could be leveraged to promote change. Participatory and/or rapid assessment approaches, employing qualitative and/or quantitative methods, can help to characterize transmission risk among specific groups or in specific settings. In addition, one of the most important components of this step involves developing a better sense of the supporting environment for specific kinds of initiatives and prevention opportunities. Many of the interventions that are believed to have contributed to Uganda's success originated from pre-existing structures, organizations, and networks. This type of information is often collected through observation and experience, but reviewing local media and conducting strategic interviews with key local and national stakeholders from a variety of backgrounds can help to generate a good picture of the supporting environment. Some other critical questions to consider in this stage include:

• What is national political, social, and cultural leadership saying or doing (or not) about AIDS and about behavior change and prevention?
• What networks or institutions are engaged (or not) in HIV prevention? (Schools, churches, NGOs, local government units, workplaces, etc.)
• What are community leaders doing or saying (or not) about HIV prevention?
• How is information about HIV/AIDS being shared within personal networks? Are people talking about HIV/AIDS? To what extent does stigma present a barrier to effective action?
• What are the gender inequities that foster the spread of HIV?
• What are the other social inequities and local practices that foster the spread of HIV?
• How is the media treating HIV prevention and behavior change?
• What additional issues are impacting the country and its HIV epidemic (e.g. war, famine, refugees, other diseases)?
• How are local experts engaged in assessing the supporting environment, including women and PLWHA?

These diagnostic questions are all critical for empowering a grassroots/community-level response to the epidemic. U.S. missions should collaborate with local experts to foster a local perspective that is culturally appropriate and sensitive. Creating a strong community-level response will aid rapid scale-up and ensure long-term sustainability.

ABC and Local Transmission Dynamics
Program planners should recognize that the relative prevention benefits associated with "A", "B" and "C" programs will vary across epidemic contexts with differing transmission dynamics. In the absence of this recognition, programmers risk responding to a "generalized" epidemic with a "generalized" response - one that lacks strategic focus in terms of both its target audiences and its behavioral objectives. This point is illustrated in the following figure, which highlights large differences in the types of exposures that are significantly contributing to new infections in five countries. The transmission dynamics that contribute to infection across these different "exposure" types helps to highlight the strategic benefits of prioritizing different ABC objectives in different settings.

(Text version of the table below.)

In the majority of the Emergency Plan focus countries, a large proportion of new HIV infections is attributable to heterosexual transmission fueled by casual sex and concurrent partnerships. Whether or not an HIV epidemic escalates depends on the existence of secondary networks that facilitate further HIV transmission to individuals who may not have direct contact with perceived "high-risk" partners.²¹

(Text Explanation of Transmission through concurrent Partnerships Graphic)

This diagram illustrates how the efficiency of HIV transmission is dramatically increased in the presence of frequent sexual contact if such contacts are "concurrent" (overlapping). Since population-level survey data from many countries indicates that regular and "low-risk" (marital or cohabitating) partnerships have low levels of condom use, the "B" or partner reduction component of the ABC approach in a "generalized" epidemic is especially important.^6,16

A lesson learned from successful country programs is that the most effective prevention interventions are ones that focus on changing the specific behaviors likely to avert the largest proportion of new infections.^2,19 In other words, the selection of intervention activities cannot be divorced from identifying the most strategic behavior change objectives at a country level, and country programs should not simply devote funding to generic behavior change activities in categories such as school programs, community-based programs, and mass media. The figure below depicts age and gender-specific HIV prevalence in Botswana and illustrates why activities must be associated with prioritized behavioral objectives. From the figure one can conclude that programs to reduce new infections in young women should focus on promotion of abstinence among young females, on reducing cross-generational sexual relationships, and on encouraging faithfulness and correct and consistent condom use among older males.

HIV prevalence by age group among men and women aged 15-49. Tebelopele VCT Centres,2003, Botswana* (Text Version)

For More Information
Please contact:
Caroline Ryan, M.D., M.P.H; Acting Senior Technical Advisor-Prevention Office of the Global AIDS Coordinator
Email: cryan@cdc.gov

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