Challenging Dogma - Fall 2007

...Using the social and behavioral sciences to improve the practice of public health.

Monday, December 10, 2007

The ABC Strategy of HIV prevention in Uganda: A critique of this Public Health approach- Racheal Nakazzi

A brief outlook at the history of the Human Immune- deficiency Virus (HIV) in Uganda
Uganda is a small country located in the eastern part of Africa, west of Kenya with a population of slightly over 23million people. The average life expectancy at birth is approximately 43 years (1).
The first cases of Acquired Immune- Deficiency Syndrome (AIDS) in Uganda were reported in 1982 from Rakai district in the south western part of the country, an area bordering the United Republic of Tanzania. The condition was popularly known as ‘‘Slim’’ disease, because of the extensive wasting that typically and classically characterizes AIDS. The spread of this disease was fuelled by a number of economic, cultural and social factors including war, poverty, traditional cultural norms, and the massive dominance of men in sexual decision making (2). Since the start of the epidemic, It is estimated that over two million people have been infected with HIV in Uganda mainly through heterosexual activity, and about half of these have died, making it one of the most heavily affected countries in the world (2).
Since the majority of Uganda’s population lives in under-served rural areas, activities and programs geared toward prevention, care or even mitigation become significantly complicated. However, on so many occasions, Uganda has been cited in many respects as a success story with regards to HIV prevention and control. This has been due to the active involvement of the president and the government in general through establishing support organizations, implementation of a national response to HIV/AIDS- program that was characterized by the involvement of cultural leaders, establishing an environment of openness, especially in schools where sex talk was considered a taboo (2).
A brief outlook at the ABC strategy.
The ABC of HIV prevention was one of the public health approaches that was funded by the President’s Emergency Plan For AIDS Relief (PEPFAR). This initiative was adopted in Uganda as a way to either reduce or eliminate the risk of becoming infected with HIV through sexual intercourse.
This approach determined that the risk could be avoided by:
A bstinence for youth which involved avoiding any sexual intercourse that could cause transmission of the disease, including delay of sexual debut and abstinence until marriage.
B eing faithful in marriage and monogamous relationships and getting tested for HIV to reduce the risk through avoiding sexual intercourse other than with a mutual faithful partner.
C orrect and consistent use of condoms for those who practice high risk behaviors such as sex workers, sexually active discordant couples in which one partner is known to have HIV, substance abusers, and others.
The ABC strategy may be a successful approach to HIV prevention. However, without considering tools that promote self-efficacy, rational decision making, social cultural and environmental factors, the relevance of the ABC strategy to HIV prevention is flawed.
A) The Health Belief Model and the concept of rational decision making in health behavior.
The ABC approach to HIV prevention is based on individual health behavior change theory (like the Health Belief Model). The model has several major flaws because it assumes rational decision making is always present. However rational thought is not always an option for individual groups like sex workers and women in abusive relationships. It assumes that people are rational beings and therefore, they consider their actions before doing them. However, sex-workers, for example, are people who have been pushed into the field because of the rampant poverty in this country, and therefore, will do anything to survive or provide for their extended families. Hence these people may not use condoms even when they intend to. Therefore, sex workers may not act according to their intentions, as the HBM suggests.
ABC program planners assume that abstaining from sex until marriage, and faithfulness in marriage are a rational individual choice. This approach assumed that an individualistic approach would be appropriate. This approach has individuals assess their degree of risk and make a cost- benefit calculation about whether or not to engage in the prevention strategy or not.
The Health Belief Model assumes that a person will take a health-related action (use condoms) if that person has a positive expectation that by taking a recommended action, this person will avoid a negative health condition (using condoms will be effective at preventing HIV) (3). However, this depends on how consistently and correctly condoms are used with different partners in these polygamous relationships(4).
B) Social cognitive theory (self efficacy concept): Adoption of health behavior.
The ABC approach does not build self efficacy in the target population. Glantz defines self efficacy as a person’s confidence in performing a particular behavior (5). As noted in social cognitive theory, if social and environmental barriers are not addressed, the population is not given realistic tools and resources to build their confidence.
Secondly, emphasis was put on abstaining from sex until marriage. According to Salazar, the concept of self efficacy outlines that two types of expectancies exert powerful influences on behavior namely; outcome expectancy and self efficacy expectancy, which is the conviction that one can successfully execute the behavior required to produce the outcome (6).However, one must wonder if it is realistic to assume that everyone can abstain from sexual activity.
C) Social sciences theory and the importance of social- cultural and environmental factors.
The ABC approach did not account for social and environmental factors, such as poverty, migration factors, a male dominated culture and the polygamous nature of marriages in this culture. The massive poverty leads people to migrate and go to work away from home- all of which are integral factors to individual behavior. Therefore, HIV can still be transmitted even when you are married.
Therefore, this approach failed to consider societal beliefs, as noted by the cultural anthropology model of health behavior. Edberg defines culture as an ongoing collective framework, developed over time by human societies and groups, for integrating meaning with events and ways of life (7).
This approach failed to account for the fact that abstinence may not be a realistic option for the millions of women and girls who are in abusive relationships, or those who have been taught to obey and subordinate to men as the culture dictates, hence issues in this approach like condom use among discordant couples are usually entirely dictated by the dominant party (the man) in the marriage. Hence abstinence-only programs have been of little use to women who cannot insist on either abstinence from sexual intercourse, or ensuring that their husbands are being faithful (8).
Moreso, there has been campaigns by religious leaders who have been trying to de- emphasize condom use, seeking to remove the “C” from the country's longstanding ABC (Abstain, Be faithful, use a Condom) strategy. Their argument has been that Ugandans should either abstain or be faithful, because, they claim that condoms promote promiscuity yet they do not guarantee safety from infection (9). This campaign against condom use and a culture dominated by polygamous marriage has not helped the ABC strategy of HIV/AIDS prevention in Uganda.
Recommendations and conclusions.
The ABC approach in Uganda has led to a dramatic fall in HIV/AIDS infection rates. However, this is more than just abstinence and needs to balance between individual and social economic factors. Neither Abstinence nor Be Faithful nor Condom use can provide a holistic answer to reduce infection rates that could be realistic and practical for every member of the population.
We need to examine the three components of the ABC strategy to HIV/ AIDS prevention in the light of the new and current developments. Therefore, there is an urgent need to re-launch and update the three issues in this strategy as all of them complement each other and are synergistic and inseparable in the overall national HIV prevention program.
References
1. Uganda-people 2000 http://www.photius.com/wfb2000/countries/uganda/uganda_people
2. Okware, kinsman, Onyango etal. Revisiting the ABC strategy: HIV prevention in Uganda in the era of antiretroviral therapy. Post graduate medical journal 2005; 1).
3. Health Belief model. Explaining health behaviors.Netherlands.http://www.tcw.utwente.nl/theorieenoverzicht/Theory%20clusters/Health%20Communication/Health_Belief_Model.doc/
4. Cohen S. Beyond slogans. Lessons with Uganda’s experience with ABC and HIV/AIDS. The Guttmacher Report on Public Policy New York, December 2003.
5.Glanz, K.etal. Health Behavior and Health Education: Theory, Research and Practice. San Fransisco: CA:Wiley & Sons.2002
6. Salazar MK. Comparison of four behavioral theories. American Association of Occupational Health Nurses 1991; 39: 94
7. Edberg M. Essentials of Health Behavior: Social and Behavioral theory in Public Health. Boston (MA): Jones & Bartlett Publishers, 2007.
8. University of Michigan. Not as easy as ABC: Uganda’s approach to HIV/AIDS and implications for the President’s Emergency Plan for AIDS relief. The Michigan journal of public affairs; 2005; 2. http://www.mjpa.umich.edu/articles/Archive/2005
9. The Lancet. vol 367, issue 9520. (29th April-5th May 2006); p.1381-1388. http://www.sciencedirect.com/science.

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