Challenging Dogma - Fall 2007

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

Tuesday, December 11, 2007

The Failure of PEPFAR and its ABC Campaign - Erin Lee

The World Health Organization (WHO) defines health as a “state of complete physical, mental and social well-being and not merely the absence of disease or infirmity… is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition.” HIV, also known as the human immunodeficiency virus, has played a major role in preventing thousands of people from obtaining this definition of health. In response to this growing crisis, the United States of America proposed an initiative to fight HIV/AIDS in some of the world’s most vulnerable countries. Known widely as the President’s Emergency Plan for AIDS Relief (PEPFAR), this initiative was created in 2003 with the goal of preventing 7 million new infections, treating 2 million people living with AIDS related illnesses, and providing care and support for 10 millions person affected by AIDS. One of the largest sources of international funding for HIV/AIDS, PEPFAR requires its beneficiaries to use one-third of the fund to promote its ABC (Abstinence, Be Faithful, Condom Use) campaign (8). However, the ABC campaign is an inefficient public health initiative because it does not incorporate the theories behind social and behavioral sciences in its implementation of programs to tackle HIV/AIDS in developing countries.

PEPFAR and Cultural Anthropology

Cultural anthropology is defined as an approach that strives to “understand and explain health behavior as part of a pattern of living that integrates action with meanings, symbols, and values, as these are connected to a larger social structure” (1). In order to create an effective public health intervention, one needs to incorporate the community and its perception of the health condition. In other words, the “behavior cannot be separated from its larger context” (1). For example, before implementing a child vaccination program, one needs to understand the local practices and their views toward vaccinating their children.

One reason why the ABC campaign is ineffective in its approach to tackle HIV/AIDS is because it fails to incorporate the ideas behind cultural anthropology. PEPFAR uses the principles behind “A” found in the ABC approach as a preventive measure to fight HIV/AIDS. It assumes that “Abstinence” can reduce the HIV transmission rates in many of these developing countries. However, this idea of abstinence is culturally ignorant because it does not acknowledge that sex may be used for different reasons (i.e. other than sexual pleasure) around the world. “Many sexual relationships include transactional or commercial sex, in order to pay for post-secondary schooling, to gain financial independence from family obligations, or to provide adequate resources for those contained in IDP camps” (2). Sex in these situations is used as a tool for survival and as a result abstinence is not an option.

In addition to being culturally ignorant, the promotion of abstinence assumes that other cultures also have a negative view towards premarital sex. As a result, this contributes to the stigmatization and demoralization of people who become infected with HIV. “Promoted evangelically, even in the context of generalized epidemics… the A/B-only message suggests that HIV negative people can prevent infection by moral fortitude” (7). This view not only stigmatizes HIV patients, but also reduces the general population’s self-efficacy to reduce HIV transmission. For example, if one cannot live a life of abstinence, one might assume that HIV infection is inevitable. Thus, this might discourage someone to have the self-efficacy to practice safe sex. By mandating its beneficiaries to promote abstinence, PEPFAR is essentially forcing U.S. based Christian ideals that premarital sex should be avoided.

The way sex is used is different depending on the culture and attitudes of its people. It is difficult to use abstinence as a preventive measure when sex is used as a tool for survival. As a result, PEPFAR and its promotion of abstinence fail to acknowledge the cultural issues surrounding HIV transmission. One way to remedy this problem is to do an anthropological study to determine the values and perception of sex found in these different countries, instead of forcing them to use abstinence as a form of prevention.

PEPFAR and Self-Efficacy

Self-efficacy is defined as a “person’s belief in his or her ability to take action” (1). It is considered as “one of the keys to change” and is needed for an individual to adopt a new behavior (1). For example, it is very difficult for an individual with the intention to quit smoking to actually change behavior if he/she lacks the self-efficacy to overcome his/her addiction to tobacco. The low level of confidence in his/her ability to fight the addiction hinders one’s ability to change the negative behavior. As a result, intention alone is insufficient to alter behavior if one lacks self-efficacy.

The ABC campaign is limited in its effectiveness in developing countries because of its failure to take into account the concept of self-efficacy. PEPFAR uses the principles behind the “B” found in the ABC approach as a preventive measure to fight HIV/AIDS. It assumes that if an individual has the intention to “Be Faithful” and is married, one has the ability to prevent the transmission of HIV. Ironically, by “promoting marriage as a prevention measure, this campaign negates one of the highest risk groups in Africa: monogamous, married women” (2). Despite their intention and commitment to marriage/being faithful, many of these women are vulnerable to HIV because of their sexually active husbands. Married men in many of these developing countries participate in extramarital sexual activity, which makes them susceptible to HIV transmission (4). Women in these countries lack the self-efficacy to protect themselves from their HIV infected husbands because they do not have the right to refuse their husbands sex (5). For these women, the ABC approach does not protect them from HIV infection because of the ineffective prevention strategy of unilateral monogamy.

As the feminization of HIV/AIDS increases, public health interventions need to address the issues faced by women in order to decrease the number of HIV/AIDS cases in developing countries. If PEPFAR wants to prevent 7 million new infections, it needs to incorporate the concepts of self-efficacy in its ABC campaign. The preventive measure to “Be Faithful” is not enough to protect these women because of their unequal relationships with their husbands. “The presumption that marriage is somehow protective is misleading and potentially dangerous for young women” (2). Since marital sex has become a major risk factor for HIV among women, prevention programs need to make extramarital sex safer (6). For example, one way the ABC approach can be more effective is to incorporate a campaign within the “Be Faithful” campaign to promote gender equality. This could be accomplished through the media with the goal of changing society’s perception of the male/female relationship. Ultimately, if PEPFAR wants the ABC approach to be a sustainable preventive measure, it needs to give women the confidence and self-efficacy to take action.

PEPFAR and the Theory of Planned Behavior

Another reason why the ABC approach does not work in developing countries is because it fails to incorporate the ideas behind perceived behavioral control/power. According to the Theory of Planned Behavior, “behavioral intention alone is not a sufficient predictor of behavior” and as a result one needs to consider the concept of perceived behavioral control/power, which “refers to the degree to which someone believes they have control over whether they can take action and the strength of that belief” (1). This theory emphasizes the point that intention alone is not enough to alter one’s behavior if one does not believe he/she has the power or control to take the necessary actions to change his/her behavior. For example, one’s intent to have safe sex and/or decrease sexual partners is insufficient when one does not believe he/she has the power or control to overcome the external issues preventing him/her from changing one’s behavior.

This idea that intention must be coupled with an individual’s perceived behavioral control/power in order to successfully change behavior can be seen in the failed attempts to reduce HIV transmission rates in internally displaced person (IDP) camps. The unstable and fragile political situations found in most developing countries have contributed to the 1.6 million people living in IDPs (3). Reducing HIV/AIDS cases in these camps has proven to be difficult because of the lack of power/control individuals have in preventing HIV transmission due to its limited resources. “The HIV/AIDS prevalence rates in IDPs… may be attributed to insufficient condom provision and inadequate sexual education in an area where control over sexual exposure to HIV is limited” (2). Lack of resources in IDPs highlight the ineffectiveness of the “C” found in the ABC approach, which is the promotion of condom use. Even if an individual has the intent to use condoms and practice safe sex, it is difficult to expect a change in behavior when the individual does not have the power/control to access the necessary condoms.

By putting the emphasis on individual behaviors, the ABC campaign does not acknowledge the underlying factors that make people living in IDPs vulnerable to HIV/AIDS. Condom use to decrease HIV transmission is impractical when these camps do not have the resources to provide its community members condoms. If PEPFAR wants its beneficiaries to incorporate the ABC approach, it needs to make sure that these countries are providing its’ camps with the necessary resources. For example, one way to remedy this situation is to provide one condom for every dollar PEPFAR donates to its beneficiaries and monitor the distribution of these condoms in the IDPs. This provides people living in IDPs with the intent to practice safe sex also have the power/control to access the condoms needed to perform the behavior. Otherwise, the principles behind the “C” of the ABC approach are not enough to change behavior because it does not provide the power/control to overcome the external obstacles of living in IDPs.


Despite PEPFAR’s goal to reduce HIV/AIDS in developing countries, the “ABC strategies dismiss the real social, political, and economic causes of the epidemic, and end up blaming infected people, because it is implied that they failed to adopt and practice the ABCs” (2). Many of these programs fail because they do not incorporate the important concepts behind cultural anthropology, self-efficacy, and perceived behavioral control/power. The ideas behind abstinence fail to recognize that the definition of sex is different in different cultures and as a result is culturally ignorant. The ideas behind being faithful fail to recognize that marriage does not protect women in relationships of unequal power. The ideas behind condom use fail to recognize that condoms are not always available especially in areas of limited resources. These examples only highlight the multifaceted and complex nature of HIV/AIDS. As a result, in order to tackle this growing epidemic, PEPFAR needs to develop a new campaign that incorporates all these complex issues by referring to the many different levels of social and behavioral sciences.


1. Edberg M. Essentials of Health Behavior Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers, 2007.

2. Murphy E. Was the “ABC” Approach (Abstinence, Being Faithful, Using Condoms) Responsible for Uganda’s Decline in HIV? PLoS Medicine 2006; 3:1443-1447.

3. Lowicki-Zucca M. AIDS, Conflict and the Media in Africa: Risks in Reporting Bad Data Badly. Emerg Themes Epidemiology 2005; 2:12.

4. Ntozi JP. Has the HIV/AIDS Epidemic Changed Sexual Behavior of High Risk Groups in Uganda? Afr Health Science 2003; 3:107-116.

5. Gage AJ. Factors Associated with Self-reported HIV Testing Among Men in Uganda. AIDS Care 2005; 17:153-165.

6. Hirsch JS. The Inevitability of Infidelity: Sexual Reputation, Social Geographies, and Martial HIV Risk in Rural Mexico. Am J Public Health 2007; 97:986-996.

7. Health Global Access Project. Health GAP Report – Between the Lines (GAO Report on PEPFAR Prevention Programs: U.S. Abstinence/Being Faithful-Only Programs Produce Stigma and Death). New York, NY: Health Global Access Project. Nttp://

8. Office of the United States Global AIDS Coordinator (2004) Appendix 2: The Emergency Plan for AIDS Relief: Fiscal year 2004 Prevention Expenditures and Program Classification Criteria. Washington (D.C.): US Department of State.

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