PEPFAR: How an emphasis on Abstinence and Being Faithful is Failing the Prevention of HIV/AIDS in Africa – Lindsay Ritz
President George W. Bush announced a plan during his January 2003 State of the Union Address for a five-year, 15 billion dollar, United States commitment to prevent and treat HIV/AIDS around the world. This plan is called the President's Emergency Plan for AIDS Relief (PEPFAR). While a seemingly generous offer, the program is not without serious flaws. Thirty-three percent of all prevention money and 66% of all behavioral prevention money was earmarked for abstinence and being faithful education only, with 2005 figures putting the actual percentage allocated for abstinence only education in the focus countries closer to 50% (22). PEPFAR fails to adequately address social and economic issues and has very obtuse and unrealistic policies to elicit individual-level behavioral changes instead of societal level changes. Because of many oversights in the PEPFAR program and Bush’s need to push a faith-based agenda, PEPFAR is not as effective of a program as it could be. New HIV infections continue to outpace treatment rollout and the prevention outlook is extremely negative.
PEPFAR’s main prevention strategy is the ABC model (abstain, be faithful, use a condom). However, there is a significant emphasis on the A/B portion by PEPFAR funds. The Bush administration has chosen to prioritize abstaining and being faithful over condom distribution. The ABC model was developed in Uganda in the 1990s and was very successful in reducing AIDS transmissions there (from 18% to 6%), but it is elsewhere. The ABC model was an outcome of many Ugandan prevention strategies including a normative-re-educative campaign to change social norms. The ABC model was not a strategy used in isolation (7). Uganda is a great model for reducing HIV transmissions because the government concurrently promoted ABC and the changing of social norms. Partly due to American pressure, the Ugandan government has unfortunately been abandoning the C of the ABC model and HIV infections are on the rise. In fact, the government is hoarding 30 million condoms and pushing the A/B as well as outlawing homosexual sex (22). The PEPFAR initiative’s prevention program fails because of its ignorance of social norms regarding the role of women, its stigmatization of the most at-risk populations and its promotion of risk elimination in place of risk reduction.
The Role of Women
One glaring area where PEPFAR seriously fails is in changing the societal view of women in Africa. PEPFAR itself acknowledges that women are the most disproportionately vulnerable population to HIV due to, in part, “sexual coercion, exploitation and violence” (15). However, there has been little commitment by the United States to change the social norms for women so that they cannot fall victim to HIV/AIDS as easily.
Many African women are forced into marriages because of practices such as wife-inheritance and young girls are often forced to marry much older men because of financial incentives. In many rural African communities, women and girls occupy the lowest social strata (10). Women are often viewed as property that can be bought, sold and inherited and are subordinate to their husbands in decision-making. Many women are forced into practicing transactional or survival sex (12,13). It is virtually impossible to maintain the A and the B in an environment where women are so powerless. PEPFAR needs to invoke a normative-re-educative strategy to create new social norms regarding the status of women. AIDS is a social disease and social problems contribute to its rapid spread.
PEPFAR assumes that rational action will be taken according to the Theory of Reasoned Action (TRA) and the Health Belief Model (HBM). However, while many women want to abstain, be faithful or use condoms, they are unable to because of social and economic conditions. TRA and HBM posit that if someone intends to make a behavioral change that they will be able to make that change (4). Both TRA and HBM argue that intention to change behavior equals behavioral change. This argument has been proven false time and time again because they do not address social and economic realities. Until African social norms are attacked through social networking and public campaigns, women will be powerless to say no to marriages in which they or their husband are HIV positive, and will be powerless to say no to sex or require condom usage. In other words, they will be powerless to abstain, be faithful and use condoms. They might have every intention to abstain, to be faithful and to use a condom, but harsh social and economic realities ensure that they will often be unable to say no, their intention will not and cannot equal their behavior.
Stigmatization of at-risk populations
The ABC message, with a significant emphasis on A/B, leads to a stigmatization and demoralization of those who cannot comply with the A/B message (those most at-risk, i.e. homosexuals, sex workers, bar maids and injected drug users) and creates a disbelief in self-efficacy (2). PEPFAR “suggests that HIV negative people can prevent infection by moral fortitude and by detecting and avoiding “carriers” (9). PEPFAR suggests that if you do not abstain or are not faithful, that you are morally corrupt and that infection is your fault. Though AIDS has affected a broad population in Africa, its rapid spread has been blamed on these at-risk populations (13). The A/B message alienates people who do not know their sero-status, injecting drug users and their partners, sex workers and their partners, and sexually-active people.
PEPFAR policies and actions do not specifically target the most at-risk groups, unlike many other AIDS prevention programs and organizations. Furthermore, by enforcing a moral code, they alienate the most at-risk populations. A/B only programming creates an environment where the infected person and whoever got them sick is blamed for the transmission (9). It has been scientifically proven that promoting condom usage and safer sex reduces AIDS transmission. The US government could promote a so-called “abstinence-plus” campaign in which abstinence is stressed concurrently with condom usage in order to not abandon their abstinence message (19). If one cannot abstain or be faithful 100% of the time, why should one bother at all? PEPFAR’s message of the need to perform the A/B behaviors to prevent the spread of HIV/AIDS goes too far and sets up these at-risk populations for failure.
PEPFAR gives money to many faith-based organizations including ones that promote homophobia and intolerance and which lead to a further stigmatization of the population, a decrease in self-efficacy, and an increased proclivity to engage in risky behaviors (3). Public health efforts to change behavior must address the way society treats homosexuals (16). In addition to homosexuals, the normative-re-educative policies of PEPFAR need to destigmatize sex-workers and injected drug users.
Risk Elimination over Risk Reduction
PEPFAR fails to recognize the importance of risk-reduction and insists on complete risk elimination (emphasizing the A/B without condoms, a significant risk reducer). One can see this problem in the fight against AIDS in the United States, where gay men have been rebelling against the safe sex message in which they are told to use condoms every time they have sex, even during with long-term partners (16). Many people in Africa cannot consistently use condoms or know their own sero-status or that of their partner. They therefore feel that they cannot maintain safe behaviors all of the time. They are chastised to avoid sex and to be completely faithful, which is not always possible, especially in a social and economic environment like Africa’s.
Efforts aimed at complete prevention ignore the maintenance of safe sex. According to the Transtheoretical Model and the AIDS Risk Reduction Model, a health behavior change occurs in stages, not in a clear-cut, linear manner. In the AIDS Risk Reduction Model, one can easily slip between changing behavior and merely understanding that there are risks and consequences if one engages in dangerous sexual behaviors (4). It is always possible to go back to a previous step (to relapse), especially if behavior cannot be maintained all of the time (5). It requires serious work and self-efficacy to maintain health behaviors, especially when there are many societal and economic factors affecting one’s sexual behaviors. One must address the contexts in which risky sex occurs in order to prevent transmission of HIV/AIDS (18).
An emphasis on risk elimination leads to a belief that if one cannot perform the behavior 100% of the time, that it is futile to even attempt to reduce risk (16). Many people adopt a fatalistic view that they are bound to become infected because, if one can not abstain all the time, it is just a matter of time before one becomes infected. The same behavior carries over to condom use, if a person has access to a condom, they might argue that there is no point in using it if they cannot use a condom all of the time, they will be in constant risk of relapsing. Some gay men in the United States even go so far in the face of risk to believe that they will never be able to trust their partner, so they do not bother to enter a stable relationship (16). Many studies have found that self-efficacy is a huge determinant of intent to use condoms (23). If one does not believe that there is even a point to maintaining the behavior, one will not perform the behavior as much as they should. In order to create a meaningful and sustainable change, PEPFAR should focus on risk-reduction instead of complete risk elimination.
Conclusion
PEPFAR fails because it does not address social norms concerning the role of women, because it stigmatizes the most at-risk populations and because it insists on complete risk elimination over risk reduction. There is significant room for improvement in the PEPFAR program. PEPFAR needs to start emphasizing the C as much as the A and the B. Condoms need to be distributed to as many people as possible, especially to those in the high-risk groups. They need to adequately address social norms and develop campaigns and social networking to change these norms. With the recent failure of Merck’s long-awaited AIDS vaccine and a possible 20-plus year wait for a vaccine, it is all the more important to focus on AIDS prevention as well as maintain a commitment to its treatment. With many significant changes, PEPFAR could truly have a significant and long-lasting impact on the AIDS epidemic.
REFERENCES
1. Aggleton P, O’Reilly K, Slutkin G, Davies, P. Risking Everything? Risk Behavior, Behavior Change, and AIDS. Science 1994; 265.5170:341-345.
2. Bandura, A. Social foundations of thought and action: A social cognitive theory. Englewood Cliffs, NJ: Prentice Hall, 1986.
3. Carter M. PEPFAR money being used to ‘promote homophobia’, charges human rights group. Aidsmap news. 2007, October 19. Retrieved 20 October 2007, from http://aidsmap.com/en/news/B990E508-29C7-4F00-A995-9DA9A58385FC.asp
4. Choi K., Yep G., Kumekawa E. HIV Prevention Among Asian and Pacific Islander Men Who Have Sex with Men: A Critical Review of Theoretical Models and Directions for Future Research. AIDS Education and Prevention 1998; 10.Supplement A: 19-30.
5. DeHart D., Birkimer J. Trying to Practice Safer Sex: Development of the Sexual Risks Scale. The Journal of Sex Research 1997. 34.1, 11-25.
6. Fredland R. AIDS and Development: An Inverse Correlation? The Journal of Modern African Studies 1998. 36.4 , 547-568.
7. Fleischman, J. Priorities for Action: Gender and PEPFAR Reauthorization. CSIS HIV/AIDS Task Force 2007. 1-10.
8. Green, J. Flirting with suicide. The New York Times Magazine 1996, September 15, pp. 39-45, 54-55, 84-85.
9. 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, 2006.
10. LaFraniere S. Forced to Marry Before Puberty, African Girls Pay Lasting Price. The New York Times 27 November, 2005 http://www.nytimes.com/2005/11/27/international/africa/27malawi.html?_r=1&pagewanted=all&oref=slogin
11. Muoso, E. Aids in Kenya: A Social Disease. BBC Africa. 1 December 1999. http://news.bbc.co.uk/2/hi/africs/545033.stm
12. Murphy EM, Greene ME, Mihailovic A, Olupot O. Was the “A/BC” Approach (Abstinence, Being Faithful, Using Condoms) Responsible for Uganda's Decline in HIV? PLoS Medicine 2006; 3.9, 1443-1447.
13. Ntozi JP, Najjumba IM, Ahimbisibwe F, Ayiga N, Odwee J. Has the HIV/AIDS epidemic changed sexual behaviour of high risk groups in Uganda? African Health Science 2003. 3:107-116.
14. Nyblade L, Carr D. Towards a Stronger Response to HIV and AIDS: Challenging Stigma. International Center for Research on Women, 2006.
15. Office of the United States Global AIDS Coordinator. Action Today, A Foundation For Tomorrow: Second Annual Report to Congress on PEPFAR. Washington, DC, 2006.
16. Siegel M. The importance of formative research in public health campaigns: an example from the area of HIV prevention among gay men (Appendix 3-A), pp/ 66-69. In Siegel M, Doner L. Marketing Public Health: Strategies to Promote Social Change. Sudbury, MA: Jones and Bartlett Publishers, 2004.
17. Salazar MK. Comparison of four behavioral theories. AAOHN Journal 1991; 39:128-135.
18. Stall R. How to lose the fight against AIDS among gay men (editorial). BMJ 1994; 309:685-686.
19. Time to grow up. The Economist. 20 September 2007 http://economist.com/science/displaystory.cfm?story_id=9831189
20. The United States Government Accountability Office. Spending Requirement Presents Challenges for Allocating Prevention Funding under the President’s Emergency Plan for AIDS Relief. Report to Congressional Committees 2006. – GAO-06-395.
21. The United States President’s Emergency Plan for AIDS Relief. Chapter 1 - Critical Intervention in the Focus Countries: Prevention. 2006
22. The War against AIDS and condoms. The Economist. 8 September 2005 http://economist.com/world/africa/displaystory.cfm?story_id=E1_QPRVPJQ&CFID=20929881&CFTOKEN=33518930
23. Wulfurt E, Wan K. Safer Sex Intentions and Condom Use Viewed from a Health Belief, Reasoned Action, and Social Cognitive Perspective. The Journal of Sex Research 1995; 32.4:299-311.
PEPFAR’s main prevention strategy is the ABC model (abstain, be faithful, use a condom). However, there is a significant emphasis on the A/B portion by PEPFAR funds. The Bush administration has chosen to prioritize abstaining and being faithful over condom distribution. The ABC model was developed in Uganda in the 1990s and was very successful in reducing AIDS transmissions there (from 18% to 6%), but it is elsewhere. The ABC model was an outcome of many Ugandan prevention strategies including a normative-re-educative campaign to change social norms. The ABC model was not a strategy used in isolation (7). Uganda is a great model for reducing HIV transmissions because the government concurrently promoted ABC and the changing of social norms. Partly due to American pressure, the Ugandan government has unfortunately been abandoning the C of the ABC model and HIV infections are on the rise. In fact, the government is hoarding 30 million condoms and pushing the A/B as well as outlawing homosexual sex (22). The PEPFAR initiative’s prevention program fails because of its ignorance of social norms regarding the role of women, its stigmatization of the most at-risk populations and its promotion of risk elimination in place of risk reduction.
The Role of Women
One glaring area where PEPFAR seriously fails is in changing the societal view of women in Africa. PEPFAR itself acknowledges that women are the most disproportionately vulnerable population to HIV due to, in part, “sexual coercion, exploitation and violence” (15). However, there has been little commitment by the United States to change the social norms for women so that they cannot fall victim to HIV/AIDS as easily.
Many African women are forced into marriages because of practices such as wife-inheritance and young girls are often forced to marry much older men because of financial incentives. In many rural African communities, women and girls occupy the lowest social strata (10). Women are often viewed as property that can be bought, sold and inherited and are subordinate to their husbands in decision-making. Many women are forced into practicing transactional or survival sex (12,13). It is virtually impossible to maintain the A and the B in an environment where women are so powerless. PEPFAR needs to invoke a normative-re-educative strategy to create new social norms regarding the status of women. AIDS is a social disease and social problems contribute to its rapid spread.
PEPFAR assumes that rational action will be taken according to the Theory of Reasoned Action (TRA) and the Health Belief Model (HBM). However, while many women want to abstain, be faithful or use condoms, they are unable to because of social and economic conditions. TRA and HBM posit that if someone intends to make a behavioral change that they will be able to make that change (4). Both TRA and HBM argue that intention to change behavior equals behavioral change. This argument has been proven false time and time again because they do not address social and economic realities. Until African social norms are attacked through social networking and public campaigns, women will be powerless to say no to marriages in which they or their husband are HIV positive, and will be powerless to say no to sex or require condom usage. In other words, they will be powerless to abstain, be faithful and use condoms. They might have every intention to abstain, to be faithful and to use a condom, but harsh social and economic realities ensure that they will often be unable to say no, their intention will not and cannot equal their behavior.
Stigmatization of at-risk populations
The ABC message, with a significant emphasis on A/B, leads to a stigmatization and demoralization of those who cannot comply with the A/B message (those most at-risk, i.e. homosexuals, sex workers, bar maids and injected drug users) and creates a disbelief in self-efficacy (2). PEPFAR “suggests that HIV negative people can prevent infection by moral fortitude and by detecting and avoiding “carriers” (9). PEPFAR suggests that if you do not abstain or are not faithful, that you are morally corrupt and that infection is your fault. Though AIDS has affected a broad population in Africa, its rapid spread has been blamed on these at-risk populations (13). The A/B message alienates people who do not know their sero-status, injecting drug users and their partners, sex workers and their partners, and sexually-active people.
PEPFAR policies and actions do not specifically target the most at-risk groups, unlike many other AIDS prevention programs and organizations. Furthermore, by enforcing a moral code, they alienate the most at-risk populations. A/B only programming creates an environment where the infected person and whoever got them sick is blamed for the transmission (9). It has been scientifically proven that promoting condom usage and safer sex reduces AIDS transmission. The US government could promote a so-called “abstinence-plus” campaign in which abstinence is stressed concurrently with condom usage in order to not abandon their abstinence message (19). If one cannot abstain or be faithful 100% of the time, why should one bother at all? PEPFAR’s message of the need to perform the A/B behaviors to prevent the spread of HIV/AIDS goes too far and sets up these at-risk populations for failure.
PEPFAR gives money to many faith-based organizations including ones that promote homophobia and intolerance and which lead to a further stigmatization of the population, a decrease in self-efficacy, and an increased proclivity to engage in risky behaviors (3). Public health efforts to change behavior must address the way society treats homosexuals (16). In addition to homosexuals, the normative-re-educative policies of PEPFAR need to destigmatize sex-workers and injected drug users.
Risk Elimination over Risk Reduction
PEPFAR fails to recognize the importance of risk-reduction and insists on complete risk elimination (emphasizing the A/B without condoms, a significant risk reducer). One can see this problem in the fight against AIDS in the United States, where gay men have been rebelling against the safe sex message in which they are told to use condoms every time they have sex, even during with long-term partners (16). Many people in Africa cannot consistently use condoms or know their own sero-status or that of their partner. They therefore feel that they cannot maintain safe behaviors all of the time. They are chastised to avoid sex and to be completely faithful, which is not always possible, especially in a social and economic environment like Africa’s.
Efforts aimed at complete prevention ignore the maintenance of safe sex. According to the Transtheoretical Model and the AIDS Risk Reduction Model, a health behavior change occurs in stages, not in a clear-cut, linear manner. In the AIDS Risk Reduction Model, one can easily slip between changing behavior and merely understanding that there are risks and consequences if one engages in dangerous sexual behaviors (4). It is always possible to go back to a previous step (to relapse), especially if behavior cannot be maintained all of the time (5). It requires serious work and self-efficacy to maintain health behaviors, especially when there are many societal and economic factors affecting one’s sexual behaviors. One must address the contexts in which risky sex occurs in order to prevent transmission of HIV/AIDS (18).
An emphasis on risk elimination leads to a belief that if one cannot perform the behavior 100% of the time, that it is futile to even attempt to reduce risk (16). Many people adopt a fatalistic view that they are bound to become infected because, if one can not abstain all the time, it is just a matter of time before one becomes infected. The same behavior carries over to condom use, if a person has access to a condom, they might argue that there is no point in using it if they cannot use a condom all of the time, they will be in constant risk of relapsing. Some gay men in the United States even go so far in the face of risk to believe that they will never be able to trust their partner, so they do not bother to enter a stable relationship (16). Many studies have found that self-efficacy is a huge determinant of intent to use condoms (23). If one does not believe that there is even a point to maintaining the behavior, one will not perform the behavior as much as they should. In order to create a meaningful and sustainable change, PEPFAR should focus on risk-reduction instead of complete risk elimination.
Conclusion
PEPFAR fails because it does not address social norms concerning the role of women, because it stigmatizes the most at-risk populations and because it insists on complete risk elimination over risk reduction. There is significant room for improvement in the PEPFAR program. PEPFAR needs to start emphasizing the C as much as the A and the B. Condoms need to be distributed to as many people as possible, especially to those in the high-risk groups. They need to adequately address social norms and develop campaigns and social networking to change these norms. With the recent failure of Merck’s long-awaited AIDS vaccine and a possible 20-plus year wait for a vaccine, it is all the more important to focus on AIDS prevention as well as maintain a commitment to its treatment. With many significant changes, PEPFAR could truly have a significant and long-lasting impact on the AIDS epidemic.
REFERENCES
1. Aggleton P, O’Reilly K, Slutkin G, Davies, P. Risking Everything? Risk Behavior, Behavior Change, and AIDS. Science 1994; 265.5170:341-345.
2. Bandura, A. Social foundations of thought and action: A social cognitive theory. Englewood Cliffs, NJ: Prentice Hall, 1986.
3. Carter M. PEPFAR money being used to ‘promote homophobia’, charges human rights group. Aidsmap news. 2007, October 19. Retrieved 20 October 2007, from http://aidsmap.com/en/news/B990E508-29C7-4F00-A995-9DA9A58385FC.asp
4. Choi K., Yep G., Kumekawa E. HIV Prevention Among Asian and Pacific Islander Men Who Have Sex with Men: A Critical Review of Theoretical Models and Directions for Future Research. AIDS Education and Prevention 1998; 10.Supplement A: 19-30.
5. DeHart D., Birkimer J. Trying to Practice Safer Sex: Development of the Sexual Risks Scale. The Journal of Sex Research 1997. 34.1, 11-25.
6. Fredland R. AIDS and Development: An Inverse Correlation? The Journal of Modern African Studies 1998. 36.4 , 547-568.
7. Fleischman, J. Priorities for Action: Gender and PEPFAR Reauthorization. CSIS HIV/AIDS Task Force 2007. 1-10.
8. Green, J. Flirting with suicide. The New York Times Magazine 1996, September 15, pp. 39-45, 54-55, 84-85.
9. 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, 2006.
10. LaFraniere S. Forced to Marry Before Puberty, African Girls Pay Lasting Price. The New York Times 27 November, 2005 http://www.nytimes.com/2005/11/27/international/africa/27malawi.html?_r=1&pagewanted=all&oref=slogin
11. Muoso, E. Aids in Kenya: A Social Disease. BBC Africa. 1 December 1999. http://news.bbc.co.uk/2/hi/africs/545033.stm
12. Murphy EM, Greene ME, Mihailovic A, Olupot O. Was the “A/BC” Approach (Abstinence, Being Faithful, Using Condoms) Responsible for Uganda's Decline in HIV? PLoS Medicine 2006; 3.9, 1443-1447.
13. Ntozi JP, Najjumba IM, Ahimbisibwe F, Ayiga N, Odwee J. Has the HIV/AIDS epidemic changed sexual behaviour of high risk groups in Uganda? African Health Science 2003. 3:107-116.
14. Nyblade L, Carr D. Towards a Stronger Response to HIV and AIDS: Challenging Stigma. International Center for Research on Women, 2006.
15. Office of the United States Global AIDS Coordinator. Action Today, A Foundation For Tomorrow: Second Annual Report to Congress on PEPFAR. Washington, DC, 2006.
16. Siegel M. The importance of formative research in public health campaigns: an example from the area of HIV prevention among gay men (Appendix 3-A), pp/ 66-69. In Siegel M, Doner L. Marketing Public Health: Strategies to Promote Social Change. Sudbury, MA: Jones and Bartlett Publishers, 2004.
17. Salazar MK. Comparison of four behavioral theories. AAOHN Journal 1991; 39:128-135.
18. Stall R. How to lose the fight against AIDS among gay men (editorial). BMJ 1994; 309:685-686.
19. Time to grow up. The Economist. 20 September 2007 http://economist.com/science/displaystory.cfm?story_id=9831189
20. The United States Government Accountability Office. Spending Requirement Presents Challenges for Allocating Prevention Funding under the President’s Emergency Plan for AIDS Relief. Report to Congressional Committees 2006. – GAO-06-395.
21. The United States President’s Emergency Plan for AIDS Relief. Chapter 1 - Critical Intervention in the Focus Countries: Prevention. 2006
22. The War against AIDS and condoms. The Economist. 8 September 2005 http://economist.com/world/africa/displaystory.cfm?story_id=E1_QPRVPJQ&CFID=20929881&CFTOKEN=33518930
23. Wulfurt E, Wan K. Safer Sex Intentions and Condom Use Viewed from a Health Belief, Reasoned Action, and Social Cognitive Perspective. The Journal of Sex Research 1995; 32.4:299-311.
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