International Organizations Respond to HIV/AIDS

International awareness of AIDS began in the early 1980s and, by 1985, the World Health Organization (WHO) had begun drafting a strategy for dealing with the emerging problem of HIV/AIDS.  WHO’s strategy identified three objectives:  the prevention of HIV infection, the reduction of the personal and social impact of HIV infection and the unification of national and international efforts against AIDS.   In 1987, the Global AIDS Strategy was endorsed at the UN General Assembly, the Venice Summit of Heads of States and the World Health Assembly.  That same year, the Global Programme on AIDS (GPA) was started, which eventually  became the United Nations Joint Programme on AIDS (UNAIDS) in 1996.    

By the early 1980s,   it was clear that HIV could be sexually transmitted and that a public health strategy for preventing sexual transmission required avoidance of the virus through three methods: not having sex, reducing the risk of transmission by reducing the number of partners and by blocking the virus from transmission through condom use.¹   Information about abstinence or delaying the start of sex, fidelity or sticking to one uninfected partner, and condom use was included in materials developed to provide information on HIV/AIDS. During the first decade of the epidemic, much attention was given to reaching high-risk groups (sometimes referred to as core transmitters), namely sex workers and their partners, truck drivers, men who migrate for work such as in coal mines and men who have sex with men.   Until generalized epidemics became common in many countries, particularly in sub-Saharan Africa, the emphasis tended to be on partner reduction and condom use, in addition to diagnosis and treatment of ulcerative STIs, which facilitate the transmission (Garnett and Anderson, 1994). 

From the beginning, then, the international response addressed A, B, and C (without so terming them) as separate elements – all important behaviors to stem the spread of HIV/AIDS.  The realization in the late 1980s that HIV transmission in most of the developing world was dominated by heterosexual transmission led to consideration of broader initiatives that focused not only on the modes of sexual transmission, but also on factors that influence the acceptability of those behaviors.  Specific behaviors were mentioned in GPA’s revised Global AIDS Strategy in 1992, in the context of addressing other social factors, including improving women’s ability to protect themselves from HIV.  “Changes in the strategy respond to the rapid emergence of heterosexual intercourse as the dominant mode of transmission…. Specific measures proposed range from the creation of an environment in which mutual fidelity and the use of condoms are the social norms, through support to all groups that can help women protect themselves, to the provision of humane care…” (WHO, 1992).    Picture 1 shows a poster from Uganda based on the 1992 GPA strategy message. 

Picture 1.  Uganda – Poster Incorporating GPA 1992 Strategy of promoting abstinence, using a condom or creating a conducive environment for marital faithfulness.  No date.

Dr. Michael Merson, director of Duke University’s Global Health Institute and former executive director of the GPA,  reported after reviewing his GPA files, “there is mention in documents from the early 1990s of condom promotion, partner reduction (no grazing) and abstinence (less so), but I cannot find the term ‘ABC’” (Merson, 2004).  Paul DeLay(2004), director of evidence, monitoring and policy at UNAIDS and formerly chief of the AIDS Division at USAID, recalled early messages about abstinence, fidelity and condom use—as well as other messages—but no consistent set of information used in program materials.  From 1988 to 1991, DeLay worked in Malawi for WHO and was closely involved in the planning and implementation of behavior change campaigns.  At that time it was considered appropriate to stress certain facets of what would be later called the “ABCs” depending on the audience and the provider of information.  For instance, working with the Catholic Church in Malawi, the messages primarily focused on faithfulness. DeLay made specific reference to a 1991 poster from Senegal with three messages:  “stick to one partner; should you have more than one partner, be sure to use condoms correctly [or without damaging them] and dispose of them after one use; and adulterous conduct between men will make them be hit by incurable diseases.” The Senegalese poster made no reference to abstinence (DeLay, 2004).   

Dr. Eric van Praag, currently country director for FHI’s AIDS Institute in Tanzania, worked with WHO in Zambia from 1988 to 1991, when the country’s national response started.   He recalls that various NGOs at that time promoted abstinence, fidelity and condom use with WHO support.  “For example, in 1988 to 1993 the Kristi' Baker Anti AIDS Clubs focused on primary school kids with abstinence messages, while the Christian Medical Association of Zambia (CMAZ) had various fidelity messages between 1988 and 1990 while at the same time the National AIDS Control Programme with support from WHO and others promoted proper use of condoms.  At an historic CZAM-MOH meeting facilitated by WHO in 1989, each partner agreed to promote its line without criticizing the other” (van Praag, 2004).  While early responses to HIV/AIDS recognized the modes of transmission and the importance of prevention strategies, activities and messages reflected the lack of a systematic, comprehensive approach; instead, organizations tended to focus on one or two strategies.