Reclaiming the ABCs - The Creation and Evolution of the ABC Approach

August 4, 2008

Karen Hardee, Jay Gribble, Stephanie Weber, Tim Manchester, Martha Wood

During the 2003 State of the Union Address, U.S. President George W. Bush announced his vision for the President’s Emergency Plan for AIDS Relief (PEPFAR), a five-year Emergency Plan designed to provide $15 billion to address HIV/AIDS prevention, treatment and care, most heavily concentrated in 15 focus countries. The strategy for preventing seven million new infections focuses on sexual transmission and draws on the “ABC” (Abstain, Be Faithful, use Condoms) approach, with strong emphasis on abstinence for youth and fidelity in marriage (accompanied by testing). Consistent use of condoms is promoted for those most at risk for transmission of HIV (OGAC, 2005).

Current discussion of ABC almost always equates the ABC approach with Uganda, as if it originated there (Cohen, 2002; Garbus and Marseille, 2003; Blum, 2004; Stulman, 2007). Did the ABC approach originate in Uganda? Ms. Mukasa Monico, head of TASO (The AIDS Support Organization) in Uganda until 2001, said, “ABC came to us from the World Health Organization…it was the standard public health approach to prevent sexually transmitted diseases” (quoted in Rosenberg, 2003). Slutkin¹  (2004) noted, “I supported their program [under WHO/Global Program on AIDS] from 1987–1994 and I think I remember having heard faint reference to it perhaps around 1994 in the halls around Geneva, perhaps as a USAID term. It [ABC] does not appear in any of the formative documents on Uganda’s program that I was involved with nor was I aware of…The program was primarily one of promoting fidelity…” Dr. Edward Green of Harvard University and a member of the President’s Council on HIV/AIDS, and one of the primary writers about Uganda and ABC, (2003a) acknowledges that, “I don’t think anybody knows who originally formulated ‘ABC.’”

This report demonstrates that the building blocks of the ABC approach have existed for many years and were implemented in independent ways in various countries. Programs aiming to prevent the sexual transmission of HIV² quickly promoted these three behaviors in different combinations and using different messages, as will be illustrated in this report.

Methodology

This report was developed through review of the early literature on HIV/AIDS policies and programs in non-industrialized countries and of media material promoting prevention of heterosexual transmission of HIV in those countries. Material from the early days of the epidemic was difficult to obtain. Most materials were long ago archived or are in personal files in “basements” as some respondents indicated. While the report focuses on the experiences of three countries,³  it also examines the early responses of international organizations to HIV in many other developing countries. Additional data were obtained using a snowball sampling technique through which the authors contacted people who had worked in HIV/AIDS programs in the 1980s and early 1990s to learn more about historic HIV/AIDS prevention strategies. The pool of respondents is not intended to be exhaustive, but the respondents provide important voices of those working in the developing world at the beginning of the epidemic.