Implementing the ABC Approach

Overarching Considerations
Effective implementation of the ABC approach requires careful evaluation of risk behaviors that fuel local epidemics. Although prevention interventions are most successful when locally driven and responsive to local cultural values, epidemiological evidence can identify risky behaviors within populations and guide specific behavioral messages. For example, in some communities, as many as 20 percent of girls aged 15 to 19 are infected, compared to 5 percent of boys the same age.¹³ Coupled with high prevalence among older men, such data can point to transmission that is fueled by cross-generational sex.^14,15 Prevention approaches must then address the risks of cross-generational and transactional sex through abstinence programs for youth and be faithful programs for men that foster collective social norms that emphasize avoiding risky sexual behavior.¹⁶

Every country program must include all three elements of the "ABCs," promoted strategically to appropriate populations and drivers of disease. Thus, the optimal balance of ABC activities will vary across countries according to the patterns of disease transmission, the identification of core transmitters (i.e., those at highest risk of transmitting HIV), cultural and social norms, and other contextual factors.¹⁷ In addition, prevention messages are most effective when they are accurate and consistent, and all implementing partners must harmonize them at the community level. The A, B, and C components must not undermine or compete with each other, and therefore program partners must not disseminate incorrect information about any health intervention or device. Implementing partners must not promote condoms in a way that implies that it is acceptable to engage in risky sex. Whenever condoms are discussed, information about them must be accurate and not misleading, and must include both the public health benefits and failure rates of condoms as they apply to preventing HIV and other diseases. Likewise, abstinence and faithfulness programs and messages must be medically sound and based on best practices that indicate effectiveness.

Emergency Plan funds may be used for abstinence and/or be faithful programs that are implemented on a stand-alone basis. For programs that include a "C" component, information about the correct and consistent use of condoms must be coupled with information about abstinence as the only 100 percent effective method of eliminating risk of HIV infection; and the importance of HIV counseling and testing, partner reduction, and mutual faithfulness as methods of risk reduction. As stated above, ABC must be balanced at the portfolio level, i.e. all three components must be represented in the country's prevention strategy, but individual programs must be appropriately designed to meet the needs of the target audience.

Priority Interventions: Abstinence and Behavior Change for Youth
Young people are the most important asset to any community or nation. Protecting them from contracting HIV is unquestionably one of the most important missions of the Emergency Plan. Young people who have not had their sexual debut must be encouraged to practice abstinence until they have established a lifetime monogamous relationship. For those youth who have initiated sexual activity, returning to abstinence must be a primary message of prevention programs. Implementing partners must take great care not to give a conflicting message with regard to abstinence by confusing abstinence messages with condom marketing campaigns that appear to encourage sexual activity or appear to present abstinence and condom use as equally viable, alternative choices. Thus, marketing campaigns that target youth and encourage condom use as the primary intervention are not appropriate for youth, and the Emergency Plan will not fund them. (For this same reason, Emergency Plan funds may not be used to actively promote or provide condoms in school settings, but may be used in schools to support programs that deliver age-appropriate "ABC" information for youth.) This means the following:

1. For 10-to-14-year-olds, the Emergency Plan will fund age-appropriate and culturally appropriate "AB" programs that include promoting (1) dignity and self-worth; (2) the importance of abstinence in reducing the transmission of HIV; (3) the importance of delaying sexual debut until marriage; and (4) the development of skills for practicing abstinence.
   
2. For older youth (above age 14) the Emergency Plan will fund ABC programs that promote (1) dignity and self worth; (2) the importance of abstinence in reducing the transmission of HIV; (3) the importance of delaying sexual activity until marriage; (4) the development of skills for practicing abstinence, and where appropriate, secondary abstinence; (5) the elimination of casual sexual partnerships; (6) the importance of marriage and mutual faithfulness in reducing the transmission of HIV among individuals in long-term relationships; (7) the importance of HIV counseling and testing; and (8) provide full and accurate information about correct and consistent condom use as a way to significantly reduce-but not eliminate-the risk of HIV infection for those who engage in risky sexual behaviors.

It must be recognized that certain young people will, either by choice or coercion, engage in sexual activity. In these cases an integrated "ABC" approach is necessary. When individual students are identified as engaging in or at high risk for engaging in risky sexual behaviors, they should be appropriately referred to integrated "ABC" programs. Such programs should have the following characteristics: (1) be located in communities where youth engaging in high-risk behaviors congregate; (2) be coordinated with school-based abstinence programs so that high risk in-school youth can be easily referred, and (3) be targeted to specific high-risk individuals or groups (i.e. not involve the marketing of condoms to broad audiences of young people). Again, for programs that include a "C" component, information about correct and consistent use of condoms must be coupled with information about abstinence as the only 100 percent effective method of eliminating risk of HIV infection; and the importance of HIV counseling and testing, partner reduction, and mutual faithfulness as methods of risk reduction. In summary:

1. Emergency Plan funds may be used in schools to support programs that deliver age-appropriate "AB" information to young people age 10-14;
2. Emergency Plan funds may be used in schools to support programs that deliver age-appropriate "ABC" information for young people above age 14;
3. Emergency Plan funds may be used to support integrated ABC programs that include condom provision in out-of-school programs for youth identified as engaging in or at high risk for engaging in risky sexual behaviors; 
4. Emergency Plan funds may not be used to physically distribute or provide condoms in school settings; 
5. Emergency Plan funds may not be used in schools for marketing efforts to promote condoms to youth; and
6. Emergency Plan funds may not be used in any setting for marketing campaigns that target youth and encourage condom use as the primary intervention for HIV prevention.

Priority Interventions: Promoting Healthy Norms and Behaviors
Communities must mobilize to address the norms, attitudes, values, and behaviors that increase vulnerability to HIV, including the acceptance or tolerance of multiple casual sex partnerships, cross-generational and transactional sex, forced sex, the unequal status of women, and the sexual coercion and exploitation of young people. To stimulate such mobilization, there is an urgent need to help communities identify the ways in which they contribute to establishing and reinforcing norms that contribute to risk, vulnerability, and stigma, and to help communities identify interventions that can change norms, attitudes, values, and behaviors that increase vulnerability to HIV. In addition, mobilization and change are most likely when messages are reinforced through a variety of fora; social and cultural networks; leaders and personal relationships, including parents, grandparents, religious and other leaders, and peers.

Emergency Plan funds can be used to support activities that will generate public discussion and problem solving about harmful social and sexual behaviors through a variety of means at both the community and national levels. Suggested activities include the following:

1. Educating parents to improve parent-child communication on HIV, sexuality, and broader issues such as limit-setting through parent-teacher groups, local associations, and faith-based groups;
2. Training local religious and other traditional leaders in HIV concerns and supporting them in publicizing the risks of early sexual activity, sex outside of marriage, multiple partners, and cross-generational sex;
3. Supporting youth-led community programs to help youth, their parents, and the broader community personalize the risk associated with early sexual activity, sex outside of marriage, multiple partnerships, and cross-generational sex;
4. Supporting media campaigns that reinforce and make abstinence, fidelity, partner reduction, HIV counseling and testing, and other safer behaviors legitimate options and standards of behavior for both youth and adults;
5. Developing and training mentors for youth who lack sufficient parental or other adult supervision, including training in messages for HIV prevention;
6. Organizing campaigns and events to educate local communities about sexual violence against youth and strengthen community sanctions against such behaviors;
7. Implementing workplace programs for older men to stress male sexual and familial responsibility, and school-based programs for younger males to provide education about preventing sexual violence;
8. Promoting the use of testing and counseling services, including developing innovative strategies to encourage and increase HIV testing, such as routine testing where appropriate;
9. Training health care providers, teachers, and peer educators to identify, counsel, and refer young victims of rape, incest, or other sexual abuse for other health care; and
10. Coordinating with governments and NGOs to eliminate gender inequalities in the civil and criminal code and enforce existing sanctions against sexual abuse and sexual violence.

Priority Interventions: Prevention of HIV Infection in the Most At-Risk Populations
Following the ABC model, and recognizing that correct and consistent condom use is an essential means of reducing, but not eliminating, the risk of HIV infection for populations who engage in risky behavior, the Emergency Plan will fund those activities that target at-risk populations with specific outreach, services, comprehensive prevention messages, and condom information and provision. As defined above, these populations include sex workers and their clients, sexually active discordant couples or couples with unknown HIV status, substance abusers, mobile male populations, men who have sex with men, people living with HIV/AIDS, and those who have sex with an HIV-positive partner or one whose status is unknown.

Some of the populations most affected by HIV/AIDS are also the most difficult to reach through conventional health care programs. Sex workers and their clients, men who have sex with men, and injecting drug users have the least access to basic health care. These populations are generally at higher risk of infection and in greatest need of prevention services. The experiences of Thailand, Cambodia, the Dominican Republic, Senegal, and other countries illustrate that targeted efforts to promote correct and consistent condom use with specific high-risk groups can prevent concentrated epidemics from maturing into generalized epidemics.¹⁸,¹⁹ In generalized epidemics, such targeted approaches remain crucial but must be augmented by balanced ABC approaches that can reach broader audiences in order to provide information to those who may be having sex with a partner whose status is unknown.²⁰

First and foremost, the Emergency Plan will support approaches directed at ending risky behavior. In addition, the Emergency Plan supports effective new approaches to serve groups at high risk through a combination of the following:

1. Interpersonal approaches to behavior change, such as counseling, mentoring, and peer outreach;
2. Community and workplace interventions to eliminate or reduce risky behaviors;
3. Initiatives to promote the use of testing and counseling services, including developing innovative strategies to encourage and increase HIV testing, such as routine testing where appropriate;
4. Promoting and supporting substance abuse prevention and treatment targeting HIV-infected individuals;
5. Promoting a comprehensive package for sex workers and other high-risk groups, including HIV counseling and testing, STI screening and treatment, targeted condom promotion and distribution, and other risk reduction education;
6. Promoting correct and consistent condom use during high-risk sexual activity; and
7. Media interventions with specially tailored messages appropriately targeted to specific populations.

Conclusion
Prevention activities under the Emergency Plan will be driven by best practices, sensitivity to the dynamics of the local epidemic, and the national strategy of host governments. Therefore, the Emergency Plan will use the ABC approach for prevention of the sexual transmission of HIV. Technical assistance is available to support the implementation of ABC programs. By strengthening our prevention efforts, the Emergency Plan will support the efforts of the nations in which we work to prevent HIV infection and preserve health and families as, together, we turn the tide against HIV/AIDS.

ABC Guidance Home Page