The Funding that has Fueled an Ineffective Intervention-Isadora Nogueira
Intervention: The President’s Emergency Plan For AIDS Relief (PEPFAR) and the Official AB Policy in Uganda
Although a public health intervention’s purpose is for societal improvement, it may be ineffective end harmful if not implemented adequately. In 2004, the Bush administration approved its plan for AIDS relief in Africa- the Presidents Emergency Plan for AIDS Relief (PEPFAR). PEPFAR provides a total of fifteen billion dollars within a five-year period to fourteen African and Caribbean countries. The White House will give $6 billion this year for global AIDS. However one of the requirements for the country receiving the funding is that one third of the overall prevention budget and two thirds of the behavioral prevention budget be spent on abstinence/being faithful (AB) programming. Not only does it dictate that thirty-three percent of the funding go to abstinence-until marriage programs, it limits condom-distribution to “high risk” groups and does not allow the funding to be spent on sex workers (1). In Uganda, with the PEPFAR funding, the government established an official “AB” policy in 2004, undermining the previous ABC policy which included promoting condom (C) usage. Before the AB policy, HIV activists in Uganda had spent the last two decades trying to normalize condom usage. PEPFAR’s guidelines for funding, which has fueled the official AB policy is ineffective and may do the opposite of its intended purpose: to decrease the spread of HIV. The past couple of years HIV in Uganda has actually increased (2). PEPFAR is ineffective because it places too much emphasis on internal characteristics of the individual. Furthermore, it does not universally address all the groups in the community while increasing the stigma on those who become infected. Lastly, it does not take into account the cultural behaviors prevalent in the community.
The AB plan heavily emphasizes internal characteristics, failing to take into account external factors.
Abstinence and Be Faithful policies emphasizes self-control and will-power of the individual. Albert Bandura’s Social Cognitive Theory (SCT) addresses the interplaying factors of behavior- the individual characteristics, environmental factors, and interactive process between the individual and social/environmental cues (3). Using the SCT, the AB method fails to consider the variety of other factors that affect behavior, and only emphasizes the internal characteristics such as behavioral capability, expectations, and self-control. However, solely addressing these characteristics is not enough. Even if the individual has the intention to avoid sexual intercourse, it may not necessarily translate into action, for we are influenced by much more than our own characteristics but by those around us. Furthermore, even excluding the environmental and social influence, sticking to the AB policy is difficult nonetheless. According to past research and interventions, abstinence is tough and even people who swear by it have a hard time sticking with it (4). Ninety-five percent of the American population has premarital sex (5). In the study Promising the future: virginity pledges and first intercourse, teens who pledged not to have premarital sex were followed over the period of six years. Sixty percent of these teens had broken their vow, which supports the notion that intention does not translate into behavior. Furthermore these teens who pledged to refrain from sexual intercourse until marriage were more likely to engage in oral and anal intercourse and less likely to use condoms compared to non-pledging teens (6). In the United States, the abstinence approach has been ineffective in twelve different states(2).
Not only has the abstinence approach been ineffective in other countries, it also goes against empirical evidence on what has been effective in Uganda. In the last decade, HIV incidence in Uganda has decreased due to comprehensive preventative efforts. The AIDS prevention campaign which was initiated in 1982 has been credited with helping decrease HIV prevalence from around 15% in the early 1990s to around 5% in 2001. This first AIDS prevention campaign was called the ABC approach - encouraging sexual Abstinence until marriage; advising the sexually active individuals to Be faithful to one partner; and advising Condom use (7). The ABC approach was effective because it took into account the possibility of the individual being affected by others around him, considering the overall social and physical environment, where it is common to have sexual intercourse before marriage. The individual may be influenced by modeling, the behavior of others and by positive or negative reinforcements from that behavior. Since the adolescent or adult are not completely resistant to societal influence, a public health intervention must include a preventative method that takes these factors into account. Hence encouraging condom usage and increasing their availability are key for HIV prevention. The number of condoms delivered and promoted by international groups rose from 1.5 million in 1992 to nearly 10 million in 1996. Within the last decade the C for condom in ABC has been removed. Uganda did not implement abstinence education on a large scale until the United States began promoting these programs internationally around 2001. During the 2000-2005 period when the PEPFAR was passed the HIV prevalence has increased to 5.4% and continues to increase since the shift to abstinence interventions were made. There are currently 940,000 people currently living with HIV in Uganda (8). Health policies in Uganda should be dictated by what has been effective in the past, which should address more than just individual characteristics, but external factors and the interactive process between the social/environmental cues and the individual.
The AB policy is not completely effective, increases stigmatization of HIV, and discriminates against certain groups.
Even if the individual is able to stick to the AB program, it does not guarantee that he or she will not be infected by the HIV virus. Abstinence does not protect faithful couples if one is already infected, married couples who have sexual intercourse outside of the marriage, rape victims, injecting drug used, sex workers and people who are already infected. And since in the AB policy, the person is expected to wait until marriage to have sexual intercourse, it assumes that everyone has the intention and capability of getting married, which is discriminatory and excludes certain groups of people. Homosexuals are not by law permitted to get married, so how does abstinence until marriage apply to the gay population? The abstinence policy also discriminates against sex workers, in which the person makes their living off of sexual intercourse. Those who support their families by this profession will most likely not follow the abstinence policy (2). The AB approach has also contributed to increase in stigma on those infected with HIV. The Behavior Change Communications (BCC) theory is an approach developed primarily in the global health context integrates several behavioral change theories ranging from Diffusions of Innovations to Social marketing theory. The BCC has been widely used in designing HIV interventions. One of the major goals of a BCC program are to reduce stigma and discrimination, an important characteristic of what makes a public health intervention effective (3). The AB policy does the opposite, and actually increases stigma and discrimination related to AIDS. Solely promoting messages that advocate abstinence and partner reduction stigmatizes and demoralizes those who do become infected. The message that for the person to prevent infection, he or she must resist temptations and maintain fortitude puts an overwhelming pressure on the individual and demoralizes him if he does become infected. And in countries where 90% of the population does not know their HIV status, how does one identify and avoid sexual interaction with those who are infected and those who are not (2)? Furthermore, for those who know of their HIV positive status, is he expected to not have any sexual interactions with anyone for the rest of their lives? Abstinence would promote that no one should have sexual encounters with the HIV positive person, an extremely demoralizing stigmatization to carry throughout life if the person is the one who is infected. The overemphasis on abstinence and faithful relationships increases stigma and discrimination on those who become HIV positive, precludes certain groups of people, and is not completely effective in certain cases.
Also, the program does not target all populations equally which furthers
contributes to the stigma. In terms of testing for HIV, instead of having widespread testing, the program heavily promotes couples getting married to be tested rather than encouraging universal testing. Also, the Ugandan government does not address the gay, lesbian, and transgendered community in any kind of AIDS prevention service, and therefore discriminates against specific groups. It also does not provide AIDS prevention service or education to sex workers. Sex workers should be a priority target due to the high risk of contracting and spreading the HIV virus, however the government does not acknowledges this fact. Furthermore, the United States only provides funding for countries that sign a contract saying the money for HIV prevention will not be spent on sex workers, therefore supporting this kind of exclusion and contributing the spread of the HIV virus. To reiterate, in the AB policy, condoms are only do be given to “high-risk” groups. However two extremely high risk groups are the gay community and sex workers, yet they are treated as if they did not exist. Currently in Uganda, the newly diagnosed HIV cases are being seen with greater intensity in married women, which is not an expected high risk group. Therefore if condoms are to be given out, they must be made available to everyone and not just certain groups that are considered “high risk”. The funding for the AB plan does not address all populations equally, for it literally excludes certain groups from being included in the funding. And since the AB plan is not applicable to everyone, it is discriminatory intervention.
The AB plan does not take into account prevalent community behavior and cognition that are entrenched in the culture
The AB plan fails to take into account the overall culture in Uganda, disregarding common behaviors and cognition prevalent in the community. According to cultural anthropologists, there is a strong connection between culture and personality and its expression as behavior. Using the Anthropological approach, the public health specialist would focus on the health behavior prevalent in the community and relate it to a larger context. In Uganda, the estimated age girls have their first sexual experience is 16.7 years for girls and 18.8 for boys as of 2001(9). According to the Uganda AIDS Commission, “Ugandan youth begin sexual activity at fairly young ages and with little sexuality information.”13. With a large population of adolescents starting sexual intercourse at a relatively young age and before marriage, the abstinence policy would be hard to push in this sort of community. A public health interventionist who uses the anthropological approach would most likely consider alternatives to address the AIDS epidemic in this community. Furthermore, one fifth of marriages are polygynous, which increases the chances the HIV transmittance if one of the people already have the virus or are unfaithful. Women also marry at a much younger age usually with men who have already been sexually active for several years and who may not have used a condom in the past. In marriages, Forty percent of women experience domestic violence. In the majority of the marriages, the woman is expected to have sex whenever the husband demands it, and the chances of her convincing the husband to use a condom are much lower than with a man who she is not married to(2). The women in the Ugandan community, based on their culture, most likely do not perceive they have power over the man in remaining abstinent and demanding condom usage. The AB plan takes away from the importance of the condom and reinforces the husband’s behavior of failing to use a condom and discourages more women to demand condom. It contributes to stigmatization of condom by denormalizing its usage. In Uganda, the overall belief of the community is that condom does protect against HIV but the AB plan is minimizing the protective power of condom usage (2). Consequently less people are using condoms and more people are infected each day. The Anthropological approach would take into account these overall behaviors and make sure the health intervention fits into the cultural behaviors.
In the Anthropological model, the culture’s cognition of health and disease are important determinants of behavior. The problem with the AB policy is that it is withholding critical information about condom protection without explaining the possible risks associated with abstinence until marriage (10). Therefore the AB policy impacts the cognition in the community, but in a negative way. The AB program was implemented in halls and classrooms of primary and secondary schools across Uganda. Although the Ugandan government had initially said that condom usage would continue to be promoted, it did not maintain this position, for according to them, it conflicts with the abstinence promotion. Out of the funding the United States is giving to Uganda, 3 million is given to a program called te Presidential Initiative on AIDS Strategy for Communication to Youth (PIASCY), which provides abstinence-until-marriage through assemblies, youth rallies, classroom activities. Inclusion of objective health information with images depicting ejaculation, body changes during puberty, the effectiveness of condoms, and proper cleaning of the foreskin were vetoed from being shown in the educational materials. The materials also includes some false statements about condom usage, minimizing their protective value and emphasizing overall religouss values (2). If the individual makes decisions based on cognition but the cognition turn out to be false, the individuals actions may be of great damage to himself and to those around him. The Ugandan government must promote honest messages and not withhold information in order for people make decisions based on truths rather than faulty information.
Uganda needs to maintain what has been effective in the past based on empirical data and not change solely based on funding requirements set by the United States. The AB program does not address alternatives to abstinence or provide preventative education that includes other contraceptive methods. Improved contraceptive use is responsible for 86 percent of the decline in the U.S. adolescent pregnancy rate between 1995 and 2002 (12). Uganda must reduce HIV by promoting effective behavioral strategies - which includes condom usage. It must make condoms available and affordable throughout the country. It must have HIV testing not only for married but for everyone. Finally, it must not discriminate against the gay community and sex workers, which right now are excluded from their HIV programs. The program must reach individuals of all educational levels, social economic backgrounds, genders. It must take into account cultural factors, statistics on what has been effective in the past in Uganda and in other countries.
The AB policy has shown to be ineffective on many levels. The AB policy places too much emphasis on individual factors, is not completely effective while contributing to stigmatization, and does not address behaviors prevalent in the culture. An effective HIV intervention in Uganda should not ignore empirical data and be based off of religious principles. Public health interventions should be effective and have the purpose to contribute to the well-being of the community.
Counter Intervention
Solution to: “The AB plan heavily emphasizes internal characteristics, failing to take into account external factors that impact behavior”
To decrease the emphasis on the internal characteristics, an intervention should promote alternatives to preventing HIV that go beyond being faithful or abstinent. To address the flaws of the AB plan, I propose reverting back to the ABC approach in Uganda, where “C” stands for condom usage. An intervention that focuses on promotion of condom usage, if implemented appropriately could address factors that go beyond the individual level. Although both the AB plan and the ABC plan to an extent rely on “internal” characteristics of the individual(e.g willpower), it has been consistently supported that remaining abstinent is significantly more difficult for the individual compared to condom usage (13). Albert Bandura’s Social Cognitive Theory (SCT) addresses the interplaying factors of behavior- the individual characteristics, environmental factors, and interactive process between the individual and social/environmental cues (14). An effective intervention would apply the SCT at some level. To address environmental factors that affect HIV infection, one would consider societal and social influences on the individual. Although condom usage still relies on the individual’s “internal” characteristic, if it is heavily promoted and widely available, the social and physical environment may be framed to help the individual make the decision to wear condoms. The intervention would educate in schools, health clinics, work-places, and throughout the community by lecturing about condom usage and HIV protection. Along would promoting their usage, condoms must be widely distributed and available. Condom usage must be encouraged by community leaders, whether it is in schools or in health clinics. By having community leaders and health workers, and other well-respected individuals advocate condom usage, the rest of the community may model their behavior. School programs could have individuals with HIV as spokespersons to tell their stories in order for the students to vicariously learn through them. Condom usage must be normalized and through behavior modeling within their social groups, a greater number of individuals will chose to use a condom or demand that the partner uses one. If there are a significant number of positive messages associated with condom usage, seeing the message would make someone who uses condoms positively reinforced to continue using them. Workshops should be incorporated in the health intervention in order to promote self-efficacy. It is important for schools to communicate with parents as well to gain their support in encouraging their children to protect themselves and to be good role-models by promoting safe-sex practices. Using the SCT model, not only would the internal characteristics, but the external characteristics would be addressed. There are endless interventions that could be done applying the SCT, but promoting condom usage, increasing its accessibility, and educating about the importance of condoms would make the physical and social environment more condom-friendly. With this, the external environment is more positively shaped to help the individual make the right decision.
Solution to: “The AB policy is not completely effective, increases stigmatization of HIV, and discriminates against certain groups.”
The second flaw of the AB approach is that it has shown to not be effective in the past within Uganda and in other countries. The new intervention would be based on facts of what has been effective in the past. The AB policy is not completely effective, for it ignores data that supports the fact that the AB policy generally does not work in preventing the spread of HIV. During the 2000-2005 period when the PEPFAR was passed the HIV prevalence has increased to 5.4% and continues to increase since the shift to abstinence interventions were made. There are currently 940,000 people currently living with HIV in Uganda (15). A public health interventionist who seeks to carry out an effective intervention must be aware of what has been effective in the past within that specific community and perhaps beyond it. Prior to the recent increase in HIV, there was a steady decline in HIV due to the public health intervention that implemented the ABC (Abstincence, Be-faithful-Condom) approach. The AIDS prevention campaign which was initiated in 1982 has been credited with helping decrease HIV prevalence from around 15% in the early 1990s to around 5% in 2001. The program included widespread availability and distribution of condoms, increasing the normalization of its usage and decreasing the spread of the virus. The number of condoms delivered and promoted by international groups rose from 1.5 million in 1992 to nearly 10 million in 1996 (16). The ABC program has been effective, while the abstinence approach has been ineffective not only in Uganda, but in many several other places including the United States. A public health interventionist would look at past data and evaluate the effectiveness of different programs. Clearly, the ABC approach is what has been effective in Uganda while the AB approach has been ineffective and therefore the ABC approach is clearly what should be implemented.
Furthermore, the AB approach increases stigmatization of those infected with HIV and discriminates against certain groups of people by not providing preventative services. The new program would decrease stigmatization of HIV and would target the entire community, rather than focusing on specific groups. A program that would prevent the increase of stigmatization of HIV would provide alternatives to abstinence and being faithful, for neither protect if the person already has HIV. An effected intervention would consider the fact that abstinence until marriage and being faithful would not prevent the virus from spreading if the person is already an HIV carrier. If it is known that the person has HIV, most likely no one will want to marry or have any kind of sexual relations with the person, feeding on to the stigmatization of HIV. An effective program would focus on how condom usage protects the spread, and therefore the person with HIV would not carry such a heavy stigma. Furthermore, a significant number of people with HIV are unaware they carry the virus, and therefore only through condom usage can it be certain that the virus will not spread. The public health intervention would promote widespread HIV testing rather than promoting only couple that are getting married to be tested. It would promote condom usage to the entire population, rather than to high-risk groups. Unlike the current approach in Uganda, the new public health intervention would not discriminate against certain groups of people (17). An effective intervention should target all segments of the population, despite social class, gender, ethnicity, occupation, and sexual preference. The gay, lesbian, and transgendered community would be included in AIDS prevention service. The new intervention would also provide AIDS prevention service or education for sex workers. Sex workers should be a priority target due to the high risk of contracting and spreading the HIV virus, The public health practitioner knows it is unwise to ignore one specific group not only because it us inhumane, but for the well-being of all the other groups as well. HIV will spread between the groups, therefore neglecting to target one group may actually harm all of the others. The program must decrease the stigma of HIV by focusing on condom promotion and it much reach individuals of all educational levels, social economic backgrounds, genders in order to be completely effective.
Solution to: “The AB plan does not take into account prevalent community behavior and cognition that are entrenched in the culture”
The new intervention would consider Anthropological factors upheld in the community. The AB plan does not take into account prevalent community behavior and cognition that are entrenched in the culture. Using the Anthropological approach, the public health specialist would focus on the health behavior prevalent in the community and relate it to a larger context (18). Since a large part of the community starts sexual intercourse at a young age, safe sex practices must be advocated to the youth, in school settings. Furthermore, the high prevalence of polygomous relationships and marriages fuel the need to invest in contraceptive education as opposed to abstinence, and further supports the need for widespread distribution of condoms(19). The normalization of condoms must occur in order to decrease stigmatization, which will occur once promotion and access to condom is available. Women must be empowered to demand condom usage through community education and workshops. The protective power of the condom must be advocated in order for the belief that it will prevent HIV infection become more widespread. Although the majority of the population is aware that condoms may protect against HIV, the AB plan is fueling the belief that it can be ineffective. The school programs must send out a clear message about the protective power of the condom, rather than focusing on other alternatives such as abstinence. The programs must teach factual, and comprehensive information regarding HIV and condom usage, without imposing any kinds of religious values. The information must not leave out pictures or figures that would be helpful for the students to understand the HIV virus and its transmittance. The intervention would educate using facts about condom usage taking into account community behaviors and cognition prevalent in the community.
As opposed to the AB policy, the ABC public health intervention would be effective if implemented appropriately. It addresses external factors rather than emphasizing internal characteristics. It decreases the stigma individuals with HIV carry. It is encompassing and target all within the population. It considers prevalent cognition and behaviors entrenched in the Ugandan community. More importantly, it has been proven effective in the past within the same community and therefore must be reimplemented in order to reverse the damages the AB intervention has caused.
References
1) Health Gap Global Access Project. 2009. President’s Emergency Plan for AIDS Relief (PEPFAR). Retrived from http://www.healthgap.org/camp/pepfar.html April 2009
2) Human Right’s Watch.2009 The Less They Know, the Better Abstinence-Only HIV/AIDS Programs in Uganda. Retrieved from http://www.genderhealth.org/pubs/HRWuganda0305.pdf . April 2009.
3) Edberg, Mark. Essentials of Health Behavior. Sudbury, MA. Jones and Bartlett, 2007.
4) Advocates for Youth. 2009. Abstinence-Only-Until-Marriage Programs: Ineffective, Unethical, and Poor Public Health. Retrieved from
http://www.advocatesforyouth.org/PUBLICATIONS/policybrief/pbabonly.html. April 2009.
5) Finer L. Trends in premarital sex in the United States, 1954-2003. Public Health Reports, 2007; 23: 73.
6) Bearman PS, Brückner H. Promising the future: virginity pledges and first intercourse. American Journal of Sociology 2001; 106:859-912.
7)The American Prospect. 2008. How Bush's AIDS Program is Failing Africans. Retrieved from
http://www.prospect.org/cs/articles?article=how_bushs_aids_program_is_failing_africans. April 2009
8)Avert. 2008. HIV and AIDS in Uganda. Retrieved from avert.org/aidsuganda.htm. April 2009.
9) Those surveyed were women between twenty and forty-nine, and men between twenty and fifty-four. UgandaBureau of Statistics (UBOS) and ORC Macro, Uganda Demographic and Health Survey 2000-2001 (Calverton, MD: UBOS and ORC Macro, 2001), p. 79.
10)Uganda AIDS Commission. 2001. “National Young People HIV/AIDS Communication Program for Young People: Concept Paper”. Retrieved from http://www.aidsuganda.org/pdf/piacy_doc.pdf. April 2008
11) Health Gap Global Access Project. 2005. 10 Months and Counting: The Condom Crisis in Uganda. 2005. Retrieved from http://www.healthgap.org/press_releases/05/082905_HGAP_Uganda_call_transcript.html, April 2009.
12) Santelli, Julia.and Laura Lingberg. Explaining Recent Declines in Adolescent Pregnancy in the United States: the Contribution of Abstinence and Improved Contraceptive Use
Am J Public Health. 2007;97(1):150-156
13) Advocates for Youth. 2009. Abstinence-Only-Until-Marriage Programs: Ineffective, Unethical, and Poor Public Health. Retrieved from
http://www.advocatesforyouth.org/PUBLICATIONS/policybrief/pbabonly.html. April 2009.
14) Edberg, Mark. Essentials of Health Behavior. Sudbury, MA. Jones and Bartlett, 2007.
15) Avert. 2008. HIV and AIDS in Uganda. Retrieved from avert.org/aidsuganda.htm. April 2009.
16) Uganda AIDS Commission. 2001. “National Young People HIV/AIDS Communication Program for Young People: Concept Paper”. Retrieved from http://www.aidsuganda.org/pdf/piacy_doc.pdf. April 2008
17) The American Prospect. 2008. How Bush's AIDS Program is Failing Africans. Retrieved from http://www.prospect.org/cs/articles?article=how_bushs_aids_program_is_failing_africans. April 2009
18) Edberg, Mark. Essentials of Health Behavior. Sudbury, MA. Jones and Bartlett, 2007.
19)Those surveyed were women between twenty and forty-nine, and men between twenty and fifty-four. UgandaBureau of Statistics (UBOS) and ORC Macro, Uganda Demographic and Health Survey 2000-2001 (Calverton, MD: UBOS and ORC Macro, 2001), p. 79.
Although a public health intervention’s purpose is for societal improvement, it may be ineffective end harmful if not implemented adequately. In 2004, the Bush administration approved its plan for AIDS relief in Africa- the Presidents Emergency Plan for AIDS Relief (PEPFAR). PEPFAR provides a total of fifteen billion dollars within a five-year period to fourteen African and Caribbean countries. The White House will give $6 billion this year for global AIDS. However one of the requirements for the country receiving the funding is that one third of the overall prevention budget and two thirds of the behavioral prevention budget be spent on abstinence/being faithful (AB) programming. Not only does it dictate that thirty-three percent of the funding go to abstinence-until marriage programs, it limits condom-distribution to “high risk” groups and does not allow the funding to be spent on sex workers (1). In Uganda, with the PEPFAR funding, the government established an official “AB” policy in 2004, undermining the previous ABC policy which included promoting condom (C) usage. Before the AB policy, HIV activists in Uganda had spent the last two decades trying to normalize condom usage. PEPFAR’s guidelines for funding, which has fueled the official AB policy is ineffective and may do the opposite of its intended purpose: to decrease the spread of HIV. The past couple of years HIV in Uganda has actually increased (2). PEPFAR is ineffective because it places too much emphasis on internal characteristics of the individual. Furthermore, it does not universally address all the groups in the community while increasing the stigma on those who become infected. Lastly, it does not take into account the cultural behaviors prevalent in the community.
The AB plan heavily emphasizes internal characteristics, failing to take into account external factors.
Abstinence and Be Faithful policies emphasizes self-control and will-power of the individual. Albert Bandura’s Social Cognitive Theory (SCT) addresses the interplaying factors of behavior- the individual characteristics, environmental factors, and interactive process between the individual and social/environmental cues (3). Using the SCT, the AB method fails to consider the variety of other factors that affect behavior, and only emphasizes the internal characteristics such as behavioral capability, expectations, and self-control. However, solely addressing these characteristics is not enough. Even if the individual has the intention to avoid sexual intercourse, it may not necessarily translate into action, for we are influenced by much more than our own characteristics but by those around us. Furthermore, even excluding the environmental and social influence, sticking to the AB policy is difficult nonetheless. According to past research and interventions, abstinence is tough and even people who swear by it have a hard time sticking with it (4). Ninety-five percent of the American population has premarital sex (5). In the study Promising the future: virginity pledges and first intercourse, teens who pledged not to have premarital sex were followed over the period of six years. Sixty percent of these teens had broken their vow, which supports the notion that intention does not translate into behavior. Furthermore these teens who pledged to refrain from sexual intercourse until marriage were more likely to engage in oral and anal intercourse and less likely to use condoms compared to non-pledging teens (6). In the United States, the abstinence approach has been ineffective in twelve different states(2).
Not only has the abstinence approach been ineffective in other countries, it also goes against empirical evidence on what has been effective in Uganda. In the last decade, HIV incidence in Uganda has decreased due to comprehensive preventative efforts. The AIDS prevention campaign which was initiated in 1982 has been credited with helping decrease HIV prevalence from around 15% in the early 1990s to around 5% in 2001. This first AIDS prevention campaign was called the ABC approach - encouraging sexual Abstinence until marriage; advising the sexually active individuals to Be faithful to one partner; and advising Condom use (7). The ABC approach was effective because it took into account the possibility of the individual being affected by others around him, considering the overall social and physical environment, where it is common to have sexual intercourse before marriage. The individual may be influenced by modeling, the behavior of others and by positive or negative reinforcements from that behavior. Since the adolescent or adult are not completely resistant to societal influence, a public health intervention must include a preventative method that takes these factors into account. Hence encouraging condom usage and increasing their availability are key for HIV prevention. The number of condoms delivered and promoted by international groups rose from 1.5 million in 1992 to nearly 10 million in 1996. Within the last decade the C for condom in ABC has been removed. Uganda did not implement abstinence education on a large scale until the United States began promoting these programs internationally around 2001. During the 2000-2005 period when the PEPFAR was passed the HIV prevalence has increased to 5.4% and continues to increase since the shift to abstinence interventions were made. There are currently 940,000 people currently living with HIV in Uganda (8). Health policies in Uganda should be dictated by what has been effective in the past, which should address more than just individual characteristics, but external factors and the interactive process between the social/environmental cues and the individual.
The AB policy is not completely effective, increases stigmatization of HIV, and discriminates against certain groups.
Even if the individual is able to stick to the AB program, it does not guarantee that he or she will not be infected by the HIV virus. Abstinence does not protect faithful couples if one is already infected, married couples who have sexual intercourse outside of the marriage, rape victims, injecting drug used, sex workers and people who are already infected. And since in the AB policy, the person is expected to wait until marriage to have sexual intercourse, it assumes that everyone has the intention and capability of getting married, which is discriminatory and excludes certain groups of people. Homosexuals are not by law permitted to get married, so how does abstinence until marriage apply to the gay population? The abstinence policy also discriminates against sex workers, in which the person makes their living off of sexual intercourse. Those who support their families by this profession will most likely not follow the abstinence policy (2). The AB approach has also contributed to increase in stigma on those infected with HIV. The Behavior Change Communications (BCC) theory is an approach developed primarily in the global health context integrates several behavioral change theories ranging from Diffusions of Innovations to Social marketing theory. The BCC has been widely used in designing HIV interventions. One of the major goals of a BCC program are to reduce stigma and discrimination, an important characteristic of what makes a public health intervention effective (3). The AB policy does the opposite, and actually increases stigma and discrimination related to AIDS. Solely promoting messages that advocate abstinence and partner reduction stigmatizes and demoralizes those who do become infected. The message that for the person to prevent infection, he or she must resist temptations and maintain fortitude puts an overwhelming pressure on the individual and demoralizes him if he does become infected. And in countries where 90% of the population does not know their HIV status, how does one identify and avoid sexual interaction with those who are infected and those who are not (2)? Furthermore, for those who know of their HIV positive status, is he expected to not have any sexual interactions with anyone for the rest of their lives? Abstinence would promote that no one should have sexual encounters with the HIV positive person, an extremely demoralizing stigmatization to carry throughout life if the person is the one who is infected. The overemphasis on abstinence and faithful relationships increases stigma and discrimination on those who become HIV positive, precludes certain groups of people, and is not completely effective in certain cases.
Also, the program does not target all populations equally which furthers
contributes to the stigma. In terms of testing for HIV, instead of having widespread testing, the program heavily promotes couples getting married to be tested rather than encouraging universal testing. Also, the Ugandan government does not address the gay, lesbian, and transgendered community in any kind of AIDS prevention service, and therefore discriminates against specific groups. It also does not provide AIDS prevention service or education to sex workers. Sex workers should be a priority target due to the high risk of contracting and spreading the HIV virus, however the government does not acknowledges this fact. Furthermore, the United States only provides funding for countries that sign a contract saying the money for HIV prevention will not be spent on sex workers, therefore supporting this kind of exclusion and contributing the spread of the HIV virus. To reiterate, in the AB policy, condoms are only do be given to “high-risk” groups. However two extremely high risk groups are the gay community and sex workers, yet they are treated as if they did not exist. Currently in Uganda, the newly diagnosed HIV cases are being seen with greater intensity in married women, which is not an expected high risk group. Therefore if condoms are to be given out, they must be made available to everyone and not just certain groups that are considered “high risk”. The funding for the AB plan does not address all populations equally, for it literally excludes certain groups from being included in the funding. And since the AB plan is not applicable to everyone, it is discriminatory intervention.
The AB plan does not take into account prevalent community behavior and cognition that are entrenched in the culture
The AB plan fails to take into account the overall culture in Uganda, disregarding common behaviors and cognition prevalent in the community. According to cultural anthropologists, there is a strong connection between culture and personality and its expression as behavior. Using the Anthropological approach, the public health specialist would focus on the health behavior prevalent in the community and relate it to a larger context. In Uganda, the estimated age girls have their first sexual experience is 16.7 years for girls and 18.8 for boys as of 2001(9). According to the Uganda AIDS Commission, “Ugandan youth begin sexual activity at fairly young ages and with little sexuality information.”13. With a large population of adolescents starting sexual intercourse at a relatively young age and before marriage, the abstinence policy would be hard to push in this sort of community. A public health interventionist who uses the anthropological approach would most likely consider alternatives to address the AIDS epidemic in this community. Furthermore, one fifth of marriages are polygynous, which increases the chances the HIV transmittance if one of the people already have the virus or are unfaithful. Women also marry at a much younger age usually with men who have already been sexually active for several years and who may not have used a condom in the past. In marriages, Forty percent of women experience domestic violence. In the majority of the marriages, the woman is expected to have sex whenever the husband demands it, and the chances of her convincing the husband to use a condom are much lower than with a man who she is not married to(2). The women in the Ugandan community, based on their culture, most likely do not perceive they have power over the man in remaining abstinent and demanding condom usage. The AB plan takes away from the importance of the condom and reinforces the husband’s behavior of failing to use a condom and discourages more women to demand condom. It contributes to stigmatization of condom by denormalizing its usage. In Uganda, the overall belief of the community is that condom does protect against HIV but the AB plan is minimizing the protective power of condom usage (2). Consequently less people are using condoms and more people are infected each day. The Anthropological approach would take into account these overall behaviors and make sure the health intervention fits into the cultural behaviors.
In the Anthropological model, the culture’s cognition of health and disease are important determinants of behavior. The problem with the AB policy is that it is withholding critical information about condom protection without explaining the possible risks associated with abstinence until marriage (10). Therefore the AB policy impacts the cognition in the community, but in a negative way. The AB program was implemented in halls and classrooms of primary and secondary schools across Uganda. Although the Ugandan government had initially said that condom usage would continue to be promoted, it did not maintain this position, for according to them, it conflicts with the abstinence promotion. Out of the funding the United States is giving to Uganda, 3 million is given to a program called te Presidential Initiative on AIDS Strategy for Communication to Youth (PIASCY), which provides abstinence-until-marriage through assemblies, youth rallies, classroom activities. Inclusion of objective health information with images depicting ejaculation, body changes during puberty, the effectiveness of condoms, and proper cleaning of the foreskin were vetoed from being shown in the educational materials. The materials also includes some false statements about condom usage, minimizing their protective value and emphasizing overall religouss values (2). If the individual makes decisions based on cognition but the cognition turn out to be false, the individuals actions may be of great damage to himself and to those around him. The Ugandan government must promote honest messages and not withhold information in order for people make decisions based on truths rather than faulty information.
Uganda needs to maintain what has been effective in the past based on empirical data and not change solely based on funding requirements set by the United States. The AB program does not address alternatives to abstinence or provide preventative education that includes other contraceptive methods. Improved contraceptive use is responsible for 86 percent of the decline in the U.S. adolescent pregnancy rate between 1995 and 2002 (12). Uganda must reduce HIV by promoting effective behavioral strategies - which includes condom usage. It must make condoms available and affordable throughout the country. It must have HIV testing not only for married but for everyone. Finally, it must not discriminate against the gay community and sex workers, which right now are excluded from their HIV programs. The program must reach individuals of all educational levels, social economic backgrounds, genders. It must take into account cultural factors, statistics on what has been effective in the past in Uganda and in other countries.
The AB policy has shown to be ineffective on many levels. The AB policy places too much emphasis on individual factors, is not completely effective while contributing to stigmatization, and does not address behaviors prevalent in the culture. An effective HIV intervention in Uganda should not ignore empirical data and be based off of religious principles. Public health interventions should be effective and have the purpose to contribute to the well-being of the community.
Counter Intervention
Solution to: “The AB plan heavily emphasizes internal characteristics, failing to take into account external factors that impact behavior”
To decrease the emphasis on the internal characteristics, an intervention should promote alternatives to preventing HIV that go beyond being faithful or abstinent. To address the flaws of the AB plan, I propose reverting back to the ABC approach in Uganda, where “C” stands for condom usage. An intervention that focuses on promotion of condom usage, if implemented appropriately could address factors that go beyond the individual level. Although both the AB plan and the ABC plan to an extent rely on “internal” characteristics of the individual(e.g willpower), it has been consistently supported that remaining abstinent is significantly more difficult for the individual compared to condom usage (13). Albert Bandura’s Social Cognitive Theory (SCT) addresses the interplaying factors of behavior- the individual characteristics, environmental factors, and interactive process between the individual and social/environmental cues (14). An effective intervention would apply the SCT at some level. To address environmental factors that affect HIV infection, one would consider societal and social influences on the individual. Although condom usage still relies on the individual’s “internal” characteristic, if it is heavily promoted and widely available, the social and physical environment may be framed to help the individual make the decision to wear condoms. The intervention would educate in schools, health clinics, work-places, and throughout the community by lecturing about condom usage and HIV protection. Along would promoting their usage, condoms must be widely distributed and available. Condom usage must be encouraged by community leaders, whether it is in schools or in health clinics. By having community leaders and health workers, and other well-respected individuals advocate condom usage, the rest of the community may model their behavior. School programs could have individuals with HIV as spokespersons to tell their stories in order for the students to vicariously learn through them. Condom usage must be normalized and through behavior modeling within their social groups, a greater number of individuals will chose to use a condom or demand that the partner uses one. If there are a significant number of positive messages associated with condom usage, seeing the message would make someone who uses condoms positively reinforced to continue using them. Workshops should be incorporated in the health intervention in order to promote self-efficacy. It is important for schools to communicate with parents as well to gain their support in encouraging their children to protect themselves and to be good role-models by promoting safe-sex practices. Using the SCT model, not only would the internal characteristics, but the external characteristics would be addressed. There are endless interventions that could be done applying the SCT, but promoting condom usage, increasing its accessibility, and educating about the importance of condoms would make the physical and social environment more condom-friendly. With this, the external environment is more positively shaped to help the individual make the right decision.
Solution to: “The AB policy is not completely effective, increases stigmatization of HIV, and discriminates against certain groups.”
The second flaw of the AB approach is that it has shown to not be effective in the past within Uganda and in other countries. The new intervention would be based on facts of what has been effective in the past. The AB policy is not completely effective, for it ignores data that supports the fact that the AB policy generally does not work in preventing the spread of HIV. During the 2000-2005 period when the PEPFAR was passed the HIV prevalence has increased to 5.4% and continues to increase since the shift to abstinence interventions were made. There are currently 940,000 people currently living with HIV in Uganda (15). A public health interventionist who seeks to carry out an effective intervention must be aware of what has been effective in the past within that specific community and perhaps beyond it. Prior to the recent increase in HIV, there was a steady decline in HIV due to the public health intervention that implemented the ABC (Abstincence, Be-faithful-Condom) approach. The AIDS prevention campaign which was initiated in 1982 has been credited with helping decrease HIV prevalence from around 15% in the early 1990s to around 5% in 2001. The program included widespread availability and distribution of condoms, increasing the normalization of its usage and decreasing the spread of the virus. The number of condoms delivered and promoted by international groups rose from 1.5 million in 1992 to nearly 10 million in 1996 (16). The ABC program has been effective, while the abstinence approach has been ineffective not only in Uganda, but in many several other places including the United States. A public health interventionist would look at past data and evaluate the effectiveness of different programs. Clearly, the ABC approach is what has been effective in Uganda while the AB approach has been ineffective and therefore the ABC approach is clearly what should be implemented.
Furthermore, the AB approach increases stigmatization of those infected with HIV and discriminates against certain groups of people by not providing preventative services. The new program would decrease stigmatization of HIV and would target the entire community, rather than focusing on specific groups. A program that would prevent the increase of stigmatization of HIV would provide alternatives to abstinence and being faithful, for neither protect if the person already has HIV. An effected intervention would consider the fact that abstinence until marriage and being faithful would not prevent the virus from spreading if the person is already an HIV carrier. If it is known that the person has HIV, most likely no one will want to marry or have any kind of sexual relations with the person, feeding on to the stigmatization of HIV. An effective program would focus on how condom usage protects the spread, and therefore the person with HIV would not carry such a heavy stigma. Furthermore, a significant number of people with HIV are unaware they carry the virus, and therefore only through condom usage can it be certain that the virus will not spread. The public health intervention would promote widespread HIV testing rather than promoting only couple that are getting married to be tested. It would promote condom usage to the entire population, rather than to high-risk groups. Unlike the current approach in Uganda, the new public health intervention would not discriminate against certain groups of people (17). An effective intervention should target all segments of the population, despite social class, gender, ethnicity, occupation, and sexual preference. The gay, lesbian, and transgendered community would be included in AIDS prevention service. The new intervention would also provide AIDS prevention service or education for sex workers. Sex workers should be a priority target due to the high risk of contracting and spreading the HIV virus, The public health practitioner knows it is unwise to ignore one specific group not only because it us inhumane, but for the well-being of all the other groups as well. HIV will spread between the groups, therefore neglecting to target one group may actually harm all of the others. The program must decrease the stigma of HIV by focusing on condom promotion and it much reach individuals of all educational levels, social economic backgrounds, genders in order to be completely effective.
Solution to: “The AB plan does not take into account prevalent community behavior and cognition that are entrenched in the culture”
The new intervention would consider Anthropological factors upheld in the community. The AB plan does not take into account prevalent community behavior and cognition that are entrenched in the culture. Using the Anthropological approach, the public health specialist would focus on the health behavior prevalent in the community and relate it to a larger context (18). Since a large part of the community starts sexual intercourse at a young age, safe sex practices must be advocated to the youth, in school settings. Furthermore, the high prevalence of polygomous relationships and marriages fuel the need to invest in contraceptive education as opposed to abstinence, and further supports the need for widespread distribution of condoms(19). The normalization of condoms must occur in order to decrease stigmatization, which will occur once promotion and access to condom is available. Women must be empowered to demand condom usage through community education and workshops. The protective power of the condom must be advocated in order for the belief that it will prevent HIV infection become more widespread. Although the majority of the population is aware that condoms may protect against HIV, the AB plan is fueling the belief that it can be ineffective. The school programs must send out a clear message about the protective power of the condom, rather than focusing on other alternatives such as abstinence. The programs must teach factual, and comprehensive information regarding HIV and condom usage, without imposing any kinds of religious values. The information must not leave out pictures or figures that would be helpful for the students to understand the HIV virus and its transmittance. The intervention would educate using facts about condom usage taking into account community behaviors and cognition prevalent in the community.
As opposed to the AB policy, the ABC public health intervention would be effective if implemented appropriately. It addresses external factors rather than emphasizing internal characteristics. It decreases the stigma individuals with HIV carry. It is encompassing and target all within the population. It considers prevalent cognition and behaviors entrenched in the Ugandan community. More importantly, it has been proven effective in the past within the same community and therefore must be reimplemented in order to reverse the damages the AB intervention has caused.
References
1) Health Gap Global Access Project. 2009. President’s Emergency Plan for AIDS Relief (PEPFAR). Retrived from http://www.healthgap.org/camp/pepfar.html April 2009
2) Human Right’s Watch.2009 The Less They Know, the Better Abstinence-Only HIV/AIDS Programs in Uganda. Retrieved from http://www.genderhealth.org/pubs/HRWuganda0305.pdf . April 2009.
3) Edberg, Mark. Essentials of Health Behavior. Sudbury, MA. Jones and Bartlett, 2007.
4) Advocates for Youth. 2009. Abstinence-Only-Until-Marriage Programs: Ineffective, Unethical, and Poor Public Health. Retrieved from
http://www.advocatesforyouth.org/PUBLICATIONS/policybrief/pbabonly.html. April 2009.
5) Finer L. Trends in premarital sex in the United States, 1954-2003. Public Health Reports, 2007; 23: 73.
6) Bearman PS, Brückner H. Promising the future: virginity pledges and first intercourse. American Journal of Sociology 2001; 106:859-912.
7)The American Prospect. 2008. How Bush's AIDS Program is Failing Africans. Retrieved from
http://www.prospect.org/cs/articles?article=how_bushs_aids_program_is_failing_africans. April 2009
8)Avert. 2008. HIV and AIDS in Uganda. Retrieved from avert.org/aidsuganda.htm. April 2009.
9) Those surveyed were women between twenty and forty-nine, and men between twenty and fifty-four. UgandaBureau of Statistics (UBOS) and ORC Macro, Uganda Demographic and Health Survey 2000-2001 (Calverton, MD: UBOS and ORC Macro, 2001), p. 79.
10)Uganda AIDS Commission. 2001. “National Young People HIV/AIDS Communication Program for Young People: Concept Paper”. Retrieved from http://www.aidsuganda.org/pdf/piacy_doc.pdf. April 2008
11) Health Gap Global Access Project. 2005. 10 Months and Counting: The Condom Crisis in Uganda. 2005. Retrieved from http://www.healthgap.org/press_releases/05/082905_HGAP_Uganda_call_transcript.html, April 2009.
12) Santelli, Julia.and Laura Lingberg. Explaining Recent Declines in Adolescent Pregnancy in the United States: the Contribution of Abstinence and Improved Contraceptive Use
Am J Public Health. 2007;97(1):150-156
13) Advocates for Youth. 2009. Abstinence-Only-Until-Marriage Programs: Ineffective, Unethical, and Poor Public Health. Retrieved from
http://www.advocatesforyouth.org/PUBLICATIONS/policybrief/pbabonly.html. April 2009.
14) Edberg, Mark. Essentials of Health Behavior. Sudbury, MA. Jones and Bartlett, 2007.
15) Avert. 2008. HIV and AIDS in Uganda. Retrieved from avert.org/aidsuganda.htm. April 2009.
16) Uganda AIDS Commission. 2001. “National Young People HIV/AIDS Communication Program for Young People: Concept Paper”. Retrieved from http://www.aidsuganda.org/pdf/piacy_doc.pdf. April 2008
17) The American Prospect. 2008. How Bush's AIDS Program is Failing Africans. Retrieved from http://www.prospect.org/cs/articles?article=how_bushs_aids_program_is_failing_africans. April 2009
18) Edberg, Mark. Essentials of Health Behavior. Sudbury, MA. Jones and Bartlett, 2007.
19)Those surveyed were women between twenty and forty-nine, and men between twenty and fifty-four. UgandaBureau of Statistics (UBOS) and ORC Macro, Uganda Demographic and Health Survey 2000-2001 (Calverton, MD: UBOS and ORC Macro, 2001), p. 79.
Labels: Cultural Issues, HIV/AIDS, International Health, Public Health, Purple, Women's Health
posted by NJD @ 10:48 AM
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