This issue was addressed during both plenary talks on prevention.
When communities set expectations about the sexual behaviour of young people,
they must also create an environment where that behaviour is possible, said
David Stanton, a clinical epidemiologist at USAID.
Although the ABC approach is an important strategy, there are a number of
challenges to this approach, said Dr Dorothy Mbori-Ngacha of CDC Kenya.
The reality is that for many women, these strategies are hard to implement,
and fail to offer real options that [fit] into their daily reality.
For example, abstinence is meaningless when women and girls feel they must
resort to sex as a matter of survival, or when sexual activity is coerced.
Likewise, being faithful is an effective strategy, only if both partners are
faithful and none of them is infected. Condoms, though effective, are a male
decision, with women having very little power to negotiate their use due to
their dependency on their male partners.
And finally, most women have limited access to female controlled methods that
will enable them to control their own sexual health. We therefore need to
recognise these limitations and make sure that our prevention programmes use the
ABC approach as a platform to incorporate other prevention strategies.
Barriers to the ABC strategy in Nakuru, Kenya
In a survey of adults and youth conducted by Horizons/Population Counsel and
Family Health International in Nakuru Kenya, a number of barriers to ABC were
There are mixed, conflicting, and inaccurate messages on the ABCs from
community as well as institutions said Naomi Ruttenberg of Horisons,
There was a perceived inability to control sexual behaviour, especially for
men: that simply it wasnt feasible, that biological urges were going to
overcome any sort of self-control and [gender-related] structural factors: the
barriers around gender-based violence and womens lack of power. No matter how
well intended in their resolve [to negotiate safe sexual behaviour], they simply
lack to power in relationships to act on it.
There were some responses about the negative perceived physical effects of
abstinence and being faithful that regular sexual activity with a number of
partners was a natural healthy thing to do and that restraining it was
unhealthy. There were also negative views about condoms and a sense of fatalism
about becoming HIV infected despite adopting safer sexual behaviour.
Ruttenberg noted that the community had conflicting views about those who are
abstinent. One participant said that the community thinks that you are
abnormal, while a male youth said the community regards one as holy and a
Polygamy and multiple sex partners
A couple of talks, including www.aidsmap.com http:>Stantons
highlighted the danger of having multiple sex partners or polygamy which is a
common practice in many sub-Saharan countries. Some US funded efforts are
specifically trying to address this, according to Dr. Mark Dybul, who is the
acting US Global AIDS Coordinator. For example, in Zimbabwe we worked very
close with a church that had for many years endorsed polygamy and we worked with
that church to explain the HIV risk associated with polygamy and multiple
partnerships and in fact as a result of our and many other peoples work with
that church in the last 8 months, they reversed their position and are in fact
teaching now against polygamy.
Likewise, another PEPFAR funded effort appears to be reducing
the number of concurrent partnership among long distance truck drivers in East
The cultural situation in many of our countries is such that parents are not
usually the ones to discuss sex with their child, but programmes in Uganda and
Kenya are challenging that norm, said Dr. Thomas Kenyon of the CDC in Namibia
at the close of the conference.
Indeed, discussions of sex between children and parents is virtually taboo in
some countries and may not entirely be helpful. In Uganda, a programme
called Straight Talk documented the lack of parental comfort discussing
sex and their knowledge around sexual behaviour. For example, 65% of parents did
not want their children to come to them with questions about sex. Worse, they
held sexist notions that could undermine prevention efforts. According to Karusa
Kiragu of the Population Council, 65% of parents agreed with the statement
women should tolerate abuse to keep families together. Many adult men
and women felt men who had multiple partners were more powerful and encouraged
According to Kiragu programmes are urgently needed to help parents
deconstruct these attitudes... and to increase parental confidence discussing
Such a programme is now being piloted in Kenya based on a 2001 needs assessment
among youth in Nyanza province in which, young people highlighted the lack of
communication about sex-related issues between adults and adolescents as an
important obstacle to effective HIV prevention, said Fredrick Onyango of the
CDC in Kenya. Working in Asembo, a rural Nyanza community, the community
embraced the idea of a parent-centred approach to youth HIV prevention.
They selected an intervention called Parents Matter from the US, which
tries to foster better communication around sex between parents and children
between 8 and 12 years of age. This model underwent substantial adaptation,
working closely with the community to be relevant in this cultural context, and
eventually became Families Matter. Although it is too soon to see whether
the intervention has had an impact on HIV transmission or sexual risk taking
among children, there have been statistically significant improved scores in
parent-child communication on sexual matters (in both children and parents).
Parents reported being very positive about Families Matter, said Onyango.
One benefit of involving parents (in particular the men) is that they may begin
to adopt more protective attitudes towards young women in their cultures, in
general, and could potentially reduce the incidence of intergenerational sex,
which both Dr. Mbori-Ngacha and Stanton noted is a major problem for prevention
programmes. For example, quite a few women in South Africa have sex partners
who are five or more years older than themselves and the result of those
partnerships is a much higher prevalence among young men and women who have
sexual partners older than themselves, noted Stanton.
In fact, according to one mathematical model presented at the meeting, ending
this practice would have a dramatic impact on the epidemic. But opinions vary
about how best to do this, whether by empowering young women to avoid casual
sexual partnerships with older men who are part of high risk sexual networks or
by getting older men to stop predating young women.
Empowering the girls or changing the men?
Not everyone was convinced that the latter approach would work, however. Even
the two plenary speakers on prevention had slightly different takes on whether
to focus on empowering girls or getting the men to change.
In order for prevention programmes to be truly effective, they need to address
the special vulnerability of women, according to Dr. Mbori-Ngacha.
Collectively we need to ensure that young women most at risk have access to
information on HIV prevention. In addition, we need to build the self-esteem of
young women and equip them with practical skills such as refusal and negotiation
skills to enable them to take control of their lives and refuse sex until they
are mature enough to engage in safe sex.
But for prevention programmes to be successful we also need to target men,
Stanton directed his attention solely to the men. When young people, mostly
young women, arent able to abstain when they want to, this is probably not
the failure of an abstinence programme. Instead, it is more likely a failure,
and sometimes the complete absence of programmes promoting fidelity, partner
reduction and sexual responsibility among men, said Stanton. I think also
the be faithful message must be given to the men in the community, so that the
younger people can actually achieve the message of A & B.
Programmes targeted towards men are needed to discourage intergenerational sex,
multiple partnerships and to encourage fidelity to their partner, as well as to
use condoms if they do have risky sex. And some evidence provided at the meeting
suggested that male involvement can indeed work, and that behaviour change is
possible over time especially following peer-based interventions.
For example, a study in Brazil investigated whether it would be possible to
encourage young men to treat young women as equals. The study enrolled three
groups with a total of 780 men from low-income communities between the ages of
15-24. One group received group education sessions led by slightly older peers,
another group received the group education combined with a community-based
education behaviour change campaign, and the third group served as a control.
At baseline, about 25% had had symptoms of a sexually transmitted infection
within the previous 3 months, and almost 40% had had multiple sexual partners in
the past month. After a year of follow-up, statistically significant positive
behavioural changes occurred in both intervention groups in attitudes towards
gender norms and equitable relationships, plus the young men were more likely to
use condoms and developed fewer STIs. A trend towards a greater effect was
observed in the combined intervention group.
The consequences of not addressing the sexual coercion of women
Of course, neither approach is mutually exclusive but if men do not change,
then, in some cultures, prevention programmes could inadvertently put the lives
of young women at risk, according to a survey of young people in South Africa.
Sexual coercion and rape were frequently cited as barriers to abstinence for
girls and women, especially by girls, said Tobey Nelson of Horizons and the
International Center for Research on Women. According to Nelson, one girl in a
focus group discussion said: If a girl abstains and boys know that, they then
want to rape that girl because they know that she does not have AIDS. The bad
thing is that they want to kill the girl after the rape.
Kiragu K et al. Preparedness of Ugandan parents to educate their teenage
children on sexual health. The 2006 HIV/AIDS Implementers Meeting of the
Presidents Emergency Plan for AIDS Relief, Durban, South Africa, abstract
102, 2006, abstract 104.
Nelson T et al. Perceptions and confusion surrounding ABC prevention messages
among in-school 11- to 15-year-olds in KwaZulu-Natal, South Africa: The
importance of contextualizing ABC messages. The 2006 HIV/AIDS Implementers
Meeting of the Presidents Emergency Plan for AIDS Relief, Durban, South
Africa, abstract 102, 2006, abstract 122.
Onyango F et a. Families Matter!: Adaptation of an evidence-based intervention
to help parents and guardians become better sex educators for their children in
rural western Kenya. The 2006 HIV/AIDS Implementers Meeting of the Presidents
Emergency Plan for AIDS Relief, Durban, South Africa, abstract 102, 2006,
Pulerwitz J et al. ABC messages for HIV prevention in Kenya. The 2006 HIV/AIDS
Implementers Meeting of the Presidents Emergency Plan for AIDS Relief,
Durban, South Africa, abstract 102, 2006, abstract 129.
Pulerwitz J. Impact of and lessons learned from program promoting equitable
gender norms to reduce young mens HIV risk in Brazil. The 2006 HIV/AIDS
Implementers Meeting of the Presidents Emergency Plan for AIDS Relief,
Durban, South Africa, abstract , 2006