Discussion

Narrowly defining “ABC” as “abstain before marriage, be faithful in marriage and only use condoms as a very last resort,” may falsely lead some people to think that these specific behaviors are all that is needed to stem the spread of HIV/AIDS. A billboard in Botswana, a country with one of the highest rates of HIV in the world, called out to passersby, “It is as simple as…ABC” (Heald, 2002). Yet without a supportive environment, individuals can rarely sustain changes to personal behavior (FHI, 1997: 2).

An important aspect of a supportive environment is that influential people are willing to take a stance in favor of change. The experiences of Uganda, Tanzania, and the Philippines illustrate the roles of such leaders in creating a supportive environment for HIV prevention. In Uganda, during the late 1980s, prevention strategies focused on abstinence and fidelity. Bishop Kawuma of the Anglican Church of Uganda challenged the conventional wisdom and offered a link between B and C when he called for people having sex outside of their marital partnership to use condoms. Around the same time in Tanzania, Father Bernard Joinet, a Catholic priest, was also contemplating ways to reach consensus on HIV prevention strategies. He developed the “Fleet of Hope,” which put the needed prevention behaviors together into one image and urged people to get on one of three prevention boats—abstinence, fidelity or condom use—and to change boats as their circumstances changed. In 1992, long after modes of transmission had been identified and interventions developed and implemented, Philippines Minister of Health Dr. Juan Flavier made famous the phrase “ABC” that is now being used around the world. Finding common ground among stakeholders contributed to creating a more favorable environment for HIV prevention in each of these countries.

Research on HIV prevention has found that comprehensive prevention programs, directed at both the individual and the community, and addressing structural factors—such as laws, policies, and social norms—have the greatest effect (Lamptey and Cates, 2003; Waldo and Coates, 2000). This broader perspective is also reflected in the idea of “ABC+,” meaning that no additional opportunities should be missed to strengthen the skills and empowerment of individuals to practice the three preventive behaviors of abstinence, fidelity/partner reduction and condom use—the ABCs of prevention of sexual transmission of HIV (USAID, 2002: 12).