The Philippines, Dr. Flavier, and the International Use of "ABC"

AIDS was first reported in the Philippines in 1984 and the country drafted its first Medium-Term Plan in response to the epidemic in 1988. In the early 1990s, when HIV was becoming a topic of discussion around the world, the tension about issues of sexuality that had developed between the Philippines Department of Health (DOH) and the Catholic Church continued to grow. President Fidel Ramos had recognized the importance of slowing population growth as critical to economic development. Similarly, the burgeoning HIV epidemic also represented a threat to national development that also needed to be addressed in the public domain. However, in the early 1990s, Secretary of Health Dr. Juan Flavier, a Catholic physician accustomed to dealing with Church leaders on similar matters related to the DOH family planning program, undertook a nationwide, high-profile campaign. Its goals were to increase awareness of HIV/AIDS, as well as promote HIV prevention behaviors through public discussion of condom use (Flavier, 1998).

The DOH proclaimed December 1992 “National AIDS Awareness Month,” and implemented a range of AIDS education and condom distribution activities. In preparation for a presidential trip to Thailand that month, Flavier gave members of the media condoms, alluding to the high HIV prevalence in Thailand at that time (Larraga, 1993). This action triggered polarized responses. On one hand, the President and cabinet fully supported what Flavier had done to raise media awareness. On the other, some senators claimed he was promoting sexual immorality and called for his resignation. Flavier won that debate, and afterward, money was allocated by the Philippines Congress for HIV prevention programs.

Courtesy of JHU/CCP.

In his dealings with the Church, Flavier was always careful to use scientific evidence as the basis for programs in order to avoid being pulled into debates of morality. In his autobiography, Flavier describes the strategy he used to promote HIV prevention. Believing that there were nearly 100,000 cases of HIV in the Philippines, Flavier said that “AIDS is avoidable, and it is absolutely crucial that steps be taken to avoid it.” The ABC approach he articulated (image 2) quickly became known worldwide:

Image 2: DKT materials promoting ABC in the Philippines. No date. Courtesy of JHU/CCP.

A­­ Abstain from sex;
B Be faithful if you cannot abstain. That is, keep to one sexual partner, because research tells us that people with multiple partners are a high risk group for HIV infection; and
C Be careful and use a Condom if you cannot be faithful.

Juan Flavier used the media and public speaking opportunities to spread messages about HIV prevention. Dr. Flavier frequently used the phrase “ABC” when making international presentations, including at International AIDS Conferences, meetings of health ministers, and at the 1994 International Conference on Population and Development, which helped link the idea of “ABC” with HIV prevention according to Nancy Williamson, Vice President at FHI (Williamson, 2004).

He “spoke frequently to the mass media, wrote a weekly column in a leading newspaper, was invited to give numerous speeches, and actually distributed condoms from his office in the Department of Health. In his view, ignorance was the biggest barrier to AIDS prevention in the Philippines” (Piotrow, 2003). During one year of his tenure as Secretary of Health—1992–1993—AIDS awareness in the Philippines increased from 12 percent to 86 percent of the population (WHO/GPA, 1993). At the commencement ceremony of the Philippines Military Academy, Flavier repeated his message of prevention to the cadets: “If you cannot be good, be faithful…If you cannot be faithful, then use a condom…And if you do not want condoms, then take a cold shower!” (Anonymous, 1993: 8). With such a direct approach, Flavier made it clear that the military—along with everyone else—has to take responsibility for avoiding HIV.

The Johns Hopkins University Center for Communication Programs (CCP) has also been involved in behavior change communication campaigns, initially for family planning and more recently for HIV/AIDS. Johns Hopkins CCP provided technical advice in the Philippines in the 1980s, and is likely to have contributed to disseminating the term “ABC” though its staff. Patrick Coleman, Senior Resident Advisor for CCP in the Philippines from 1990 to 1996 writes, “Our institutional relationship with Dr. Flavier undoubtedly led to our staff not only being exposed to the ABCs…I have no doubt they talked about them both within our Center and with our partner organizations throughout the world, [but] I cannot quantify how much we contributed” (Coleman, 2004). In fact, it is likely that CCP made major contributions to the spread of the term “ABC” as they have applied it in a number of countries throughout the world, including Uganda.