Was the "ABC" approach responsible for Uganda's decline in HIV?

The much-publicized "ABC" approach to HIV prevention continues to be mired in controversy, partly because of its focus on abstinence-only sex education programs over condom promotion, a focus that pits political and religious conservatives against their liberal counterparts.

Nevertheless, the ABC approach is sometimes credited as being responsible for Uganda's dramatic decline in HIV rates. A provocative debate in PLoS Medicine considers the two sides to the question of whether the ABCs are helpful or harmful in the battle to control the HIV pandemic.

Elaine Murphy and Margaret Green (George Washington University School of Public Health and Health Services) argue that "ABC behaviors were attainable in Uganda" and the promotion of ABC messages was "exceptionally successful." They acknowledge, however, that in some parts of the world women are not empowered to insist on abstinence or fidelity, which leaves them at risk of infection.

Nevertheless, they say, many women in Uganda had little power at the outset of the AIDS epidemic. "Fortunately," say Murphy and Greene, "a 'this could not work here' attitude did not deter Uganda from moving forward to implement its wide-ranging HIV prevention program and adding gender-related elements when it became clear that this strategy was necessary."

In Uganda, they say, policies to advance women's status were part of the ABC strategy. "In the context of Uganda's political leadership, nationwide social mobilization and gender empowerment policies, both women and men benefited and HIV prevalence declined."

Countering Murphy and Greene's viewpoint, Alexandra Mihailovic (University of Toronto) and Peter Olupot-Olupot (Mbale Regional Referral Hospital, Uganda), argue that "by emphasizing abstinence, the ABC approach is political and not evidence-based." Uganda receives funding from the US President's Emergency Plan for Emergency AIDS Relief, which has a major focus on abstinence-driven public health campaigns.

Such campaigns, say Mihailovic and Olupot-Olupot, assume that abstinence will allow young women to focus on going to school, controlling their relationships, and becoming socially empowered. Yet the reality for many young women in Uganda, they say, is that social circumstances drive them into transactional or commercial sex to pay for, among other things, schooling or gaining financial independence from family obligations.

"Encouraging abstinence, while at the same time excluding sexual education and protection against HIV," they say, "puts these girls at great danger of exploitation and ignorance, depriving them of the opportunity to learn the needed tools to approach sexuality in a healthy and informed manner."