ABC prevention successes claimed in Nigeria, Kenya

Some PEPFAR funded ABC prevention projects are having an effect on behaviour according to presentations at the PEPFAR’s 2006 Implementers meeting, with reports of delayed sexual debut in Nigeria and reduction in the number of sex partners in East Africa. Although it is too soon to assess the impact of these interventions on HIV transmission, data were presented from other countries, in particular Kenya, demonstrating that these behavioural changes do correlate with lower HIV prevalence rates.

One of the criticisms of PEPFAR’s ABC prevention platform has been that it is quite difficult to get people to change their sexual behaviours, and yet, a growing body of evidence suggest that people do adopt (or at least report adopting) practices to reduce their risk of infection — even abstinence.

One example comes from the Zip Up campaign, a mass media abstinence project in Nigeria. Zacch Akinyemi of the Society for Family Health reported on a survey evaluating the impact of the intervention, which is aimed at promoting the delay of sexual debut among young people between the ages of 15 and 19 years.

Before the campaign, research suggested that even though most youth aged 15 to 19 reported that they had never had sex, most of them thought that the majority of their peers were engaging in sex. “The creative challenge,” said Akinyemi “was to make abstinence the perceived norm among the youth.”

The campaign was developed by the National Action Committee of AIDS and the Society for Family Health/PSI working with both Christian and Muslim faith based organisations (FBOs). The slogan Zip Up was chosen because suggested abstaining from sex (by the act of zipping up) and because it was felt to have a modern and streetwise feel.

The campaign started in 2004 with TV ads, radio spots and billboards reading supported by sensitisation seminars held by FBOs throughout Nigeria. Since then there have been two other waves of the campaign, which have included caps, T-shirts, posters and banners. In addition, the campaign produced cards for men’s wallets or women’s purses with questions and answers to help them negotiate not having sex.

Some examples?

Q: Why won’t you have sex if you love me?

A: My love’s based on respect, not sex.

Q: I promise there’ll be no pregnancy.

A: Keep your empty promises. I’m staying zipped cos it makes me feel hip!

Whether these answers are as ‘hip’ or streetwise as ZIP UP’s designers would like, the project seems to be having an impact. 2,145 respondents in 2003 and 2,383 respondents in 2005 were surveyed to assess the impact of the intervention. In 2005, 83% of the male respondents claimed that they had never had sex, up from 76.9% in 2003 (p=0.0001). In women, 80.1% respondents reported that they had never had sex, up from 73% in 2003, though this effect did not reach statistical significance. Overall, there was a increase in the median age of first sex for women from 16.8 years in 2003 to 17.6 in 2005. Furthermore, the youth who were exposed to Zip Up were more likely to report not having sex.

Other examples of ABC interventions reporting results at the conference included a reduction in the number of sexual partners and other risky behaviours among long distant truck drivers in East Africa and young men in Brazil. Many of the other PEPFAR interventions discussed at the conference are still in fairly early stages of development — which could spell trouble for meeting the PEPFAR target of seven million HIV infections averted by 2010.

Perhaps PEPFAR will utilise data on reductions in prevalence that are being reported in several countries where ABC has been in practice for years.

According to Dr Dorothy Mbori-Ngacha of the CDC in Kenya, “most HIV prevention programmes in sub-Saharan Africa have adopted the ABC approach as a strategy for encouraging behaviour change. These programmes specifically include basic information about HIV, personal risk assessment, coupled with risk reduction counselling and skills building; and the introduction of [prevention to] specific risk categories. [ABC] focuses on the promotion of abstinence and delayed sexual activity for young people who are not sexually active, faithfulness to one HIV-negative partner for those who are sexually active and correct and consistent condom use in all other sexual encounters.”

“[According to] evidence from several countries, this approach is correlated with a reduction in the prevalence of high risk sexual behaviour...” she said, “and there is now evidence from population-based surveillance surveys that these behavioural indicators have been associated with a decline in HIV prevalence in a number of countries.”

Indeed the UN 2006 Global Report on HIV/AIDS reported some of these changes, although in some of the cases, the declines were just in urban areas. However, some of the other declines were the result of improved surveillance — and, in general, the stabilisation in HIV prevalence still tended to be at alarmingly high levels.

But some countries reported more than 25% reduction in HIV prevalence. One of these was Zimbabwe. However, Zimbabwe may prove to a rather unsteady foundation upon which to base the case for ABC, because of the high mortality, political and economic turmoil and emigration from that country (see related article).

Perhap more convincing evidence that the ABC prevention efforts could be having an impact comes from Dr. Mbori-Ngacha’s home country.

Data from the Kenyan 1998 and 2003 Demographic Health Surveys, show clear reductions in :

• the proportion of young women and men between aged 15-24 who have ever had sex,
• the percentage of 15-49 years old adults who have multiple partners, and
• an increase in condom use during the last high-risk sexual encounter among sexually active adults (see graph below).

“In addition, a behavioural survey conducted in Kenya during this period also indicates an increase in the age of first sex,” said Dr. Mbori-Ngacha. “that was most marked in young women where the age of first sex increased by one year from 16 to 17 years (see graph below). This behaviour survey also reported high rates of both primary and secondary abstinence.”

In other words, even youth who had previously been sexually active were now reporting abstaining from sex.

These indicators of behaviour change have been correlated with a decrease in HIV prevalence in Kenya. Data from the demographic survey and sentinel surveillance in antenatal women demonstrate that the national prevalence has fallen from a high of around 10% in 1997 to 6-7% in 2003 and the trends are similar in both urban and rural settings (see graph below).

“We’ve been trying to get the Kenyan data published in an editorial page,” said Dr. Mark Dybul, acting US Global AIDS Coordinator in a press conference during the conference. “But no one seems to want to publish the successes of ABC.”

He was quick to point out, however, that these successes in Kenya and possibly other countries can not be claimed by PEPFAR. “The success is not ours, the success is the people of Africa’s and of long-standing programmes that we are now privileged to support... and commensurate with that decline of prevalence is a remarkable change in behaviour.

We’re seeing great success, and where we’ve seen success we need to look at what’s been done and replicate it,” he concluded.