Remarks at the Center for Strategic and International Studies (CSIS) ABC Guidance RoundtableDr. Mark Dybul, Deputy U.S. Global Aids Coordinator
December 15, 2005
The slides that Dr. Mark Dybul presented at this roundtable discussion are available online.
DR. MARK DYBUL: Thank you very much, Steve, Phil, and Jen, and thank you all for coming here. We greatly appreciate the opportunity Center for Strategic and International Studies (CSIS) has given us to have a dialogue, and we appreciate the relationship with Center for Strategic and International Studies (CSIS) in continuing dialogues on many issues, this being one of them. We really are open to discussion on many things, including prevention. It’s an evolving field, data changes regularly, experience changes regularly, and we all need to stay on top of it and have discussion. What we’d like to do is have an open, fair dialogue and that’s what we hope to have today, and continuing forward—that many people have used. Nobody has the right answers, particularly in a difficult area like this, and it’s helpful to discuss them and to come up with the best way forward; especially when there’s an absence of clear data, which unfortunately we have in many areas of HIV/AIDS. So, we greatly appreciate the opportunity, and we thank Center for Strategic and International Studies (CSIS) once again, and Jen also with the Kaiser Foundation, for the opportunity to spend some time with you all and to hear your thoughts. As we talk about the ABC guidance of the U.S. Government, we think it’s important to talk about how we got to the U.S. guidance. So if we could just talk about some data, and I think it’s important to look at some recent data, because they’ve just come out, and some people aren’t familiar with them, particularly in Kenya and a couple of other places that were presented a couple weeks ago with The Joint United Nations Programme on HIV/AIDS (UNAIDS) document.
Kenya has seen really a remarkable effect from 1998, when they’ve had a reduction in the black-line there, and the national prevalence from about ten percent to seven percent, with decreases in urban and rural areas. So it’s occurring across the board, in about the same pattern, which is remarkably encouraging. This is not an artifact of, “Did they shift from A and C data to more general data, so there wasn’t really a change in prevalence?” it was just how we measured it. As you can see from these data, there has been a true decline in the A and C data as well. So that going from a peak of around thirteen percent in 2000 down to a peak of around… just above seven percent in the A and C setting. So, the decrease in national prevalence isn’t an artifact of shifting from A and C data, which tend to be higher than many areas; in fact we’re seeing the same thing in the A and C data as well. I should point out that these slides come from the permanent secretary of the Minister of Health from Kenya who came to our office, and has asked us to use these slides whenever we want to. These are their data and their putting together of what they’re seeing. They’ve done an interesting mathematical model—and this is one of the most interesting, exciting things that I’ve seen in a long time. Based on what they saw in the prevalence and some data we’ll run through, they modeled what’s happening in terms of new infections—not just prevalence—and the death rate to get at, “Why is the prevalence changing?” So this is a model—they readily admit they need to work on it, but this is their current model. So you can see a remarkable thing—one thing is a dramatic decline in new infections and also an increase in the death rate, accounting for that change in prevalence—it was both things. But remarkably, for those of you familiar with public health, what this says that there were more deaths than new infections—that means the infection rate has turned—that means that the epidemic has turned. That’s the definition of basically a control of an epidemic. So these [data] are really exciting. Again it’s a mathematical model that’s being worked out.
So why was this change? What happened in the country? And, of course, as all of you know, with demographic health surveys, a bit you’re reading tea leaves—you’re looking at results, and trying to figure out what happened; but this is how the Kenyans put it together. They—Kenya—has a formal national strategy of ABC, which they have been implementing before PEPFAR, and so they’ve looked at in their demographic survey what mattered. And as you can see under the AB’s, both among young men and young women, there’s been a significant decrease in those who have had sexual activity in the age fifteen to twenty-four timeframe; a significant decrease in multiple partners among men, going from thirty to seventeen percent; in condoms, a clear increase in condom-use among females, age fifteen to forty-nine. Not much a change among the men, but a significant change among the women. So it was from these data they put together, that it was ABC that led to the change in their epidemic.
Some backup data, in terms of abstinence: the increase of first sexual activity increased by about a year overall, from about 16.1 to 17.1, if you look at the averages. So an increase of about a year in the age of onset of first sexual activity.
If you look at abstinence—and these are pretty dramatic—you know, there’s been a lot about, “Is secondary abstinence ever possible?” These are the first data I am familiar with that show clearly that secondary abstinence works. If you look at people who have ever been sexually active—had sex in the last year—there’s been a dramatic decrease. And so people who had been sexually active, it appears, had become non-sexually active over the last year. So secondary abstinence seems to have contributed to their controlling of the epidemic.
As we mentioned, a significant decrease in people with multiple sexual partners, most pronounced—this is looking at men—twenty to twenty-four was the most dramatic, but overall they saw a decrease in the number of partners.
They also saw an increase in condom use among young women—and you saw the data already—that there was an increase in condom use from sixteen to twenty-four percent—so, remarkable increase—leading to their conclusions.
I think everyone’s familiar that…it’s not easy over a lifetime to do A, B, or C—that these are very difficult things. You need to have correct and consistent use of condoms and you need to abstain and be faithful on a very regular basis. These are data that just looked at condom use overall, and of course you can see to the left that, correct and consistent condom-use generally decreases infection between eighty to ninety percent. These are data at eighty percent, but there are other studies that show ninety percent. But, it has to be correct and consistent use. So if you just look all the way to the left it’s a seventy-nine percent reduction. When you use consistent-use there’s a 4.4 percent infection rate; irregular use- there’s a 16.5; but seventy-nine percent when you don’t use condoms at all. So you have to use them consistently. Ward Kates reported these data at the Brazil meeting, looking to see over a ten-year period what happens with condom use—and you could probably do this with abstinence and faithfulness as well—it’s just a little more difficult to do. And as you can see, with male condom use over a ten-year period, if you’re doing perfect-use, your infection rate is very low. But realistic-use means that there is only about a thirty percent effect over a ten-year period. So it basically emphasizes that you need to do A, B, and C on a regular basis, and that that’s not easy—behavior change is difficult.
One thing that we’re all focusing on now is that condom use among regular partners is very low, and that as we’re moving forward in addressing the epidemic, this may be our most important target. So discordant couples or other couples that are in regular relationships have very low use of condoms, and so we need to target use in this new population, and it is one of the things we are working on.
We’ve been talking about Kenya mostly, and the data we’ve seen from Kenya, which are very dramatic and for which we have a lot of data. Joint United Nations Programme on HIV/AIDS (UNAIDS) also reported that prevalence among pregnant women declined in Zimbabwe from twenty-six percent to twenty-one percent over a two-year period—pretty dramatic. And the report attributed the decline to condom use among casual partners and also a reduction in the number of sexual partners. So again, the BC message was very important. And the conclusion from Peter Piot was that Kenya and Zimbabwe, though the declines in HIV rates have been due to increases in changes in behavior, including increasing use of condoms, delaying the first time they have sexual intercourse, and people having fewer sexual partners. So ABC—again emphasizing that you need all three components, and this is universally pretty much agreed upon now—and the data are becoming more and more clear. There are data from Ethiopia, Zambia, South Africa, Haiti, Zimbabwe, and Tanzania now that demonstrate ABC behavior change effectiveness, and that’s where the data are moving all of us.
So that’s kind of a background into how we got into ABC from a data standpoint, or where we are now from currently available data. So let’s talk a little bit about how that’s fit into the Emergency Plan.
Our overall approach is based upon what we just talked about; evidence based in public health. And the evidence base for ABC we believe is substantial and very strong—as strong as you can get in behavior—which is of course much different than other parts of science.
I think the public health approach is something we want to emphasize a lot because it’s also a sense of personal responsibility. The ABC data are very strong, and it’s also common sense; the one hundred percent effective ways to avoid HIV are to abstain from exposures, or to be faithful to an HIV-negative partner. It’s very important that the fidelity is between HIV-negative people, or an HIV-positive and negative person who use protection, or use condoms. Condoms are effective as well, but they’re not as effective, and they need to be used correctly and consistently. Our fundamental belief is that people deserve that information—that it’s our responsibility as public health officials to provide people with the information that will most reduce their risk and allow them to make choices. Should they choose to engage in riskier activity, they ought to be provided with a condom, but people can’t make decisions if they don’t have the data. And so we have the responsibility to provide them with the information. In a similar way, we don’t just assume people will smoke; we tell them the risk of smoking and try to encourage them to practice the most safe activity. But if they choose to engage in the risky activity, at least they know the risk and made a personal choice.
Finally, we believe it’s essential that we support national strategies. It’s the national strategy and formal national policy in South Africa, Kenya, Uganda, Ethiopia, and multiple other countries to do an ABC approach, and we think we have a responsibility to support those national strategies.
The U.S. Government did not begin ABC with PEPFAR. In 2002, United States Agency for International Development (USAID) issued a guidance, which was directed towards ABC, based on the data that were available then. And in 2003, MEASURE Evaluation also did a further analysis. So this ABC data has been building for years, beginning in Uganda. But they’re building further; and the U.S. Government policies go back to before PEPFAR, but are now fully part of it, continuing the U.S. government strategy. And I thank United States Agency for International Development (USAID), the other staff from OGAC, and our other colleagues from the U.S. Government, who helped put together these slides and helped create the policy.
As everyone knows, ABC needs to be a balanced approach, and it needs to be targeted towards people in their own countries and have messages that are consistent with cultural activities and cultural sensitivity, and that it’s different from country to country but that it needs to be balanced.
We issued in January 2005 our formal PEPFAR guidance on ABC, building on the availability of data, and also building on previous guidance. Just to run through that, because some of this is our responsibility, and we have not done a great job of communicating, and we need to do a better job. And so we very much welcome and thank all of you for joining us, for the opportunity to do this and to listen to everybody’s thoughts on this. It is open; guidance can change and evolve, so we need to have a constant discussion.
The guidance is really structured to define the ABC approach, implementation of the ABC approach, and then some conclusions and also some guidance on the appropriate mix of ABC interventions, because it is different from country to country, and it is specific to country to country. In terms of the ABC approach, the guidance mentions that it needs to be a balanced approach—that we can’t be heavily weighted in one direction or another, that we need a balanced approach in a generalized epidemic. And it needs to be targeted to the specific needs and circumstance of different populations. And that we need to build human resources necessary to implement all of these. As in treatment and care, we need to build the infrastructure necessary for a balanced ABC approach.
It is not a simple approach, so I am not going to go through all of these… this is the formal guidance, so we wanted to provide it to people, but abstinence is one approach. There are many things that need to be done to have effective abstinence programs; many things that need to be done to have effective faithfulness programs. These aren’t easy approaches, and I would say as a physician that behavior change is substantially more difficult than treatment. You have to build an infrastructure for treatment, but we know what to do—it’s pretty basic—and we have the science. Behavior change is a remarkably difficult thing that requires a lot more activity, and so these are complicated areas.
As you can see, there’s not a lot of difference between the complexity of abstinence, faithfulness, or condom use—these are all complicated areas, and need complicated strategies and approaches.
I think one of the things that has caused most concern is what do we do in terms of abstinence; and one of the phrases I would like to get off the table is “abstinence only.” “Abstinence only” is for kids; it’s for young children who should receive nothing more than “abstinence only” education. Once you get past that age, messages are more nuanced, and ABC is what you need to talk about, but again within the confines of cultural sensitivity and age importance. So one of the things people need to stop doing is saying that our congressional directives and our approach is “abstinence only” because it’s not; it’s on ABC, with abstinence directed only at the appropriate age, where that is all they should get. And to be honest, people can disagree here. I’ve rarely come across someone who believes you should do anything more than abstinence education for a ten-year-old. And it’s kind of interesting to talk to people who have a policy position, and you ask them what they would do with their own daughter or their own son and they say, “Well of course, I would just tell them to abstain.” It’s a common sense approach, and I think ninety percent of people would agree on that.
Once you get past fourteen, the guidance directs an ABC message that is appropriate, as people enter a different phase of their lives, with heavy emphasis on AB, but also knowledge about C as well. Another difference that we have in schools and out of schools—in schools, we can provide education on ABC, but we will not provide condoms in schools. If people decide to engage in risky activity, they are to be referred out of the schools. So above fourteen, we support the education of condoms, but not the distribution of condoms. Outside of schools for youth we do support the distribution of condoms; so it’s a complicated, nuanced approach, and I encourage you to read the guidance to look at it to see what we actually do support and don’t support.
There are priority interventions for behavior change as well, and I’m not going to spend a lot of time on this either. I just want to again emphasize that there are important issues around even education for youth; that you don’t just target youth in schools, that you have to get to the parents, get to the leaders in the community. That this is another approach to get another children and youth behavior change, and you don’t just emphasize school or out of school programs, that you need into the homes and into the thought leaders in the community as well, and this just emphasizes that again.
But I want to emphasize something here—because this is another area that there seems to be confusion in, and we need to do a better job of describing. We talk about two aspects of condom promotion and behavior change: high-risk activity and high-risk groups. It’s important to remember that what we’re dealing with in general in Africa are generalized epidemics, not concentrated epidemics; and in generalized epidemics, you’re talking about activity in the generalized population. You know, in parts of Botswana where seventy-five percent of women are infected, whole countries where adult populations thirty to forty percent are infected—these are generalized epidemics. So it’s high-risk activity within a generalized epidemic, and then there are high-risk groups. In concentrated epidemics, of course, high-risk groups are identifiable and you can target them much more easily and effectively. In a generalized epidemic, you have high-risk activity, and then you have a subset of high-risk populations. So we talk about both—the need to address both in a generalized epidemic. We talk about high-risk activity—and this gets to educating people about what their risks are—abstinence and faithfulness to an HIV-negative person being the most, one hundred percent effective way to avoid infection. But if you’re going to engage in risky activity, in the setting of a generalized epidemic, condoms need to be available for anyone who engages in high-risk activity, including young adults and others. But also, even within generalized epidemics you still have concentrated epidemics among prostitutes and their clients, among substance abusers… I actually have never approved of men who have sex with men as a high-risk group, like heterosexuals who engage in high-risk activity are not. And we know from Thailand, Cambodia, the Dominican Republic and other places that if you target high-risk populations you can have an effective approach. But it’s not enough in a generalized epidemic to just concentrate on those populations; you have to deal people of high-risk activity as well. And I think there’s been a lot of confusion what our policy and practice is here, and our policy and practice is you still target high-risk populations, but you also involve everyone who engages in high-risk activity in a generalized epidemic. If there is a better way to describe this and to communicate this, please help us with it. It’s a complicated area, we know, and we’re trying to describe things as best we can.
So that’s our policy—that’s actually what we guide people to do: full ABC, with A really being directed to young kids, [and] as you advance older it’s AB and ABC, with a difference for in school and out of school and targeting parents, looking at high-risk activity and high-risk groups. How does that break down into what we actually do?
If we look here at budget allocations, I think it’s important to note something we sent up to Congress in June of 2004. As many of you know—and we’ll talk about it in a second—there’s a congressional directive for thirty-three percent of all prevention for abstinence until marriage programs. We have formally defined for congress that abstinence until marriage basically means A and B. And the reason for that is—except young children—you would never segregate an A-message from a B-message—that you have to give them together, once you get out of young kids. So we have formally defined abstinence until marriage as abstinence and fidelity, abstinence and partner-reduction, abstinence and faithfulness until marriage—that that’s all part of the same message. So that thirty-three percent really is covering AB. And that was sent up to Congress in June of 2004.
As Phil mentioned—and as I just mentioned—there is a congressional directive that in this year, 2006, being a full directive, you will achieve thirty-three percent—not less than thirty-three percent of the amount pursuant to the act, shall be expended for abstinence-until-marriage programs. We have just defined for you what abstinence until marriage is, but this is a formal directive that must be met this year.
In order to guide countries to achieve the congressional directive, we issued additional guidance in August on how you could get to the congressional directive. And here it’s important to note—which we’ll talk about in a moment—that prevention is not just sexual transmission; prevention is prevention of mother to child transmission and safe blood and safe medical injections. And so that accounts for some of our budget as well. In fact, as we’ll see in a moment, about half of our budget expenditures are in prevention of mother to child transmission and safe blood and safe medical injections. The reason for that is that those are much more expensive activities. It’s not because fifty percent of infections occur in those activities; it’s because those are much more expensive interventions than sexual transmission. So fifty percent of your budget is for non-sexual transmission. Within the fifty percent that is sexual transmission, sixty-six percent devoted to abstinence, or AB, gets you to thirty-three percent overall. So fifty percent of sixty-six percent is the same as thirty-three percent of one hundred percent. Nothing has changed. It’s the same percent; it’s just guidance and how to achieve the congressional objectives.
I would point out that we were very clear with people, and that the guidance itself states very specifically, that if this percent is not appropriate for your country, tell us why, and submit an operational plan that doesn’t utilize it. Using the specific example of Vietnam, where we would not expect Vietnam to follow this kind of guidance, or a concentrated type of epidemic to follow this type of guidance.
If you look at the budget from 2005, you’ll see this breakdown: sixty-six percent went for treatment, about twenty-six percent went for care, and then for prevention, which was twenty-eight percent of total prevention, seven percent went for AB activities, seven percent went for condoms and related activities, three percent for injection safety, five percent for blood safety, and six percent for mother to child transmission. So it basically shows that fifty percent went for these medical interventions, and fifty percent for sexual transmission. And within that, last year we were at about fifty-six percent AB and forty-four percent condom-promotion and related activities. We need to get to sixty-six percent to meet the directive and also to have some good programs.
I just want to point out something else that I’ve seen, and we just want to make it abundantly clear. There are actually comments that we are reducing the number of condoms that we provide around the world—absolutely untrue. But what we want is a balanced approach. The condoms we provide are now within the context of ABC—they are not condom-only programs; they are ABC programs. So we have significantly increased our AB program, and we’ve also increased our C program to have that balance we’ve talked about. So from 2001, the last budget of the previous administration, the U.S. Government provided around 350 million condoms to the world. In 2005, we provided around 570 million condoms to the world—clearly not an aversion to condoms; an aversion to condoms that aren’t prevented in an ABC context.
If one looks in the focus countries, in 2001, the U.S. Government provided around 115 million condoms, in 2005, 241 million condoms—more than double. And if you look country by country, every country stayed approximately the same, or went up significantly. The one exception is South Africa, where in 2001, there were 21 million condoms, and in 2005 there were zero. Well, what happened there?
Well, in the year 2000 it was zero too. In 2001, the government needed a short-term stop gap measure so we supported some condom purchase. In South Africa, the government pays for all the condoms; so in virtually all years our number is zero because the South African government covers it itself. So this is not an opposed-to-condoms program. This is a condoms-within-a-fully-ABC program to combat HIV/AIDS on the continent of Africa, consistent within the national strategies of those countries, which emphasize A, B, and C—cause you have to have the AB component. And you have to emphasize the AB component as well as condoms if people choose to engage in risky activity, or you’re not going to combat the epidemic.
I want to touch briefly on some large-scale issues, which we talk about as well. ABC is by far the most effective approach to tackle HIV/AIDS in the generalized epidemic, particularly in Africa. And the data are clear; but there are circumstances where ABC is difficult. In gender issues, it’s difficult for women to negotiate A, B, or C, and so we need to deal with gender as a broad-scale issue if we’re going to tackle HIV effectively. There are many data, which many of you are familiar with, that some of the highest risk groups are young girls. And that the issue of cross-generational sex, or older men having sex with young girls, is a fundamental driver of the epidemic in certain areas. And so we need to address these issues if we’re going to fully combat HIV, if we’re going to allow ABC to work, fully. It works extremely well, but to have it have the greatest impact, we need to address gender issues. Coercive sex, as many of you know, is a significant risk factor in many places. So gender is a priority for us if we’re going to tackle HIV/AIDS and prevent HIV/AIDS.
So we’ve established a technical—well I don’t want to start this way—I hate it when the government says, “Well, the way we’re dealing with an issue is by developing a working group and having meetings.” But we are in fact developing a working group and having meetings—as a starting point, but that’s a starting point. What we’re doing now is gender consultation, which will occur early in this year, which will help us design programs so that we can, in 2006 and 2007—and we’ve set aside money for this—implement programs based on that consultation that will address gender and evaluate the most effective programs so that we can spread them out. So there will be a significant push in 2006 to do programmatic interventions that we can then evaluate.
There’s a significant focus on the 2006 Country Operational Plans (COPs) on men and B, which we think is very important to address gender issues, fidelity issues, and men, so that they don’t do bad behavior, and continuing our support for microbicide research, the availability of female condoms, sharing of best practices, and significant rape prevention and post exposure prophylaxis (PEP) programs. We have some great programs focused on gender-based violence in Zambia and Kenya, working with men to change norms in South Africa, trying to decrease cross-generational sex in Uganda, and women’s access to services. Women’s access to services is critical and, as many of you know, fifty-six percent of those who received antiretroviral therapy in 2004 were women.
Alcohol and HIV is a significant issue and we’re beginning to address it, and this is one of those cross-cutting things we need to deal with. We had an interagency meeting in August of 2005 that’s leading to best practices and evidence base that will lead to more alcohol programs.
So that’s all I wanted to talk about. I just want to conclude with something that President Bush said on World AIDS Day. “We’re working with our partners to expand prevention, emphasize abstinence, being faithful in marriage, and using condoms correctly. This strategy, pioneered by Africans, has proven its effectiveness, and America stands behind the ABC approach to prevention.” We continue to stand by it, we are trying to enforce it, and we look forward to working with you to see how we can best do it and to address information as it becomes available. So, with that, I’d like to open it up for conversation.