An Update on the ABC Approach to HIV Prevention

An Update on the ABC Approach to HIV Prevention Ted Green & Allison Herling AIDS Prevention Research Project Harvard University CCIH Annual Conference May 28, 2007

The ABC book • New evidence constantly being added • HIV declines and evidence of behavior change in urban Malawi and Cote d’Ivoire • Recently added question: Does marriage place women at a higher risk of HIV?

Policy update • Continuing confusion over what is meant by “ABC,” types of epidemics in which ABC is an appropriate strategy • A recent report on PEPFAR (by Institute of Medicine) seemed to criticize ABC • Strong possibility that current PEPFAR AB earmarks will be repealed

Marriage as a risk factor for HIV? • The June 2007 issue of the American Journal of Public Health published the findings of three studies. According to the press release from Columbia University, "The findings, indicating that globally, prevention programs that take a 'just say no' approach and encourage men to be monogamous are unlikely to be effective, underline the need for programs that make extramarital sex safer, rather than—unrealistically—trying to eradicate it"

Marriage may place younger women at greater risk • Some studies have shown that married 15-19 year old women have a higher HIV risk than unmarried sexually active 15-19 year old women (Clark, 2004) • Kisumu, Kenya: 48% higher risk • Ndola, Zambia: 65% higher risk • Reason: more frequent sexual contact, more likely to be unprotected (less ability to negotiate condom use), husbands are often much older

But marriage is generally protective • Bongaarts (2006 and 2007) found in a 33-country study that marriage is protective: • Risk for HIV infection per year of exposure among sexually active women is higher before than after first marriage (individual level data in Ghana and Kenya) • High average age at marriage leads to a long period of pre-marital sexual activity during which partner changes are relatively common, resulting in higher risk (e.g. in countries of southern Africa this “gap” is 7 years)

But things are complicated… • Two sets of risk factors for married and unmarried women that are partially offsetting. Unmarried women have a net higher risk (per year) • More infections occur within marriage than before marriage, but incidence is higher for unmarried women. • Married women have older partners than unmarried women (risk factor).

Main point (the issue is child marriage!) • “The key issue is timing of first marriage in relation to timing of first sex. If a young girl marries before the age at which she would otherwise become sexually active (around 18 in much of SSA), then she is exposed to an elevated risk of infection that would not occur in the absence of early marriage.”

Other data on marriage/HIV risk Data from Nairobi Cross-Sectional Slum Survey, 2000: • Co-habitating women nearly 10X as likely to have multiple partners as married women, even adjusting for other factors of education, ethnic group, religion, age. • Odds Ratio of reporting >1 partner in past year:Married, co-residing: 1.00Married, not co-residing: 1.64Not married, co-resides: 9.50 Widowed: 15.56 Divorced or separated: 31.33Has co-wives: 4.36 Cohabitation, marriage, and ‘sexual monogamy’ in Nairobi’s slums.” (Hattori MK, Nii-Amoo Dodoo F. Social Science & Medicine 64 (2007), 1067-1078.)

Data on marriage/HIV risk (cont) • Data from Rakai showed that men were twice as likely as women to bring HIV into the marriage • Women with HIV-positive spouses had 105.8 times the HIV incidence of women with HIV-negative spouses • Men’s infidelity places women at risk

Bottom line • Women/girls who are married too young are put at risk • Women who are faithful can be placed at risk through husband’s infidelity • But women are still far better off married than widowed, separated, or divorced, all of which drastically increase HIV risk (DHS data consistently shows this)

An Update on the ABC Approach to HIV Prevention