GENERALIZED/CONCENTRATED EPIDEMICS
The failure of the major donors has been to promote only risk reduction
interventions. ABC offers risk reduction plus risk avoidance.
A broader approach is better than a narrower one, given the variability
of human behavior and circumstances in which people are found. Do not
perpetuate the risk reduction-only mistake, especially in a generalized
epidemic such as the one found in Uganda.
USAID and PEPFAR wisely adopted an ABC model for generalized epidemics.
Part of the reason for premature consensus against ABC is a failure
to understand the difference between concentrated and generalized HIV
epidemics. Professor David Wilson made this distinction in a recent presentation
to the World Bank:
Epidemics (are) "concentrated" if transmission (occurs)
mostly among vulnerable groups and if protecting vulnerable groups
would protect wider society. Conversely, epidemics (are) "generalized"
if transmission (occurs) mainly outside vulnerable groups and would
continue despite effective vulnerable group interventions.
This is an important distinction. The major AIDS organizations only
endorse condoms, testing, drugs, and sterile needles, the exception being
PEPFAR and USAID since 2003 (but even here there has been minimal change
on the ground or in the field). Most AIDS and reproductive health organizations
only have high-risk groups in mind when designing and implementing prevention
programs. But that is leaving out the majority population
in any country. As
Wilson observes, we can supply as many medical products or services (condoms,
drugs, VCT) as anyone might want, but HIV infections "would continue
despite effective vulnerable group interventions."
Therefore we need one approach for high risk groups, and a different
one for general populations. It does no good to confuse the issue by
insisting that all African women are powerless or are selling
themselves for sex, all African men are polygamous by nature,
and African children start to have sex at age 12. Survey data such as
DHS (Demographic and Health Survey) do not support these characterizations
or stereotypes.
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http://ccih.org/conferences/presentations/2005/uganda-trends.doc
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