Monday, June 26, 2006

Letter to editor of The Lancet defends ABC asevidence-based, not PEPFAR driven


This message is a defense of the ABC approach to preventing the sexual transmission of HIV. This correspondence responds to a recent editorial in The Lancet commenting on the US Government's PEPFAR priorities which argued that "what is really needed is a complete reversal of policy. Rigorous implementation of the “C” part of ABC is crucial if PEPFAR is to reach its target of preventing 7 million new infections by 2010." The editorial writers concluded by urging the U.S. Congress to "ask whether the $600 million ear-marked for prevention programmes based on abstinence and faithfulness is an effective use of US tax-payers' money. Many more lives will be saved if condom use is heavily promoted alongside messages to abstain and be faithful." Here is the letter to the editor, accessible online at

The Lancet 2006; 367:1978-1979. DOI:10.1016/S0140-6736(06)68879-X

PEPFAR and HIV prevention in Africa

Richard Kamwi a, Thomas Kenyon b, and Gary Newton c

We offer a country perspective on your Editorial (April 15, p 1213)1 about the President's Emergency Plan for AIDS Relief (PEPFAR). Because of an unprecedented influx of funds in early 2004, African countries, US government agencies, and partners have indeed been mounting an accelerated emergency response to the HIV/AIDS crisis based on local strategies and priorities. This response includes support for a balanced ABC (abstention, be faithful, use a condom) approach,2 which was originally and independently adopted by African countries in the 1990s to prevent sexual transmission—the major source of HIV in Africa. Findings from Uganda, and more recently Kenya and Zimbabwe, show an association between declines in HIV prevalence and behaviour change consistent with the ABC approach.3–5

ABC is therefore evidence based 3–5 and is not driven by PEPFAR but by African countries,2 which is critical for sustainability. We know how to prevent HIV transmission—it is urgent that we mobilise resources to do so in a locally appropriate manner. Condom programmes receive support from numerous partners, making PEPFAR support for a balanced ABC portfolio all the more necessary. Shifting resources to “C” at the expense of “AB”, as called for in your Editorial, could compromise expansion of programmes to empower young people to say no to sex and to empower individuals to restrict their number of sexual partners.

Difficult decisions about funding must continue to be made in partnership with host governments. Many more lives will be saved if we can remain focused on urgently addressing unmet HIV prevention needs, recognising that ABC is currently the most effective way to do that.

We declare that we have no conflict of interest. The views and opinions expressed in this letter do not necessarily reflect those of the governments of Namibia or the USA.

1. The Lancet. HIV prevention policy needs and urgent cure. Lancet 2006; 367: 1213. Full Text PDF (32 KB) CrossRef

2. Halperin DT, Steiner MJ, Cassell MM, et al. The time has come for common ground on preventing sexual transmission of HIV. Lancet 2004; 364: 1913-1915. Full Text PDF (103 KB) CrossRef

3. Kirungi WL, Musinguzi J, Madraa E, et al. Trends in antenatal HIV prevalence in urban Uganda associated with uptake of preventive sexual behaviour. Sex Transm Infect 2006; 82 (suppl 1): i36-i41. CrossRef

4. Cheluget B, Baltazar G, Orege P, Ibrahim M, Marum LH, Stover J. Evidence for population level declines in adult HIV prevalence in Kenya. Sex Transm Infect 2006; 82 (suppl 1): i21-i26. CrossRef

5. Mahomva A, Greby S, Dube S, et al. HIV prevalence and trends from data in Zimbabwe, 1997–2004. Sex Transm Infect 2006; 82 (suppl 1): i42-i47. CrossRef


a. Minister of Health and Social Services, Windhoek, Namibia
b. Global AIDS Program, Centers for Disease Control and Prevention,
Windhoek, Namibia
c. United States Agency for International Development,
Windhoek, Namibia