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The "ABCs" of HIV Prevention: Report of a USAID Technical Meeting On Behavior Change Approaches To Primary Prevention of HIV/AIDS U.S. Agency for "ABC" Experts Technical Meeting International Development Washington, D.C. | September 17, 2002 This document was prepared by the Population, Health and Nutrition Information (PHNI) Project. The PHNI Project is funded by USAID's Bureau for Global Health. The Project is managed by Jorge Scientific Corporation with The Futures Group International and John Snow, Inc. under contract HRN-C-00-00-00004-00. Population, Health and Nutrition Information Project 600 13th Street, NW, Suite 710 Washington, DC 20005 Tel.: (202) 393-9001 Fax: (202) 393-9019 E-mail: firstname.lastname@example.com Contents Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii Panel 1: What's the Data? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Epidemiological Overview, David Wilson, University of Zimbabwe Uganda/DHS Analysis, Rand Stoneburner, Cambridge University UNAIDS Multi-Site Study Analysis, Bertran Auvert, University of Paris UNAIDS Data/Perspectives, Michel Carael, UNAIDS Summary of Panel Presentations and Discussion Panel 2: Data and Programmatic Implications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 FHI and BSS Data and Program Implications, Carol Larivee, FHI/IMPACT Youth Perspective/Data, Bob Magnani, Tulane University School of Public Health and Tropical Medicine USAID-Uganda ABC Experience, Elizabeth Marum, CDC Faith-Based Perspectives, Dorothy Brewster Lee, Christian Connections for International Health Summary of Panel Presentations and Discussion Synopsis of Panel Presentations, Daniel Halperin, USAID . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Break-Out and Report Back Sessions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 What have we learned about the impact of "A" and "B" interventions on HIV incidence and prevalence? What do the existing data tell us? What are the relative advantages and disadvantages of condom interventions targeted at high-risk populations versus those targeted at the general population? How can we effectively implement all three ("A," "B," and "C") interventions to maximize total impact (i.e., how to avoid messages that might negate or contradict one another)? How can we operationalize the promotion of "B" (fidelity and/or partner reduction)? How can we effectively monitor and evaluate ABC behavior change programs? Final Wrap-Up and Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Appendix: Meeting Agenda . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 The "ABCs" of HIV Prevention i ii The "ABCs" of HIV Prevention Introduction On September 17, 2002, the U.S. Agency for International Development (USAID) hosted a technical meeting in Washington, D.C., to consider behavior change approaches to HIV/AIDS prevention, sometimes referred to as the "ABCs" of primary prevention. More than 130 HIV/AIDS and reproductive health experts shared research findings and lessons learned. The participants included representatives and researchers from UNAIDS, the World Health Organization, UNICEF, the United Nations Population Fund, the U.S. Centers for Disease Control and Prevention, the Bill & Melinda Gates Foundation, USAID cooperating agencies, and U.S. and European universities. As Connie Carrino, Director of USAID's Office of HIV/AIDS, noted in her opening remarks, analyzing sexual behaviors and behavioral changes — such as the "ABC" approaches of Abstinence/delay of sexual debut, Being faithful/partner reduction, and Condom use — is key to understanding and combating sexual transmission of HIV. The meeting's objective was not to make new decisions or pursue consensus about ABC approaches but to examine what we know about what works from empirical evidence, reach a better understanding of why successful interventions work, and consider how to further use and apply that knowledge and understanding. This report summarizes the meeting's presentations and discussions. The "ABCs" of HIV Prevention iii iv The "ABCs" of HIV Prevention Panel 1:What's the Data? Epidemiological Overview: David Wilson of the Wilson then turned to "promising trends" regarding ABC University of Zimbabwe introduced his presentation behaviors and HIV prevalence in Uganda and probably with a quotation from the survey literature: "Many men Zambia during the 1990s. In Uganda, HIV prevalence and women said they were limiting sexual activity to one dropped during the decade from more than 30 percent in partner as a way to avoid infection, but only a minority many research populations to the 5 to 10 percent range. … said they had begun using condoms with those part- The decline in prevalence was especially marked among ners." Wilson suggested that this wording implied an youth (figure 2). This decline followed significant increases inherent bias on the part of many researchers and pub- in abstinence or deferring initial sexual activity among lic health officials, i.e., that monogamy/partner reduc- Ugandan youth. Deferred sexual debut is vital not only tion is not as valid a behavioral change as adoption of for avoiding immediate risks but is also predictive of condom use. He also noted "There is plenty in the data lower levels of future high-risk sexual behaviors and to bother everyone!" increased protective practices. Being faithful/partner He then noted the regional variations in adult HIV reduction behaviors also increased sharply in Uganda prevalence reported from sub-Saharan Africa, as indicat- (figure 3). While condom use also increased, national ed by seroprevalence testing among pregnant women in estimates of "ever use" remained below 20 percent. urban settings. Seroprevalence in this group generally In Zambia, there appears to have been some reduction remains below 10 percent in West African countries, in HIV prevalence among urban youth from the mid- to ranges from about 15 to 25 percent in East Africa, and late 1990s, although the surveillance data are not as approaches or exceeds 30 percent in Southern Africa. He clear-cut as for Uganda. However, clear and positive then pointed out the inverse association between these changes in all three of the ABC behaviors have been regional variations and levels of male circumcision, i.e., reported by Demographic and Health Surveys (DHS), relatively low HIV/high circumcision in West Africa, and a significant decline in casual sex occurred among typically intermediate levels of each in East Africa, and both men and women between 1996 and 1999 (figure 4). high HIV/low circumcision in Southern Africa (figure 1). HIV Seroprevalence for Pregnant Women, 1985–2000, and Estimated Male Circumcision Rates, Selected Urban Areas of Africa Francistown, Botswana Kwazulu/ Natal, South Africa 50 Blantyre, Malawi 45 Harare, Zimbabwe Lusaka, Zambia 40 Kampala, Uganda HIV Seroprevalence (%) 35 Nairobi, Kenya Abidjan, Côte d'Ivoire 30 Lagos, Nigeria 25 Yaounde, Cameroon 20 Dakar, Senegal 15 Male Circumcision < 20% 10 Male Circumcision 20%-80% 5 Male Circumcision >80% 0 1985 1987 1989 1991 1993 1995 1997 1999 2001 Figure 1. Adaptation of D. Wilson slide. Source: U.S. Census Bureau HIV/AIDS Surveillance Data Base 2000; Halperin DT, Bailey RC. Male circumcision and HIV infection: 10 years and counting. Lancet 1999 354;9192:1813-5. The "ABCs" of HIV Prevention 1 HIV Prevalence Among Pregnant Ugandan Women, Age 15–19 1991–2000 40 35 30 Prevalence (%) 25 20 Rubaga Nsambya 15 Jinja 10 Fort Portal 5 Mbarara Gulu 0 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 Figure 2. Source: HIV/AIDS Surveillance Report, STD/AIDS Control Programme, Ministry of Health, Uganda, June 2000. Implications and conclusions to draw from Uganda's epidemics spread largely by heterosexual transmission. experience include in particular the importance of part- They remain essential, however, in interventions targeted ner reduction, which has not occurred in other African to high-risk groups. countries to the extent it did in Uganda. Partner reduc- The lessons from Uganda and Zambia, as well as other tion by adult males has the added benefit of protecting "success story" countries such as Senegal, Thailand, and young women, for whom safe adolescent behaviors are Cambodia, suggest that revitalized and balanced ABC indicators of probable safe adult behaviors. Rates of approaches might be implemented in the form of "A" condom use, and increases in them, have been similar interventions promoting sexual deferral to younger, sex- across a number of other African countries, suggesting ually inexperienced youth; "B" interventions promoting that condoms may not be the primary intervention for partner reduction to sexually experienced youth and the reducing HIV prevalence in generalized high-prevalence general adult population; and "C" interventions promot- Ugandan Males Nonregular Partners Reporting Casual in Zambia, 1996–1999, Sex in Past Year, Population Services International Study 1989–1995 , 50 30 40 25 30 20 Percent Percent 15 20 10 10 1989 5 1996 1995 0 1999 Urban Rural 0 Male Female Figure 3. Source: Global Programme on AIDS, Geneva. Figure 4. Source: Agha S. Declines in Casual Sex in Lusaka, Zambia: 1996-1999. AIDS 2002; 16:291- 93. 2 The "ABCs" of HIV Prevention ing condoms, with enhanced STI services, to highly sex- Kenya, Malawi, and Zambia suggest that the unique fac- ually active youth and adults, especially sex workers. tor in Uganda was the steep decline in multiple sexual Outside of Africa, "D" interventions, which address the relationships (figures 5 and 6). In comparison with these high risk of injection drug use, must be added. countries, Uganda at the time was also unique in the Interventions need to respond to the most critical extent to which personal communication networks (figure aspects of HIV transmission dynamics with epidemio- 7) and knowing people who had AIDS were the sources logically sound strategies that take into account culture, of knowledge and acknowledgement of the disease. This context, and community values as well as "state-of-the- factor also appears to relate to the reported lower levels art" high-tech approaches. Wilson noted the irony that of stigma in Uganda than in other African countries. As an age-old traditional practice, male circumcision, has the acceptance of partner reduction in Uganda occurred probably so far prevented more HIV infections in Africa before interventions such as condom promotion, social than all the Western-derived interventions combined. marketing, and VCT were implemented, the country's success appears to have taken root from the behavior Uganda/DHS Analysis: Rand Stoneburner of changes motivated by this communication-based, com- Cambridge University presented a closer look at the munity-level response to the epidemic. evidence for the role of behavior change in the decline of HIV prevalence in Uganda. The decline in prevalence UNAIDS Multisite Study Analysis: Bertran Auvert documented in groups such as pregnant women, draftees, of the University of Paris reported on the UNAIDS secondary school students, blood donors, STD clinic study examining the heterogeneity of the HIV epidemic attendees, and clients of voluntary counseling and testing in sub-Saharan Africa, a key to a better understanding of (VCT) clinics should put doubts about Uganda's success effective prevention. The study modeled the spread of to rest — this success is not overstated. A decline, by as infection in Cotonou, Benin; Yaounde, Cameroon; much as 80 percent among youth and young adults, in Kisumu, Kenya; and Ndola, Zambia. Benin and new HIV infections during the late 1980s and early 1990s Cameroon are countries with relatively low HIV preva- fits with models of the epidemiological dynamics of lence, while the Kenya and Zambia sites have high HIV, which require a decline in incidence (new infections) prevalence. The study created models of heterosexual in the years preceding a decline in prevalence. (HIV HIV transmission based on the role of various factors prevalence in Uganda began declining in 1991 or 1992.) such as spousal and nonspousal partnerships, age at first Such a drop-off in incidence in turn suggests a preceding sex, condom use, genital herpes and other sexually trans- process of behavioral change to avoid risk of infection. mitted infections, and viral substrains of HIV, and varied In the case of Uganda, this behavioral change primarily the models from baseline assumptions within reasonable took the form of partner reduction. While condom use ranges. Statistical analyses of data from the study sites and delay of sexual debut also increased, the in-country were quite consistent with the models and found that the data and comparisons with mid-1990s DHS data from impacts of different factors can be highly variable but Condom Use With Last Non-Regular Partner Never Married Married 70 60 Condom Use (%) 50 40 30 20 Males 10 Females 0 Uganda Kenya Zambia Malawi Uganda Kenya Zambia Malawi 1995 1998 1996 1996 1995 1998 1996 1996 Figure 5. Demographic and Health Surveys. The "ABCs" of HIV Prevention 3 Sexual Partnerships With Non-Regular Partners Males Females 100 80 Percent 60 40 15-19 yrs 20-24 yrs 20 25-29 yrs 30+ yrs 0 Uganda Kenya Zambia Malawi Uganda Kenya Zambia Malawi 1995 1998 1996 1996 1995 1998 1996 1996 Figure 6. Demographic and Health Surveys. that number of lifetime partners and male circumcision prevalence figures five to six times higher than Yaounde in particular had very important impacts (figure 8). The and Cotonou. Such findings, brought about by progress interplay of these factors was also evident. In Yaounde, in epidemiology and improved understanding and mod- male study subjects averaged 10 lifetime partners, com- els, illustrate the complexity of the dynamics of the epi- pared with five reported from the three other sites. With demic and also highlight number of lifetime partners nearly universal male circumcision, however, HIV preva- and male circumcision as key factors for understanding lence remained relatively low. HIV prevalence was lowest the heterogeneity of the epidemic in Africa. in Cotonou, which combined nearly universal male cir- UNAIDS Data/Perspectives: Michel Carael of cumcision with a lower number of lifetime partners. UNAIDS began by presenting data showing the propor- Kisumu and Ndola, with lower numbers of lifetime part- tions of 15- to 19-year-old women in sub-Saharan ners but much lower rates of circumcision, had HIV African countries who have had sexual intercourse and Receive AIDS Information Via Friends/Relatives Network: Evidence of Differences in AIDS Communication Channels 54.7 Malawi 1996 36.2 Females Males 42.9 Kenya 1998 39 65.8 Zambia 1996 59.5 80.9 Uganda 1995 69 30 40 50 60 70 80 90 % Receiving Information Via Personal Network Ugandans are more likely to receive AIDS information through personal friendship networks. Women cite this source more than men. Figure 7. Demographic and Health Surveys. 4 The "ABCs" of HIV Prevention Heterogeneity of HIV in Sub-Saharan Africa UNAIDS Multicenter Study (selected findings) Cotonou Yaound• Kisumu Ndola (Benin) (Cameroon) (Kenya) (Zambia) Exposure Age at first sex (M/F) 18.5/18.4 17.3/17.1 16.3/15.9 17.7/17.0 Age at first marriage (M/F) 28.1/22.0 29.0/23.1 25.0/19.2 25.5/19.0 Age difference between partners 4 (1-7) 4 (1-7) 3 (1-6) 4 (2-7) Number of lifetime partners (M/F) 5/2 10/3 5/2 5/2 Contact with sex workers (%) 4 12 3 6 Transmission Condom use (F) (%) 11 16 20 24 Male circumcision (%) 99 99 29 9 Results HIV (%) (M/F) 3.9/4.0 4.4/8.4 21.1/31.6 25.4/35.1 HSV-2 (%) (M/F) 13.9/33.4 29.1/55.4 36.9/72.4 39.7/60.1 Figure 8. Source: AIDS, Vol 15, Supplement 4, August 2001. the positive relationship between young age at sexual the U.N. General Assembly Special Session on debut and increased number of premarital sexual part- HIV/AIDS includes the percentage of young people ners (figure 9). In addition to predicting an increased reporting condom use with nonregular sex partners, and number of sexual partners, early sexual debut is associat- the methodology for collecting data to measure this ed with a lower level of condom use and increased STD indicator will also provide information for measuring risk. Factors that influence age at sexual debut include levels of and trends in abstinence and faithfulness/part- parent-child communications, marriage patterns, and the ner reduction behaviors. Measurement difficulties will larger sexual culture. remain in attempting to understand why behavior To sustain preventive behaviors — such as delayed sexu- changes occur or do not occur, as quantitative data do al debut — by youth, UNAIDS advocates a mix of not comprehensively measure the underlying elements mutually reinforcing approaches including youth-friendly that drive these changes. services, sexual health education, and social mobilization. Summary of Panel Presentations and Discussion: Meeting the needs of both youth who are sexually active Helen Weiss of the London School of Hygiene and and youth who are not sexually active requires compre- Tropical Medicine summarized main points from the hensive, multipronged ABCD (for delay) approaches. panel presentations. She mentioned the global diversity Abstinence promotion needs to recognize that sexuality of HIV/AIDS; the need for targeted interventions, is healthy and natural and define abstinence as "nonen- especially with high-risk groups (such as sex workers) as gagement in penetrative sexual intercourse." In advocat- opposed to the general population; the importance of ing faithfulness, the need for mutual monogamy must be "low-tech" approaches; the need for multisectoral approaches involving governments, nongovernmental emphasized. Condom promotion involves issues of organizations, community groups, etc.; the need to informed choice, empowerment, environment, and sup- understand why changes in behavior take place; the low ply and demand. Efforts to promote delayed sexual use of condoms, despite ABC approaches; the risks to activity also need to help young people develop the married women in "faithful" relationships if husbands capacity to make informed decisions about their sexual do not remain faithful; condom use within marriage; health, including pregnancy and HIV/STD prevention. approaches to youth; the recent recognition of the Measurement of the outcomes of interventions in these importance of genital herpes in HIV infection; and the areas has tended to focus on condoms ("C"), neglecting issue of the trustworthiness of responses to questions "A" and "B." The set of core indicators developed by about behavior change — can we believe them? The "ABCs" of HIV Prevention 5 Audience comments and discussion of the panel presen- ment is an important determining factor. Studies of tations followed. Topics included: Uganda, for example, need to look at the combination of Possible biases in the reporting of behavior change and changing approaches. The role of mass media should not be over- social norms. Panelist Michel Carael noted that some types looked. Interpersonal communication may act as a cata- of questions and surveys appear more valid than others. lyst for individuals to absorb mass media messages. Reports of age at sexual debut are regarded as quite Panelist David Wilson observed that mass media was solid, while data gathered by school questionnaires are part of a constellation of political and communal factors less valid. UNAIDS tries to triangulate and find a middle at work. way between believing all findings and none of them by New data from Uganda. Further data from the Rakai study using biomarkers or observable related data (such as in Uganda are turning out to be more complex than STD rates) to complement reports of behavior change. anticipated. In particular, there is evidence of changes in Whether delayed sexual debut itself causes reductions in number of ABC behaviors from previous years along the lines of sexual partners or if a third factor might be at work. Panelist less "A" and "B" and thus an increase in risky behaviors, Michel Carael said that data from six countries on three apparently related to increased condom promotion. The continents indicate that early behavior patterns anticipate latter has evidently resulted in both greater (but generally later patterns and that early sexual debut anticipates later inconsistent) condom use and lower risk perception. In increased levels of risk behavior. Biological or psychoso- other words, condom promotion may inadvertently be cial characteristics, such as early puberty or intensity of resulting in increased behavioral "disinhibition." emotional attachment, may be involved. Those who have The "fear factor." Panelist Rand Stoneburner observed a late sexual debut may invest more emotion in relation- that some youth in South Africa are now abstaining ships. It is not clear how to modify behaviors related to from sex because they are scared and said that he felt sexual debut. A comment from the audience noted the fear also played an important role in keeping Thai men important effect of more "distal" contextual factors out of commercial sex establishments, especially after such as family and peer relationships on youth behaviors. the HIV prevalence rates among sex workers were pub- These social antecedents may be the "drivers" underlying licized (figure 10). It was also pointed out that the fear both early sexual debut and the higher risk factors asso- factor had a role in changing risk behaviors among gay ciated with early debut. It may also be simple common men in San Francisco. sense that with later sexual debut, people have a shorter period of exposure and fewer sexual partners before The lack of references to Latin American and Caribbean coun- marriage. It was also observed that early sexual debut of tries in the presentations. Daniel Halperin of USAID girls often occurs under duress or threat of violence. responded to this audience comment by noting the stabi- lization of the HIV epidemic in the Dominican Republic "High-tech" vs. "low-tech" behavior change intervention. "Low- and findings of declining HIV prevalence in girls in their tech" does not necessarily mean simple. Local environ- Age at Sexual Debut and Number of Premarital Partners, Men , 6 5 # Premarital Partners 4 3 2 Lusaka 1 Tanzania Côte d'lvoire 0 <15 years 15-19 years 20+ years Age at Sexual Debut Figure 9. Source: UNAIDS report, 11/16/01. 6 The "ABCs" of HIV Prevention Behavioural Changes and HIV Infection, Thailand 1990–1995 100 9 8 80 7 % Behavioural Markers % Biological Markers 6 60 5 4 40 3 2 Condom use with sex worker 20 % Men visiting sex workers 1 HIV prevalence Modeled HIV incidence 0 0 1988 1989 1990 1991 1992 1993 1994 1995 Figure 10. Source: Stoneburner R. and Daniel Low-Beer. "Epidemiological elements associated with HIV declines and behav- ior change in Uganda: Yet another look at the evidence." late teens and fewer partners and visits to commercial discussion of sex and sexuality issues. The resulting sex workers reported by men. The country has used tar- "Join the Race for a Healthy Future" campaign geted promotions more along the Thai model ("100 per- addressed these issues by tailoring its programming to cent" condom policy) than the Ugandan model, these local circumstances and communicating different although, similarly to the latter, surveys have found sig- messages to different audiences — i.e., condoms and nificant evidence of increased "B" behaviors as well. partner reduction for transport and sex workers; partner reduction and delayed sexual debut for students; and delayed sexual debut, stigma and discrimination reduc- Panel 2: Data and tion, and fidelity for church attenders. Multiple organiza- tions (including local/state governments, faith-based Programmatic Implications organizations, unions, women's groups, advocacy proj- ects, and health care providers) participated in the cam- paign and used multiple communication channels (mass Family Health International (FHI) and Behavioral print and broadcast media, billboards, outreach, peer Surveillance Survey (BSS) Data and Program education, pulpits, social networks, and community Implications: Carol Larivee of FHI/IMPACT events) to communicate these messages to the audiences. reported on behavior change communication (BCC) pro- gramming in Nigeria and Cambodia. BCC programming In Cambodia, a BCC program targeted high-risk popula- underlies comprehensive prevention, care, and support tions (sex workers and members of the uniformed serv- programming. In Nigeria's Anambra State (one of West ices) and the general population in the late 1990s. Africa's largest population centers with a population of 2 Interventions for high-risk groups included outreach to million and an increase in HIV prevalence from 0.4 to sex workers to promote condoms; "100 percent" con- 6.5 percent between 1991 and 2001), BCC programming dom policy; condom social marketing; sex worker mobi- developed a strategy using in-country literature, epidemi- lization; peer education for sex workers and uniformed ological information, data on transport workers from the service members; and STI and VCT services. For the 2000 BSS, formative audience research that asked why general population, interventions included mass media people act the way they do, and in-depth assessment that campaigns, condom social marketing, STI and VCT serv- identified risk behaviors, risk settings, and social net- ices, and HIV/STI education in schools. By 1999–2000, works. These sources indicated that programming need- condom use by sex workers had increased, visits to sex ed to target a mobile population that had high levels of workers by uniformed service members had decreased, sexual networking, early sexual debut, self-treatment for and HIV and STI rates in sex workers had decreased. STIs, and HIV stigma and denial, but low levels of open The Nigeria and Cambodia examples demonstrate how BCC programming can tailor a mix of messages to local The "ABCs" of HIV Prevention 7 situations and specific target populations. Message were secondary benefits. There was also a community design should be based on local data and information, emphasis on "D" for delayed sexual activity — this mes- and messages and programs should be carefully targeted. sage seemed to get through to young people better than abstinence. With financially independent married women Youth Perspective/Data: Bob Magnani of Tulane more likely to report abstaining from sex, the ABC … University School of Public Health and Tropical Delay continuum was extended to "EF": Empowerment Medicine started by observing there has been "a bit of a of women through Financial independence. disconnect" between the HIV/AIDS research communi- ty and the youth research community. There is evidence, Beyond ABC activities, Uganda also delivered care, pro- however, that youth populations have been pivotal to vided testing, involved people who had HIV/AIDS in declines in HIV prevalence in sub-Saharan African coun- service delivery, and engaged in advocacy and stigma tries. In addition to indications of delayed sexual debut reduction activities. Donor support covered 70 percent and partner reduction, recent data from South Africa of Uganda's prevention and care activities and amounted show that declines in HIV prevalence among youth may to $180 million from 1989 to 1998, or an estimated also be associated with increases in condom use. $1.80 per adult per year. USAID's activities were distin- guished by support for recurrent costs and salaries of There are two bodies of research relevant to understand- front-line workers; limited budgets for overhead, admin- ing the role of youth — research into the contextual istration, capacity building, workshops, and meetings; determinants of sexual behaviors and research into the early support for care and VCT programs; grants to in- effectiveness of interventions. Contextual influences country organizations, which empowered local groups; such as peer behaviors and family relationships are and support for innovative, "unproven" interventions. important influences on some behaviors, including sexu- Lessons learned from the USAID experience include the al debut. Beyond sexual debut, however, individual fac- importance of involving faith-based organizations; the tors such as knowledge and attitudes become more need to compensate front-line workers and provide important in influencing behaviors such as single or mul- workers who have HIV/AIDS with the best care avail- tiple partnering and condom use. Programmatic inter- able; and the need to support recurrent costs and salaries ventions are effective in improving knowledge and atti- over capacity building, training, and one-time expenses. tudes; behaviorally, they seem to have less effect on In addition, Marum underscored the need to use per- delaying sexual activity than on partner reduction and formance-based funding mechanisms that emphasize use of contraceptive and other reproductive health serv- service provision and show evidence of impact rather ices. The effects on these behaviors appear to be mod- than funding mechanisms that reward administration and est, short-term, and transitory. other non-service activities. It is important to recognize special circumstances related to youth sexuality, including sexual violence/rape as part Faith-Based Perspectives: Dorothy Brewster Lee of of sexual debut; age differences between partners; and Christian Connections for International Health sexual exchange behaviors (exchanges of gifts or favors began by noting that faith-based perspectives previously as opposed to monetary exchange in commercial sex). could not offer a lot of data but that the evidence of the Indicators to measure context of first sex, the extent of continuing spread of HIV/AIDS suggests that the world violence and rape at first sex, and sexual mixing and has more experience with what has not worked than exchange behaviors are needed. Age differences between with what has. In Cameroon, where faith-based organi- marital partners, which may leave young wives with low zations (FBOs) were marginalized because they would status and little power for self-protection, and the "con- not support condoms, HIV infections among pregnant dom conundrum" (in which the condom prevents infec- women continue to increase. Interventions that have tions but may also prevent a desired outcome such as proven effective in Europe and North America should first pregnancy) are other special circumstances pertaining not be stamped into African settings without considera- to youth. tion for indigenous culture, including views of recre- ational or casual sex — it is worth noting that many USAID-Uganda Experience: Elizabeth Marum of African countries have higher rates than the United CDC reviewed how Uganda implemented ABC and States of under-15-year-olds who have not had sex. HIV other activities and the role of donor and USAID sup- prevention approaches have generally failed to provide port. Abstinence and faithfulness/partner reduction were fair and balanced recognition to abstinence and faithful- often covered in combination through the "zero grazing" ness. Instead, the reports and strategies of UNAIDS and concept. Free and social marketing condoms were pro- other international organizations give condoms much moted and distributed, and public debate and family dis- more attention and emphasis. cussions arising from controversies over these activities 8 The "ABCs" of HIV Prevention Faith-based organizations can be especially important Neill McKee of Johns Hopkins University/Center partners of international organizations in rural areas of for Communication Programs then summarized points sub-Saharan Africa, where they are already providing from the panel presentations and Dr. Nantulya's account: health and educational services. African FBOs are engag- • Behavior change communication underlies pre- ing in "South-to-South" exchange to become fuller part- vention, care, and support, and uses local sources of ners in HIV prevention. In Malawi, the Presbyterian information to tailor approaches to specific groups Church has pledged its commitment and will observe and audiences. World AIDS Day through prayer and offerings. Studies of the effects and good practices of FBOs are needed, and • HIV/AIDS researchers and programs can learn the faith-based community appeals to the research com- from youth researchers and programs about munity to study these matters. Resources are also desper- approaches that work best for specific youth ABC ately needed — four ministers in Malawi who can reach behaviors, both before and after initiation of sexual 350,000 youth have declared their commitment to activity. In addition to contextual factors, youth- addressing HIV/AIDS but have only one computer related issues include coercion or violence at first among them. The FBO movement can be a major partner sex, age and status differences between partners, and in HIV/AIDS prevention and will continue to work on the "condom conundrum." this problem, whether it is accepted as a partner or not. • The Uganda experience included, in addition to ABC, "C" for care, compensation, and controversy; Summary of Panel Presentations and Discussion: "D" for delay; elements of "E" and "F" in empow- Vinand Nantulya of Harvard University was first ering women financially; "G" for getting tested and asked to describe Uganda's response to the earliest signs greater involvement of people with HIV/AIDS; and of the emerging AIDS epidemic. When his village in "I" for innovation in unproven initiatives. Mbale district was confronted in 1982 with an unknown, horrible, incurable, and fatal disease, initial reactions • The FBO community feels there has been too included excitement, pandemonium, and paralysis. An much emphasis on social marketing of condoms — evolution occurred, however, as the community learned where are "A" and "B"? FBOs should be included the causes of the disease and how to avoid risk and max- in the strategies of looking at and encouraging imize the opportunity to live. The community communi- local initiatives. cated internally from the very start, as fears of curses, witchcraft, and cancers gave way to the realization that • Uganda's early response demonstrated the this was an infectious disease transmitted through sex importance of locally driven community-based that affected not only "bad people" but everybody. approaches in facilitating behavior change. Following this realization came a locally driven, or Discussion of the panel presentations focused on: endogenous, common-sense, community approach — if The varying degrees of emphasis given the individual "A," "B," a young person had not yet begun to have sex, then he and " C" approaches. Sometimes it appears that only lip or she should wait. If a young person had just begun to service is given to the abstinence and "be faithful" have sex, then he or she should stop. If a person was approaches, but this may be an issue of insufficient already sexually active, he or she should adopt the faith- resources. Abstinence and condom interventions have fulness/partner reduction practice of "zero grazing." As been employed with young people more than "B" Uganda developed national strategies and approaches, approaches of fidelity/partner reduction, which may be official messages were in concord with the early endoge- perceived as "too complicated" for youth populations. nous messages. This concordance made national success Yet the epidemiological outcomes, as evidenced in the possible, while purely externally driven, or exogenous, data from Uganda, Zambia, and other countries, appear interventions such as condom promotion would not to be most significant with use of the "B" approach. have been accepted nearly as well. The community-level However, some argue that fidelity/partner reduction response, in which communities assessed their risk and may be a "tougher sell" to youth, who tend to have mul- devised their own risk reduction strategies, was vital to tiple, but not concurrent, sexual partners (serial Uganda's national success, especially in the late 1980s monogamy) and for whom "zero grazing" may be less and early '90s, the important early years of responding applicable. Panelist Vinand Nantulya reiterated that in to the epidemic. Uganda condom promotion was an exogenous interven- tion that followed the earlier endogenous (locally driven) "AB" approaches. The "ABCs" of HIV Prevention 9 What constitutes "consistent" condom use? Some studies have Synopsis of Panel used condom use with last three partners as a criterion. Panelist Elizabeth Marum noted that while there is a lot Presentations of evidence for the protective effects of consistent con- dom use, consistent use with nonregular partners was only 12 percent in Kenya, while inconsistent use was Daniel Halperin of USAID reiterated that today's meet- more than 40 percent. ing was not looking for answers but rather for questions to pursue as we consider the programmatic implications Faith-based organizations and the ABC approaches. There is a of ABC approaches. The morning's panel presentations need to avoid being judgmental toward groups that do and discussions included the following themes: not adhere to ABC approaches. At the same time, faith- based organizations should try not to disparage con- The potential advantages of ABC approaches: There is room doms even if they do not support them. Panelist at the ABC table for all points of view — Uganda wel- Dorothy Brewster Lee said that FBOs did not mean to comed many people to the table with no litmus test. discourage condom use in targeted high-risk populations While some of the ABC approaches carry historical, but to encourage delayed sexual activity in the more gen- political, and moral baggage (which at times has pro- eral youth population. She also noted that many duced lecturing as the main form of communication), Christian FBOs are increasingly taking the approach of one take-home message has been that, as in Uganda, being less concerned with how people might have con- Senegal, and other places, it is possible to discuss every- tracted HIV infection than with seeing them as people thing from condom promotion to religious group partic- who need care. ipation at the same table. HIV testing. Panelist Elizabeth Marum noted that testing Data: There are no absolute quantitative certainties, even of married couples and premarital couples was on the in physical science. In the social sciences — including rise in Uganda and provided a positive experience for the measurement of HIV-related behavior change —- couples to talk about sex within marriage. It was also data-checking and triangulation are necessary to reach a noted that couple testing in faith-based settings in Kenya certain level of "ethnographic confidence" that desired discovered that more than 20 percent of couples were outcomes are occurring. HIV-discordant. Working with such couples could be a Uganda: We have "ethnographic confidence" that some- fruitful area for FBOs. Panelist Dorothy Brewster Lee thing significant happened in Uganda in terms of mes- reported that churches and mission hospitals in Malawi sages and community-based, norm-altering behavior were engaged in mother-to-child transmission prevention changes. It is hard to know exactly what the role was of activities, including a curriculum to motivate women to more "distal" factors such as political will, but the data get tested. Couple ministries and women's guilds were on seroincidence and resulting prevalence decline indicate also working in this regard. that something of a large magnitude took place in the Female empowerment in Uganda. Panelist Elizabeth Marum more direct "proximal" factors of ABC behavior noted that the hiring of women with HIV infection by changes. The main one appears to be related to partner Ugandan AIDS care and prevention organizations coin- reduction in the late 1980s, although changes in age at cided with the efforts of other programs to help women sexual debut and increased condom use with nonregular advance in commercial enterprises or pursue income partners were also important. Distal factors alone are not through homegrown activities. Panelist Vinand Nantulya sufficient — fundamental behavior changes are needed noted that the government at the time was deliberately for prevalence to actually come down. The 1995 Uganda trying to empower women through use of quotas to Demographic and Health Survey findings attest to the ensure substantial female representation in the legislative importance of these changes, as 89 percent of men and executive branches of government as well as in their reported they had changed their behavior to avoid AIDS, own women's caucuses and other political forums. with most of them adopting faithfulness to one partner and other partner-related changes. DHS and other UNAIDS data from many other countries indicate the strength of "B" messages, especially when they are part of a community-based indigenous response for changes in personal behavior and the underlying social norms. 10 The "ABCs" of HIV Prevention Halperin's synopsis concluded with some discussion of: data are worth analyzing, as reasonable comparisons can be made across data sets. • Fear-based interventions — These seem to be most effective when a specified behavioral response Low-prevalence and emerging epidemic countries to the fear is also presented as an option. need to be cautious of focusing only on high-risk target groups. National-level warning messages for gen- • The "zero grazing" message— In Uganda, did eral populations are also needed. Although it is impera- that translate into perfect monogamy, or perhaps tive to target high-risk groups, there is an important need function more as part of an overall norm-changing to combine both targeted and national approaches. When encouragement to have fewer partners? Perhaps it implementing interventions targeted at marginalized pop- doesn't matter so much, as these are matters of ulations, care must be taken to avoid stigmatization. degree, as opposed to the absolutes of never, only, or always. And it's important to note that much of Topic: What are the relative advantages and dis- the zero-grazing effort was directed at older men, advantages of condom interventions targeted at who often had much younger female partners. high-risk populations versus those targeted at the • Stigma — How to carry out ABC interventions general population? without increasing AIDS-related stigma? HIV/AIDS is relatively less stigmatized in Uganda than in other Conclusions: countries, showing that is possible to promote ABC Never do "C" without "A" and "B." We cannot do interventions and not raise stigma at the same time. "C" without "A" and "B" and must keep all three in mind, even if we cannot operationalize all three equally. • Youth and condoms — Studies in a number of We should not favor one approach over another, but countries, such as South Africa and Jamaica, have instead combine them as appropriate, given program found that youth are more likely to use condoms for intentions, country values, and needs. Condom promo- pregnancy than HIV. tion strategies depend on the stage of the epidemic. • "Mass communication" — Uganda again pro- There are places where targeting high-risk groups makes vided an endogenous example when early in the epi- most sense, and other cases where there should be a demic the president traveled the country to address combination. Targeting is often challenging given stigma, villages and communities, usually with only a mega- marginalization, and lack of organization. Approaches phone in hand. should be based on the cultural context as well as the state of the epidemic. This is also true for the mixed use of "A," "B," and "C" messages. Break-Out and Report Back We need to balance public health impact with how we distribute condoms to individuals. Targeted dis- Sessions tribution is necessary, especially when few condoms are available. The availability of condoms is a major con- Topic: What have we learned about the impact of straint to successful condom promotion in some places. "A" and "B" interventions on HIV incidence and Condoms should be placed in more strategic locations prevalence? What do the existing data tell us? (bars, etc.) and not just clinics. There have been experi- ments where condoms were placed next to beds in Conclusions: high-risk settings. Many of these condoms were used. Partner reduction is a big message to take forward We need to confront and answer questions about the and the main "take-home" message. We need greater pro's and con's of condom promotion. General con- complementarity and synergy among the "A," "B," and dom promotion can increase and normalize discussion "C" approaches. We need to avoid mixed messages while of sex. It can be a vehicle to opening up discussion of providing clear targeted messages to different groups sex, as in Thailand, or it can be an enticement to risk- according to different phases and levels of the epidemic. taking behavior. This is a question that warrants further We need to improve survey instruments and data exploration. What effect or impact do general promotion and do a better job in attributing cause and effect campaigns have on youth who are not sexually active? and analyzing program inputs. There is much ambi- For youth who have not yet thought about sex, condom guity in the available data. This hinders the ability to promotion can be an enticement. Condoms are associat- determine the effectiveness of "A" and "B" interven- ed with high-risk groups, so their use has become stig- tions. We must look at overcoming this by identifying matized in some places. There is also a strong belief that weaknesses and improving our survey instruments. All condoms break. The "ABCs" of HIV Prevention 11 Topic: How can we effectively implement all three Topic: How can we operationalize the promotion of ("A," "B," and "C") interventions to maximize total "B" (fidelity and/or partner reduction)? impact (i.e., how to avoid messages that might negate or contradict one another)? Conclusions: There is no one formula for operationalizing "B." Conclusions: We need to consider the setting and socioeconomic envi- "ABC+" means no missed opportunities with an ronments; look at norms, values, and sexual behavior in emphasis on skills and empowerment. ABC behav- context; and draw on lessons learned. We need to know iors and target audiences can be segmented without den- the current practices and sexual ethnography of the cul- igrating any of them. Target populations and behaviors ture. Uganda's early "A" and "B" responses were natural need to be identified. "A" has been defined by different once AIDS was identified as a deadly STD. The presi- people to mean delay among youth, postpartum absti- dent (who was a foe of family planning) said condoms nence, "revirginization" (secondary abstinence), nonpen- were not the answer and instead called for a return to etrative sex (abstaining from sexual behaviors that can family values, delaying sex until marriage, and "zero result in HIV transmission or pregnancy), and abstinence grazing" (fidelity/partner reduction). among divorced or other unmarried adults. "B" includes We cannot operationalize "B" without the full range being faithful, reducing the number of partners, and of "A," "C," "D," etc., options. Schools and faith- being careful in partner selection. "C" is particularly based organizations can be partners in operationalizing important when not practicing "A" and "B" behaviors. "B." In partnering with a faith-based organization, it is The conditions of condom use might vary with marital important to understand its core values. Operationalizing or extramarital sex partners. The same agent does not "B" might also be linked to voluntary counseling and need to disseminate the same message. Different mes- testing services where they are available. Operation- sages need to be shaped for different providers and alizing "B" for youth must take into account their serial clients. There has to be guidance and skills building in monogamy pattern of sexual behavior. choosing and correctly using ABC behaviors. We need to focus on men. "B" messages need to be We need to see the ABCs as reinforcing one another aimed at both married and single men and consider why and to know when to use what message with whom. they have multiple partners and who their partners are. Messages should not be pitted against one another (such Behavior change options include partner reduction in as "Condoms don't work," or suggesting "It's OK to conjunction with condom use and remaining faithful have as many partners as you want, whenever you want, within marriage. Gender issues impact upon sexual val- as long as you use a condom"). The goal should be ues and behaviors. Issues for women include self-esteem, informed choice for all ABC behavior changes. People choice, coercion, and violence. can understand complex messages and should be treated as intelligent individuals who can decide for themselves We need to work toward creating new or revitalized what to do. Following the cafeteria approach, facts (e.g., social norms that increase understanding and HIV is an infectious disease) should be laid out for indi- assessment of personal and community risks. "B" viduals who should then be presented with a range of can be promoted through individual self-risk assessment prevention options. The goal should be framed as avoid- with a presentation of the full range of prevention ing HIV infection by choosing one or more of the options. An individual can then choose his or her own options. More research is needed on what people will most appropriate option. Implementing self-risk assess- choose from an ABC "menu." ment depends on the setting. In Uganda, HIV/AIDS was very visible and concrete. In other places, it remains more ABC behaviors need to become embodied in the abstract. Community discussion can reduce the distance development of new social norms or the revitaliza- between the epidemic and the individual and move tion of traditional norms. This requires an enabling toward accepting "B" as a community norm. Fear of environment and individual empowerment, as well as other STDs can be a motivation. Self-risk assessment can moral and informed decisionmaking capabilities. We need be a challenge in low-prevalence countries and communi- to make "A," "B," and "C" into social norms, learn how ties, where fear-based messages will not be as effective. they affect individual decisions, and encourage informed choice for individual behavior change. This often involves "B" must be defined and its behaviors (faithfulness, issues of morals and values. It also requires knowing and partner reduction) disaggregated. It has several mes- presenting a complete and honest picture of the epidemi- sages — be faithful to current partner, reduce number of ological data related to various interventions. partners, and also be careful whom you choose as partners. 12 The "ABCs" of HIV Prevention A clear definition is also needed to develop indicators and Final Wrap-Up and instruments for measuring the different "B" behavioral changes. Choice of partner also plays a role in "B". Discussion Topic: How can we effectively monitor and evaluate Jim Shelton of USAID and Edward Green of ABC behavior change programs? Harvard identifed some areas of consensus that had emerged during the meeting's presentations and Conclusions: discussions: The monitoring and evaluation tools are there, but we need to bring them together. Measurements of 1.) There is clearly a need for a balance of "A," quality can be borrowed from family planning and other "B," and "C" interventions. fields. Behavioral Surveillance Surveys (BSS) and 2.) Interventions need to be targeted for better Demographic and Health Surveys (DHS) are available efficiency and because of crucial differences among tools for measuring behavioral change, but they must be different populations. put together in a different way, with better links to rou- tinely collected data. Designs should link broad-based 3.) Other country examples should also be stud- "core" surveys (such as BSS and DHS), more specific ied. Senegal achieved Uganda-like behavior change extended multiround surveys, operations research, and with a balanced ABC program even in a low-preva- monitoring and evaluation. lence setting. User-friendly STI services and out- reach to sex workers have been key in other settings, Monitoring and evaluation needs to track the effects such as Jamaica. of broader contextual factors. Many outside factors that may or may not be related to the subject of a survey 4.) Partner reduction emerges as probably the can contribute to behavior change and render evalua- most important element of ABC, at least in general- tions inaccurate or ineffective. Only looking at ized epidemics. Delayed sexual debut as part of "A" HIV/AIDS can miss, for example, family planning and is also very important, especially for young women, other interventions taking place. Environmental condi- as is targeted condom promotion for sex workers tions such as famine and war or "critical incidents" that and people engaging in casual sexual encounters. occur during survey intervals can affect risk behaviors 5.) The nature of the epidemic is also a major and consequently HIV rates. In Uganda, for example, factor. In Southeast Asia, HIV/AIDS is still largely the death of a pop star from AIDS may have had a confined to high-risk populations, among whom major impact on behavior. We should also be cautious of condom use is relatively easy to implement. In many lumping people into broad categories such as "youth," African countries, the epidemic is more generalized some of whom are also parents, ex-soldiers, and/or and thus requires an appropriate mix of "A," "B," heads of households. and "C" approaches. We need more work on "why," in addition to "what." It is often difficult to pinpoint the exact causes of behavior change. We often know what happened on To conclude the meeting, Connie Carrino welcomed the individual or population level, but not why it hap- USAID Assistant Administrator Dr. Anne Peterson. Dr. pened. We need theory-driven tools to understand what Peterson noted that a balanced ABC approach to pre- we are seeing in the data and what the implications are vention sets aside history and politics in the interest of for programming. what is right from a public health perspective. It also helps clarify the different yet complementary roles of program partners in overcoming the epidemic. USAID would like to continue working with this balanced approach, with special attention to monitoring and eval- uation. Carrino added that there is a need to look beyond Uganda and sexual transmission to other areas of prevention, care, and treatment. The "ABCs" of HIV Prevention 13 14 The "ABCs" of HIV Prevention Appendix Meeting Agenda 8:30 – 8:40 Welcome & Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Connie Carrino, Director, USAID Office of HIV/AIDS Panel 1: What's the Data? 8:40 – 9:45 Epidemiological Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .David Wilson, University of Zimbabwe 9:00 – 9:15 Uganda/DHS Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Rand Stoneburner, Cambridge University 9:15 – 9:30 UNAIDS Multi-Site Study Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Bertran Auvert, University of Paris 9:30 – 9:45 UNAIDS Data/Perspectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Michel Carael, UNAIDS 9:45 – 10:30 Questions & Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Helen Weiss, London School of Hygiene and Tropical Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Norman Hearst, University of California-San Francisco 10:30 -11:00 Coffee Break Panel 2: Data and Programmatic Implications 11:00 – 11:15 FHI and BSS Data and Program Implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Carol Larivee, Family Health International/IMPACT 11:15 – 11:30 Youth Perspective/Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Bob Magnani, Tulane University 11:30 – 11:45 USAID-Uganda ABC Experience . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Elizabeth Marum, Centers for Disease Control and Prevention 11:45 – 12:00 Faith-Based Perspectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Dorothy Brewster Lee, Christian Connections for Int'l Health 12:00 – 12:45 Questions & Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Vinand Nantulya, Harvard University . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Neill McKee, Johns Hopkins Univ. Center for Comm. Programs 12:45 – 1:30 Lunch 1:30 – 1:45 Synopsis of AM Sessions/Introduction to Break-Out Sessions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Daniel Halperin, USAID The "ABCs" of HIV Prevention 15 Meeting Agenda (cont.) Break-Out Sessions A-E: 1:45 – 3:00 A) What have we learned about the impact of A and B interventions on HIV incidence and prevalence? What does the existing data tell us? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Steven Hodgins, USAID-Zambia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Peter McDermott, UNICEF/USAID B) Although existing data suggests that targeted condom interventions (focused on higher-risk populations) are more effective than more dispersed/general population approaches, why is this strategy often still not as understood or adopted in the field? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Malcolm Potts, University of California-Berkeley . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Josh Volle, FHI/IMPACT C) How could we effectively implement all three (A, B, and C) interventions to maximize total impact? (I.e., how to avoid messages that might negate or contradict one another?) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Douglas Huber, Management Sciences for Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Jeff Spieler, USAID D) How can we operationalize the promotion of "B" (fidelity and/or partner reduction)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Ray Martin, Christian Connections for International Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Hally Mahler, YOUTHNET E) How can we effectively monitor and evaluate ABC behavior change programs? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Robert Kelly, Population Services International/AIDSMARK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Sohail Agha, Abt Associates 3:00 – 3:15 Coffee Break 3:15 – 3:45 Reporting Back of Key Themes from the Break-Out Groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Jim Shelton, USAID, moderator . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Edward Green, Harvard University, discussant 3:45 – 4:30 Final Wrap-Up and Open Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Connie Carrino, Director, USAID Office of HIV/AIDS 16 The "ABCs" of HIV Prevention United States Agency for International Development Washington, D.C. www.usaid.gov
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Balanced view preferred
I apologize to Tom Shea for my redundant letters rebutting Neil Davis's letters. I'm getting tired of writing them, too, but I'm also tired of the relentless Tea Party propaganda and feel that both sides of the issues should be addressed.
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Comments about 'Hispanic Republicans look to raise profile on immigration'
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Why does the media keep pushing this compact? It aint going to fly. The american people are tired of paying for a free ride (health care, free food etc. etc.) for the illegals, while having their wages suppressed. All, so the fat cats can have cheap labor, and the demos getting the votes. Believe me, people are tired of it. It showed last november and it will show the next election also.
- 5:52 p.m. Jan. 13, 2011
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The Compact is just window dressing. They will push the agenda forward but in the long term they may win out. Yes we are tired of it. Hope Utah Legislature does something about it. Go Sandstrom
- 6:03 p.m. Jan. 13, 2011
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Now if we could actually get some of these groups to help the Feds figure out how to enforce our laws, that would be great.... rhetoric is nothing more than...rhetoric.
- 10:50 p.m. Jan. 13, 2011
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We need to get past the excuse of it being a civil offense. It's still a crime.
The fact that the US government prefers to deport people in a civil court,
instead of giving them a fine and jail time in a criminal court is irrelevant.
It's a crime.
I doubt the politicians need to be reminded that there are Hispanic voters. Should that make a difference on how we enforce our laws?
Other than the liberal New York times article, The Utah compact gets very little attention outside of Utah. People see it as it as a ploy to stop immigration enforcement.
We need honesty and transparency in the illegal immigration debate. People are here illegally, they are not undocumented, their documents were given to them by their country. The Compact signers are mostly far left liberals, many support open borders between the US and Mexico. It's intention is to sway public opinion towards amnesty.
All we want is enforcement of our laws, that is not asking to much.
- 2:36 a.m. Jan. 14, 2011
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I can't understand why some Hispanics continue to nurture allowing people of
their ethnicity to break the law.
Whether it is merely being in this country illegally or committing fraud by stealing someone elses identification,
it casts a long and dark shadow on the legal Hispanics who
condone and support it.
- 6:46 a.m. Jan. 14, 2011
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I believe most states are facing budget deficits and are looking to cut services
and other budget items to balance things out. How can any state justify
spending millions to subsidize the presence of non-citizens who are illegally
Politicians and pundits were outraged at the whistle blowers who exposed "the list" last year, but where is the outrage that so many illegal aliens are receiving taxpayer money ahead of citizens? How can Utah propose cutting back on medical services to the poor while continuing to pay millions to subsidize in-state college tuition for illegals? This is even more wasteful because educated or not, an illegal is barred from working.
I just read the article about the crumbling prison in Draper. If Utah does intend on being the illegal alien Mecca, it had better be prepared for the rise in crime and build additional jail/prison space.
- 8:02 a.m. Jan. 14, 2011
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Yet another Compassionate display of affection by the DNEWS to its Latino
the real truth....?
These Mexican GOPers sound like another version of RINO's...I thought we got rid of Bob Bennett~!
- 4:22 p.m. Jan. 14, 2011
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Reviewed By Asia B (Waldorf, MD) Reviewed for a 2007 Mazda 3 —10/23/2014 5:03 PM
These rotors look the part and perform as expected. Driving predictably and confidently is what is expected from EBC and they have surpassed expectations.
Reviewed By Michael J (FORT WORTH, TX) Reviewed for a 2011 Chevy Camaro —6/25/2015 4:52 AM
bought the power stop drilled and slotted rotors and they warped after 2 months so I exchanged and bought the Baer Decala rotors and they are beautiful and keep the shiney look and appearance gets a lot of compliments. if you cn afford to wait and get the Baer do it its worth it. and also get the full ceramic brake pads with it to keep dust to a minimum.. makes my Camaro look so much more appealing to the eye...


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• DIAL IN: Outside of your data coverage or roaming overseas? No problem. When you don't have access to data, simply dial in from a phone line.
• MEET FROM YOUR COMPUTER: When you're at your desk, host and participate in meetings easily from your Windows PC or Mac.
• SAVE IT FOR LATER WITH COMPUTER RECORDING: By saving meeting audio to your computer, you can save calls for distribution or simply to recall important information and actions later.
Get the free app to join BBM meetings or as part of your BBM Meetings subscription. To learn more please visit www.blackberry.com/bbmmeetings
BES12 Client
• Secure access to work email, calendars and contacts
• Easy installation and management of your organization's approved mobile apps
• Automated configuration of work-related policies, Wi-Fi® and VPN settings
• Dual business and personal use of mobile devices for Bring Your Own Device (BYOD) policies
IMPORTANT NOTE: to activate BES12 Client your organization must use BES12 or BES10 enterprise mobility management platform. Please check with your organization's mobility experts before downloading this app. You will not be able to activate BES12 Client unless your organization creates an account for you from a compatible version of BES.
BlackBerry Blend
Read and respond to your BBM and text messages instantly on your tablet. You can also access your email and work files without the need for VPN.
No wires, no saving to a cloud, no transferring information between devices, it's just there.
BlackBerry Blend requires you to sign in with the BlackBerry ID associated your BlackBerry smartphone* as your BlackBerry ID will be used to access your BBM, email, text messages, files, and all other device content.
For more information, visit www.blackberry.com/BBID.
*BlackBerry Blend works with select BlackBerry phones. Visit www.blackberry.com/blend to check if your smartphone is supported.
Secure Work Space for BES12
Email Features:
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Browser Features:
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• Search Field
• Browse corporate intranet pages via BlackBerry® Secure Connectivity
IMPORTANT NOTE: to use Secure Work Space for BES12 your organization must use BES12 or BES10 enterprise mobility management platform, and an active user account and credentials are required. Please check with your organization's mobility experts before downloading this app. Secure Work Space for BES12 will not run unless your organization uses a compatible version of BES to manage mobile devices, apps and content.
Work Space Manager for BES12
IMPORTANT NOTE: Work Space Manager for BES12 is required for Secure Work Space for BES12 by BlackBerry, and your organization must use BES12 or BES10 enterprise mobility management platform. Please check with your organization's mobility experts before downloading this app. You will not be able to activate Work Space Manager for BES12 unless your organization creates an account for you from a compatible version of BES.
Work Security ID for BES12
Work Security ID for BES12 is RSA Ready Program Certified.
Once activated, Work Security ID for BES12 enables:
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• Use for standard authentication tasks, such as VPN, Wi-Fi and secure access to corporate intranets
• Quick deployment to employee devices with Secure Work Space with RSA Authentication Manager
IMPORTANT NOTE: Work Security ID for BES12 an active account in BES12 or BES10 (enterprise mobility management platform) and Secure Work Space by BlackBerry. Please check with your organization's mobility experts before downloading this app. Work Security ID for BES12 will not run unless your organization uses compatible versions of BES by BlackBerry to manage mobile devices, apps and content, Secure Work Space by BlackBerry, and RSA Authentication Manager.


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American Civil War Fortifications: Bk. 2: Land and Field FortificationsPaperback Fortress
List price $18.70
You save $4.07 21% off
Free delivery worldwide
Dispatched in 1 business day
When will my order arrive?
- Publisher: Osprey Publishing
- Format: Paperback | 64 pages
- Dimensions: 180mm x 244mm x 6mm | 222g
- Publication date: 30 November 2005
- Publication City/Country: Osprey
- Edition statement: New.
- Illustrations note: Illustrations (some col.)
- Sales rank: 839,523
Product description
The American Civil War saw a massive development in the use of land and field fortifications. This book, the second in a sequence of four, studies the many forms of land and field fortifications used during the War Between the States. It considers some of the 70 land fortifications erected to defend Washington DC during the first few months of the war. It covers lunettes, advanced redoubts, rifle pits, redan lines, bomb-proof shelters, covered ways, and powder magazines among others. The daily experiences of the soldiers in the trenches are also covered in this detailed and authoritative volume.
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Ron Field was born in 1943. A history teacher for over 30 years, Ron is presently Head of History at the Cotswold School in Burton-on-the-Water, UK. He was awarded the Fulbright Scholarship in 1982 and taught at Piedmont High School in California from 1982-83. He has traveled extensively in the US conducting research at numerous libraries, archives and museums, and has written numerous books on 19th-century American history. This is his second book for Osprey's Fortress series.


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Originally written on Fox Sports | Last updated 2/9/13
Kobe Bryant barely shot the ball in the first half Friday night against the Charlotte Bobcats. Almost no one else shot for the Los Angeles Lakers in the final seven minutes when the game was on the line. Bryant shrugged off a scoreless first half - he attempted only two shots - to finish with 20 points, eight assists and seven rebounds as the Lakers defeated the Bobcats 100-93. The formula - where Bryant facilitates early and scores late - is one that forward Antawn Jamison anticipates fans will see more of from the Lakers down the stretch this season. ''I think in the future that is how you're going to see us play with Kobe getting guys involved early on, seeing how it goes, and then as the game goes into the fourth quarter he begins to take over a little bit,'' Jamison said. Bryant doesn't mind. What he does mind is the way the Lakers played against the Bobcats, the NBA's worst team. Bryant said he was ''irritated'' at the way the Lakers passed up good shots, committed turn...
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Town Square
U.S. Open golf championship is completely sold out again
Original post made on Jun 13, 2012
Read the full story here Web Link posted Wednesday, June 13, 2012, 10:21 AM
Comments (1)
a resident of Mountain View
on Jun 13, 2012 at 11:38 am
if you have the time and the money for it, buy tickets to the u.s. open event way in advance. this is a good golf course to play on and the notable players look pretty interesting. good luck and enjoy the golfing and spectating
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Calave wine bar opens in Palo Alto
By Elena Kadvany | 9 comments | 2,245 views
Constitution Guarantees Nationwide Right to Same-Sex Marriage
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text: The Five Characters In Search Of A Madman! wiki last edited by sniktawt on 08/21/14 06:57PM View full history OverviewFive Characters In Search Of A Madman!Luke Cage says to the Invisible Girl that he has been wondering why she is not the Invisible Woman. Sue tells him that she has thought of changing her name, but that the other one is too long and unwieldly. She explains to Luke that she thinks she will go on being the Invisible Girl a while longer. (Little could she know then what we know now. Sue Storm did not change her name until the end of FF #283, "Torment", the issue where Psycho-Man tortured Sue Storm right up to the verge of an emotional breakdown. Hence, it took another 114 issues before Sue eventually changed her name from the Invisible Girl to the Invisible Woman.)Suddenly, seemingly out of nowhere, Luke says that he has got to kill and he throws some heavy furniture at Sue. The gorgeous blonde turns invisible to escape, but Luke catches her with curtains. Sue breaks free with her force field. However, Luke Cage is powerful and he hammers away at the Invisible Girl's force field until it finally shatters! Just as Luke is about attack Sue, a human Ben Grimm intervenes. However, Luke Cage takes care of Ben with one punch. He then successfully attacks both the Human Torch and Mr. Fantastic. Luke files away in the Fantasti-Car The story ends when Reed shows Ben what appears to be an exact duplicate of himself in The Thing form.NotesFeatures the Hostess Cup Cakes ad, Spider-Man And The Cupcake Caper


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Sunset Cocktails and (free) Live Jazz
- Music
- 420 Park Avenue South, New York, NY, 10021
Seton Hall Parents "Lunch & Learn" with Professor Mary Balkun
Sandro Tejada, Director of SHU Parents Program - 973-378-2635 or email@example.com
Saturday, January 25, 2014 from 12:00 PM to 2:00 PM (PST)
Dear Seton Hall Parent,
You are cordially invited to attend our first "Seton Hall Parents Lunch & Learn" with Professor Mary Balkun. This inaugural event will be held at the Chancellor's Suite in Seton Hall University. In Dr. Balkun's presentation, you get a sense of your student's classroom experience at Seton Hall University.
Dr. Balkun is a Professor and Chair of the Department of English at Seton Hall University and her research interests include material culture, gender studies, women's travel narratives, and the construction of identity in literature. She is the author of The American Counterfeit: Authenticity and Identity in American Literature and Culture, as well as articles on Phillis Wheatley, Sarah Kemble Knight, Walt Whitman, F. Scott Fitzgerald, and William Faulkner. Dr. Balkun also teaches a variety of courses, both undergraduate and graduate, including the University's first-year core course, The Journey of Transformation, Women and Literature II, American Romanticism, Studies in American Literature, and Senior Seminar.
It is my hope to see you there.
Kind Regards,
Sandro Tejada Director of SHU Parents Program 973-378-2635 or email@example.com
Seton Hall parents are invited to help advance the University's goals and priorities by volunteering their time and talents, and through their financial support. Directed by the University Advancement, in collaboration with Students Services, the Parents Program offers parents the following opportunities, and more:
Assist with admissions efforts at Freshman Orientation
Provide internship or career opportunities
Host a reception for Seton Hall University Facilitate contacts with corporations/foundations
Help with fundraising efforts for the Parents Fund
A special group of very active and engaged parents will be invited to join the Parent Leadership Council, which requires a minimum annual gift of $2,500 to the Parents Fund. Council members will meet regularly with representatives of University Advancement to discuss issues of vital importance to Seton Hall parents, and will receive exclusive invitations to Seton Hall events both on and off campus.
All Seton Hall parents are encouraged to get involved in their student's educational experience.
Join millions of people on Eventbrite.
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July 4th Sale: Enjoy 20% Off All Clearance Styles! — Shop Now —
Select your desired product options and we will notify you when it is back in stock.
Taos Shoes are inspired by the natural beauty and creative culture of the American Southwest. Using beautiful leathers, rich fabrics, rugged buckles, playful embroidery and intricate stitching you never have to choose between style and comfort.
Taos Gift Black Leather Women's Sandal
Features include:
Love love love love these shoes! So much so that I own 4 pairs in different colors! I was unable to find the bronze anywhere except here so I ordered them for the first time at Footwear Etc. they didn't have my size readily available so they actually called AND emailed me to let me know that the shoes had to be ordered from the vendor and did I still want them since it would take a little longer to get them! What awesome customer service! They said it could be about 2 weeks, but I had them
Sign up to receive new arrival, sale & special event info from us.
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"These are the only shoes I wear! I can only buy them on line though, as no one in my town carries them. I was in Munich, Germany, recently, and couldn't find them there either (though I didn't search high and low).
For years I purchased shoes that, in the end, did not work out for me. I had a closet full of expensive shoes. When I discovered these last year, I gave away dozens of perfectly good shoes."
©2015 Footwear Etc. All Rights Reserved. For any questions or assistance call 1-800-720-0572.


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Windows Vista Step by Step
By Joan Preppernau, Joyce Cox, Online Training Solutions, Inc.Published by Microsoft Press (http://oreilly.com/catalog/9780735622692)Experience...
By Joan Preppernau, Joyce Cox, Online Training Solutions, Inc.Published by Microsoft Press (http://oreilly.com/catalog/9780735622692)Experience...
Citrix claims that the new X1 Mouse will streamline the Windows app experience on iPad and Android devices when working remotely.
Redmond has said that the FREAK security flaw is found in versions of its Windows operating system from Windows Server 2003, Windows Vista, and higher.
Microsoft's Enhanced Mitigation Experience Toolkit (EMET) tightens the security screws in Windows and applications. It's set up for enterprise deployment and management.
Microsoft will share more about the Windows 10 'consumer experience' at an event on January 21 in Redmond.
Microsoft's MDOP 2014 R2 set of management and deployment tools for Windows, adds new application and user-experience virtualization features.
This update improves the compatibility, reliability, and stability of Windows Vista. This update includes the following improvements: It...
Microsoft is going to do more than reintroduce a Start menu as part of its plan to make Windows 9, a k a 'Threshold,' more appealing to Windows XP, Vista and Windows 7 users.
BlackBerry said BBM for Windows retains the native user experience and modern design of the Windows UI.
Nokia's Android experiment was fun while it lasted. Microsoft's Stephen Elop says: 'We plan to deliver additional lower-cost Lumia devices by shifting select future Nokia X designs and products to Windows Phone devices.'
The PC industry worldwide sold 136 million desktop PCs last year, along with 160 million traditional notebooks driven by keyboards and touchpads. Those big numbers explain why Microsoft is feverishly improving the desktop experience for "the next iteration of Windows."
Windows Phone continues to improve with the latest 8.1 update, and offers enterprise users a personal experience with the power of Microsoft and Exchange in their hands.
Sony unveiled the smallest laptop with a good keyboard ever produced in 2009. The Vaio P wasn't without its problems due to the small size, and it was saddled with Windows Vista. This little laptop with today's hardware, Windows 8.1, and a touch screen would be rather nice.
Unlike tablets on other platforms, Windows tablets need good keyboard accessories to round out the user experience.
Microsoft researchers are looking at ways to allow Windows 8, Windows Phone and Xbox users able to interact directly with Live Tiles.
There have been recent reports of problems with Windows 8 Updates destroying Linux/Windows dual boot setups. My experience has been that, while there may be problems, they probably aren't as serious as some reports make them sound.
Non-critical patch addresses problems in the Windows Update system files which could cause errors in future updates.
The Windows tablet experience improved quite a bit with the Windows 8.1 update. Rumors about what's coming next could muddy the waters if they turn out to be accurate.
Microsoft is continuing to tweak the Windows 8 user interface to make life easier for users who prefer the desktop experience, as new Windows 8.1 Update 1 screen shot leaks indicate.
A seamless Microsoft remote desktop experience between your Windows Phone and Windows desktop? It isn't happening.
Macs running Windows under Boot Camp may encounter some trouble when it comes to Thunderbolt niceties — in other words, the Mac experience.
Microsoft is giving its search experience on Windows Phone 8 devices an overhaul. Here are more details on how and when Microsoft will be delivering these updates.
Enterprise Software
Perfectly legal ways you can still get Windows 7 cheap (or even free)
How much does an iPhone 6 really cost? (Hint: It's way more than $199)
How to survive an iPhone liquid submersion (hint: it's not rice)
Windows 10


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Rockettes are coming back to Nashville
NASHVILLE, Tenn. — "The Radio City Christmas Spectacular" starring the iconic Rockettes is returning to the Grand Ole Opry House during the Christmas season, and tickets are now on sale.
The show will run from Nov. 16 through Dec. 24 for its 12th season in Nashville.
Part of the Gaylord Opryland Resort's annual "A Country Christmas" celebration, the Rockettes show features the number "Christmas Dreams," the showstopping numbers "The 12 Days of Christmas" and "Christmas in New York," and their classic presentations of "Parade of the Wooden Soldiers" and "The Living Nativity," which have both been part of the show since the beginning of "Christmas Spectacular."
In "Christmas Dreams," audiences will be a part of the ride of a lifetime seen through 3D glasses as Santa flies by Washington Square Park, speeds past the Empire State Building, coasts through Central Park and dashes by the holiday-clad windows of Fifth Avenue in his quest for a gift for Mrs. Claus.
The technological enhancements coupled with the imagery of New York at Christmas create an memorable experience as the magic of the holidays is brought to the iconic Grand Ole Opry House in this film.
In the "Christmas Spectacular's" 19-year history outside of New York, as well as the production at Radio City Music Hall, the show has played to more than 73 million people.
Ticket prices range from $25 to $99 and are available at www.ChristmasAtGaylordOpryland.com and by calling 877-889-6611.
More information about the 30th-annual "A Country Christmas" at the Gaylord Opryland Hotel, which features 2 millions lights and Christmas décor, "ICE! featuring Frosty the Snowman, Lorrie Morgan's Enchanted Christmas Dinner & Show and more is available at www.ChristmasAtGaylordOpryland.com.


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If you know you've been exposed to hepatitis B, tell your doctor right away. Treatment can be given within 24 hours of exposure to the virus, which may reduce the risk of infection.
To diagnose hepatitis B, your doctor will ask you about any symptoms you may have. He or she will perform a physical exam, and may order blood tests to diagnose hepatitis B and determine:
Knowing all your options can make life's toughest decisions a little easier.


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Request a Deal
Love this business? The more people who sign up, the more likely we are to get a deal.
People make it happen. Spread the word to request a deal!
21 signed up for this.
From Our Editors
Tony Cutrona, owner of Spa Riviera, specializes in microdermabrasion. During these treatments, tiny crystals dance over skin surfaces to remove dead cells and reduce the appearance of fine lines and blemishes. According to an article in the Daily Breeze, Cutrona's favorite part of his job is seeing the results on his clients' faces. He calls it "a wonderful feeling," adding, "they look healthier, so that's rewarding for me." Cutrona also offers a collection of facials, including one that focuses on acne-prone skin.


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NYC Parks Events Calendar
Get up, get out, and do something! Just about any day of the year, you can find something fun, informative, and healthy to enjoy at an area park. Feel free to browse the listings below, or use the search tools to find an event that matches your interests and location.
Viewing 951–960 out of 17,980 events
from October 5, 2012 (x) to April 25, 2026
Saturday, June 21, 2014
Shape Up NYC: Zumba
at McDonald Park House (in McDonald Playground), Staten Island
9:30 a.m.–10:30 a.m.
Zumba is a fusion of Latin, International and popular music dance themes creating a dynamic, exciting, effective fitness system!
Category: Fitness
Chair Exercise
at J. Hood Wright Recreation Center (in J. Hood Wright Park), Manhattan
9:30 a.m.–10:30 a.m.
This energizing, seated workout for adults and seniors invigorates and infuses new interest and enthusiasm in fitness. Recreation Center membership is required.
Category: Accessible, Fitness
GreenThumb Summer Festival
at The Marcus Garvey Park Amphitheater (in Marcus Garvey Park), Manhattan
10:00 a.m.–4:00 p.m.
Enjoy live music and dance, gardening workshops, children's activities, food demonstrations and much more.
Category: Arts & Crafts, Education, Concerts, Dance, Nature, Games, Kids, Free Summer Concerts, Food
Bryant Park Moves
at Bryant Park Lawn (in Bryant Park), Manhattan
10:00 a.m.–11:00 a.m.
Experience the joy of movement and dance! Open to all levels.
Category: Dance, Fitness, Outdoor Fitness
Dinosaur Safari: Mysteries Revealed
at Bronx Zoo (in Bronx Park), Bronx
10:00 a.m.–5:00 p.m.
See more than 30 animatronic dinosaurs, including a 40-foot long tyrannosaurus rex, on this ride through the two-acre safari.
Category: Education, Nature, Kids
Chair Exercise
at J. Hood Wright Recreation Center (in J. Hood Wright Park), Manhattan
10:00 a.m.–11:00 a.m.
This energizing, seated workout for adults and seniors invigorates and infuses new interest and enthusiasm in fitness.
Category: Accessible, Fitness
Weird, Wild & Wonderful
at The New York Botanical Garden, Bronx
10:00 a.m.–11:00 a.m.
The New York Botanical Garden invited members of the American Society of Botanical Artists to participate in a study of the eccentric, creating works of art based on unusual plants.
Category: Nature, Art
Crochet Two-Color Easy Open Mesh Beach/Market Bag
at Poe Park Visitor Center (in Poe Park), Bronx
10:00 a.m.–11:00 a.m.
Category: Arts & Crafts
It's My Park Day at Astoria Park
at Shore Boulevard, Queens
10:00 a.m.–1:00 p.m.
Please join the Astoria Park Alliance as they clean Astoria Park. They will be picking up litter and cleaning the shoreline.
Category: Volunteer, It's My Park
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Related Information
- Get information on upcoming events directly in your inbox by signing up for our Email Newsletters.
- Know about an event that's not on the calendar? Send us a tip!
- Planning an event and considering hosting it in a park? Make sure to read our Planning an Event page.


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Michelle Williams on the red carpet at the 2011 Oscars in Hollywood, CA on February 27, 2011.
She's ready for the summer!
Work it, girl.
Mariah Carey, her boobs and her new beau James Packer, aka the fourth richest man in Australia, took their love to Ibiza, Spain where they gallivanted on a yacht with her kids.
Bad Girl RiRi? More like Braless RiRi.


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Borges: Brandon Spikes a fighter to the end
Borges: Brandon Spikes a fighter to the end
In recent weeks, there has been much talk about the toughness of Patriots Pro Bowl left guard Logan Mankins, and rightfully so. Bill Belichick went so far as to say he could think of no other player he's coached who was tougher, and that seemed easy to believe judging by the number of serious injuries Mankins has ignored during his often-painful time in New England.
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