After more than two decades of HIV/AIDS, we have learned a great deal about how it is transmitted, care and treatment options, its global impact, its developmental roots, and what preventive measures are most feasible and effective. Yet it sometimes seems as if these science-based lessons are lost in the cacophony of ideological, religious and political rhetoric that surrounds discussion of HIV/AIDS today. The uproar about ABC (abstinence, being faithful, condom use) is an excellent case in point, for the narrow manner in which this model of prevention is being interpreted may be undermining the global response.
On the face of it, few would argue with the basic premise of ABC. It is epidemiologically and programmatically sound—a tiered approach to prevention that is appropriately calibrated to levels of risk. Indeed, as implemented in Uganda and other places, the ABC approach has been successful and effective in reducing the rate of new infection and deserves the support and the praise it has received.
But it's not that simple.
Marriage as a Risk Factor
The reality of AIDS in Sub-Saharan Africa—still the region bearing the overwhelming share of the global AIDS burden—is that marriage (and the illusion of fidelity among supposedly HIV-negative couples) is increasingly seen as a risk factor. As health providers, we see that married, monogamous women are highly vulnerable to HIV infection due to their lack of rights within marriage, difficulties negotiating safer sex, extended partner absence and domestic violence.
In Sub-Saharan Africa, the majority of newly HIV-positive women are contracting the virus within marriage from their husbands.1 This pattern is reflected around the world. In Cambodia, prevalence is falling among sex workers but rising rapidly in married women: Fifty percent of all married women who contracted the virus in 2002 were infected by their husbands.2 Furthermore, in one recent study, more than 80% of HIV-positive women were monogamous,3 and in a study in Rwanda, 25% of women who were HIV-positive said they had had only one sexual partner in their lifetime.4 These women had complied with the prevention messages they were given, and yet doing so failed to protect them. Promoting abstinence or faithfulness as the only ways to prevent HIV transmission will leave millions of people without the ability to protect themselves from infection.
Improving women's status and negotiating skills are thus key areas for any prevention strategy. Women are increasingly vulnerable to HIV infection.5 In 1997, women made up 41% of people living with HIV; by 2002, this figure had risen to almost 50%. In 2003, UNAIDS estimated that five million people were newly infected and 40 million people were living with HIV/AIDS. Half of those infected were women.
Another critical issue is condom stigma—the association in many people's minds between condoms and illicit sex. Many women and men feel shame about using—and frequently refuse to use—condoms within marriage. A tremendously important goal must be the desensitization of condom use, the removal of the taboo on this method and, indeed, on communication between partners about condom use. The genius of Senator Mechai in Thailand and, early on, President Museveni of Uganda was their ability, as political leaders, to create an environment in which open discussion of HIV transmission permitted discussions about sexuality—at the community, family and couple levels. Once options were discussed, real behavior change occurred. In Thailand, this resulted in phenomenal changes in condom use, and in Uganda it resulted in a more multidimensional, but nonetheless highly effective, behavioral response.
Indeed, effective condom use is real behavior change. It has been said that past programs were primarily focused simply on providing condoms and hoping people would use them correctly. But for many years, IPPF has been teaching people how to use condoms correctly and serious efforts have been under way for several years to help young people understand how to use condoms properly. By promoting condoms as part of a standard package of prevention measures, we can help to destigmatize and normalize their use.
It comes down to this: Serious efforts at behavior change communication may succeed in delaying sexual debut and limiting the numbers of partners. But among HIV-positive people—the majority of whom may be unaware of their status—sex is an undeniable reality and, in the absence of any other technology to protect sexually active people from the risk of infection, prevention messages must stress correct and consistent use of condoms.
Evidence That Condoms Work
What is the evidence that condoms are an essential part of the battle against AIDS? First, a recent position statement from WHO, UNAIDS and UNFPA reads, in part:6
"The male latex condom is the single most efficient available technology to reduce the sexual transmission of HIV and other sexually transmitted infections. …Condoms will remain the key preventive tool for many, many years to come…."
According to a meta-analysis commissioned by UNAIDS, condom use is 90% effective in preventing transmission, and condom use has been a key element in reductions in HIV prevalence in many countries.7 In Thailand and Brazil, for example, where transmission has primarily been within the commercial sex trade, condom promotion has been especially effective.
But, where the epidemic is largely heterosexual and widespread, evidence on the effectiveness of condom programs has been more mixed and less clear. In Uganda, while it is clear that condoms have played a role in lowering infection rates, reducing the number of sex partners appears to have played at least as large a role. In other words, condoms should not be seen as distinct from other strategies but as an integral part of comprehensive strategies that also counsel abstinence and reducing the number of sexual partners. This view is also expressed in the 2004 UNAIDS Report on the Global AIDS Epidemic.8
Furthermore, the effectiveness of condoms in preventing disease transmission (and unwanted pregnancy, for that matter) lies not in the inherent quality of the product but in its effective use. Evidence from family planning programs over many years makes it abundantly clear that the condom is a safe and relatively effective method, but that compliance in its use is difficult to achieve with consistency over extended periods of time. For this reason, family planning fieldworkers often recommended other methods of birth control over condom use, although condoms were always known to be the best and, indeed, one of the only forms of prevention of STIs.
There is a good analogy between moralizing against condoms and moralizing against needle exchange programs. In both cases, the moralizers wish to deny human nature and behavior. A 2004 evidence assessment by the Cochrane Collaborative Review Group on HIV Infection and AIDS shows that clean needles, methadone substitution for injecting drug use, and condom use by injecting drug users are effective in reducing the spread of HIV.9
Of course, rehabilitation and detoxification efforts must continue, and we must search for ways to make them better. One way to do this is by providing not just one, but a suite of care services that recognize the reality of injecting drug users' lives. Just as abstinence and fidelity are not substitutes for condom use, so rehabilitation and detoxification are not substitutes for clean needles.
Distorting the ABC Model
Abstinence for younger adolescents, faithfulness in marriage and condom promotion have a place in international HIV/AIDS programs. Unfortunately, by twisting the ABC concept important international voices—the U.S. government and the Vatican, in particular—have made ABC controversial. The actions of these major political actors are not only regrettable; given their influence over millions of people around the world, they represent a serious setback to efforts to bring HIV/AIDS under control.
Conservative U.S. government officials have made clear the Bush administration's preference for abstinence-only approaches and have registered strong misgivings about the moral and ethical advisability of providing condoms as part of AIDS prevention programs, arguing—incorrectly—that condoms may encourage early sex and sexual promiscuity. In addition, U.S. officials have removed scientifically accurate information about condom use effectiveness from the Web sites of several federal agencies and have questioned whether or not condoms provide protection against STIs, including HIV.
This issue of abstinence-only programming needs to be addressed head on. Not only are there question marks over exactly what defines abstinence and what makes it sustainable; there is no clear evidence that it works.
As the largest international funder of HIV/AIDS programs, the attitude and recommendations of the U.S. government have far-reaching consequences for the health of people across the world. The "ABC" approach is a central prevention component of the new U.S. Global AIDS Strategy, yet the government channels one-third of all HIV prevention funding to abstinence programs, particularly those that counsel abstinence until marriage.10
To date, however, there is no conclusive proof that abstinence-only programs have been successful in any country in the world in reducing HIV transmission.11 In a recent review of abstinence programs in the United States by DiCenso and colleagues, pregnancy rates among the partners of the young male participants were no lower than those among the partners of nonparticipants.12
Similarly, the effectiveness of abstinence as a long-term strategy—particularly for young people—was refuted by a study presented at the annual meeting of the American Psychological Society that reported that not only was the "virginity pledge" broken by more than 60% of the pledgers, but 55% who reported keeping their virginity admitted to engaging in risky forms of nonvaginal sex.13
For its part, the Vatican has conducted a global campaign of disinformation about condoms. Not only has the Vatican echoed the Bush administration's concerns about the effect of condoms on Christian morality, but many in the church hierarchy have denigrated condoms as flawed products.14 In 2003, the president of the Vatican's Pontifical Council for the Family, Cardinal Alfonso López Trujillo, told a BBC Panorama program, "the AIDS virus is roughly 450 times smaller than the spermatozoon. The virus can easily pass through the 'net' that is formed by the condom."15 In countering the Vatican's claims, WHO and IPPF were supported by research from the U.S. National Institutes of Health, which concluded that "intact condoms are essentially impermeable to particles the size of STD pathogens, including the smallest sexually transmitted virus."16
In other words, the HIV prevention approach we are talking about here is not ABC in its pure form but rather ABC as it has been perverted by the religious conservatives who wield such strong influence within the Bush administration and the Vatican.
Science, Not Ideology
We live in a world that is complex and diverse. Many things in addition to the ABC approach are necessary to control the epidemic: Voluntary counseling and testing—a cornerstone of the WHO "3 by 5" initiative—needs to be linked to treatment access; destigmatization campaigns are required to promote a better environment for those seeking prevention and treatment; and increased efforts need to be made to improve the status of women and young girls. The UNAIDS Global Coalition on Women and AIDS provides an excellent platform to revitalize our global prevention agenda. And while the ABC approach will form part of the response, it should be firmly grounded in science, not ideology.
Instead of debating CNN vs. ABC, we must recognize the complexity of sexual relations, which embrace every facet of our lives, including issues of culture, tradition, power and status. We must acknowledge the unequal power relationships between men and women, especially older men and younger women, and we must design interventions that provide realistic choices. Above all, we must resist efforts to impose a particular morality on individuals. We must respect the individual and find ways of giving people realistic and effective options. We must not deny men and women access to information or technologies that enable them to protect their health and even their lives. Forty years of experience in family planning and reproductive health has shown us that empowering individuals to make informed choices is the only approach that really works.