Abstinence, be faithful, use a condom

Certain cultural factors in resource limited settings pose significant challenges to prevention efforts and must be addressed to make it possible for people (especially youth) to adopt behaviours such as abstinence, being faithful, and correct and consistent condom use (ABC) according to several presentations at the 2006 PEPFAR Implementers Meeting held mid-June in Durban, South Africa. Some PEPFAR-funded prevention programmes are attempting to change cultural norms around polygamy, cross-generational sex, male attitudes towards women, sexual coercion and violence, taboos surrounding discussing sex, economic pressures and social expectations to have sex. Failure to confront these challenges could lead to the failure of prevention programmes, and could also have extremely negative unintended consequences including, potentially, the rape of girls known to be abstinent.

The US-funded strategy of ABC - Abstinence, Be Faithful, use Condoms - is in effect an abstinence- and pro-marriage monogamy-only strategy in Uganda, according to a new 80 page report, The Less They Know, the Better: Abstinence-Only HIV/AIDS Programs in Uganda, released on Wednesday by Human Rights Watch.

Washington -- For the first time since the breakout of AIDS, infection rates are showing widespread signs of stagnating or declining in some of the hardest-hit urban areas in sub-Saharan Africa, according to a new US analysis. US and United Nations officials have found a decline or leveling off of HIV rates in cities in 11 countries, greatly expanding earlier reports that the deadly virus was in retreat in Uganda and among young people in Zambia. But analysts say that the rates are still disturbingly high in those areas and that they are unsure whether to attribute the relative stability or decrease in the number of HIV cases to improved prevention efforts, changes in sexual behavior, or more ominously, an upswing in the numbers of people dying. A US Agency for International Development study of data from the US Census Bureau, which was obtained by the Globe, found that urban areas in Rwanda, Ethiopia, Tanzania, and Uganda have had steady declines in HIV prevalence. It showed that the virus was leveling off in cities in Zimbabwe, Malawi, Zambia, Kenya, Ivory Coast, Republic of Congo, and Senegal. But the study also showed several urban areas in which HIV continues a long-term trend of increasing. Those cities are in South Africa, Namibia, Nigeria, Mozambique, and Cameroon. The new report comes seven months after the National Intelligence Council, a think tank inside the CIA, projected that the number of HIV and AIDS cases could jump to more than 100 million worldwide by the year 2010, compared with more than 40 million now. Piot and others acknowledge that they do not know exactly what is causing the drop or leveling off of HIV infection rates in the urban areas. Paul S. Zeitz, director of the Global AIDS Alliance, an advocacy group, called the figures potentially ''exciting,'' especially in areas of high prevalence, such as Zimbabwe, Zambia, and Malawi. ''Does this mean, though, that death rates are accelerating?'' he said. ''We don't know. It could mean that so many people are dying that people are starting to change their behavior.''(Source:John Donnelly, Boston Globe 5/11/2003)

A former World Health Organization researcher has said Uganda's ABC strategy to combat HIV/AIDS --Abstinence, Be faithful, use Condoms, in that order -- could cut HIV infections by 80 percent if expanded across Africa, according to a feature in today's Washington Times. International aid workers have rebuffed the policy, calling it a cover for a right-wing agenda. Since Uganda launched the strategy in 1986, HIV/AIDS rates there have steadily declined, while infection rates in much of the rest of Africa have skyrocketed. Under the program, HIV prevalence among pregnant women -- a common yardstick for assessing HIV transmission in a population -- dropped in Uganda from 21 percent in 1991 to 6 percent in 2001. Some experts said the key to the program's success has been in changing Ugandans' sexual behavior by focusing on sexual fidelity, something international aid workers reportedly were doubtful about. According to epidemiological data, the focus on faithfulness may be the most important ingredient in the overall program's success. Women had to take responsibility for their own lives, said Sophia Mukasa Monico, a Ugandan who is a senior AIDS program officer for the Global Health Council. Wives told their husbands to be faithful, use a condom, even in marriage, or there would be no sex. Many women in Uganda had celibate marriages or moved out on their own, she said, adding that today, 60 percent of Ugandan women live on their own or are self-sufficient. The number of men reporting two or more sexual partners plummeted from more than 70 percent in 1989 to 15-20 percent in 1995. Among women, that figure dropped from 18 percent in 1989 to 2.5 percent last year. According to the Washington Times, Ugandan President Yoweri Museveni began the program after almost one-third of his top military officers tested positive for the virus during a trip to Cuba in 1986. Later that year, Cuban President Fidel Castro reportedly took Museveni aside and told him, Brother, you've got a problem. Uganda mobilised as if it were World War III, said Elaine Murphy, a global health specialist at George Washington University. They did this without donor money, on their own. At the time, the AIDS establishment laughed at him. ... But Museveni was right, said Norman Hearst, an epidemiologist at the University of California, San Francisco. I've had people tell me that the only reason they were successful in Uganda is that there were no European or American experts there. A more common international approach that relies heavily on condom distribution has been deemed largely a failure by some. There really is not any clear evidence that condom promotion by itself has been able to roll back the AIDS epidemic in any country where there is widespread transmission, Hearst said. The historical approach to HIV has been little A, little B and big C. The public health community at large did not believe in abstinence, but Africans were far ahead of the worldwide public health community on this, said Anne Peterson, a U.S. Agency for International Development global HIV/AIDS official. The core of Uganda's success story is big A, big B and little C. But U.S. HIV/AIDS workers have reportedly been reluctant to implement ABC-style programs, which have been endorsed by President George W. Bush and many faith-based organizations, for fear ABC is a cover for an abstinence-only policy. Hearst said that those who oppose ABC are just as religious in their beliefs as missionaries, and no more constructive. They are willing to let Africans die rather than embrace something that goes against their way of life. The Washington Times reports that ABC may be gaining more acceptance. ABC programs launched in Senegal and Zambia are reportedly showing positive results, and AID in December embraced ABC. Thinking people have to ask the question, 'What works? What saves lives?' said Murphy (Source: Washington Times, March 13).