Skip to comments.Sex Change; Uganda v. condoms.
Posted on 05/20/2002 1:54:38 PM PDT by anniegetyourgun
In 1986, not long after his guerrilla force seized power in Uganda, Yoweri Museveni sent 60 top officers from his bush army to Cuba for training. Several months later Fidel Castro approached Museveni at a conference in Zimbabwe with a staggering bit of news: Medical exams in Cuba had revealed that 18 of the 60 officers were HIV-positive. "Brother," Castro told Museveni, according to the version of the story the Ugandan leader has shared with many visitors, "you have a problem."
It was a terrible understatement. Years of war, displacement, pillage, and rape had entrenched HIV in Uganda as early as the late 1970s. Perhaps because his army was threatened, Museveni took Castro's warning to heart. Within one year he was leading a nationwide mobilization against AIDS that drew in bishops, imams, and public health experts, as well as thousands of small community groups nationwide. The program would become known as ABC, for "Abstain, Be Faithful, or wear a Condom"--very much in order of emphasis.
"Ugandans really never took to condoms," says Dr. Vinand Nantulya, an infectious disease specialist who helped dvise Museveni--they are high school chums from the southern Ugandan town of Mbarara--and who currently co-directs a Harvard School of Public Health study of the Ugandan experience. Instead the message, promoted everywhere from Museveni's speeches to elementary school curricula, was that children should abstain from sex until marriage and then practice "zero grazing"--i.e., fidelity. "You tether your animal around a tree, and it can only feed where it is tethered," Nantulya says with a chuckle. Billboards with this message are omnipresent in Uganda.
By last year the number of pregnant Ugandan women testing positive for HIV antibodies had fallen from 21.2 percent at the height of the epidemic in 1991 to 6.2 percent. By contrast, in neighboring Kenya the rate is roughly 15 percent; in Zimbabwe it stands at 32 percent; and in Botswana fully 38 percent of mothers-to-be are HIV-positive--with rates continuing to rise in each country.
And since Uganda's success is nearly unique in sub-Saharan Africa, more and more people are asking how it can be duplicated. Clearly, Museveni's strong leadership was key. (Senegal, a country with equally strong anti-HIV leadership, has also done well against the plague: HIV rates there have remained low.) But as researchers have begun picking apart the reasons for Uganda's success, controversy has dogged their work, perhaps because most of them agree on one troublesome fact: Condoms had relatively little to do with it.
By far the most striking epidemiological feature of Uganda's success is the drastic reduction in multiple partnering by Ugandan adults. Among women aged 15 and above, the number reporting multiple sexual partners fell from 18.4 percent in 1989 to 8.1 percent in 1995 to 2.5 percent in 2000, according to Nantulya's colleague in the Harvard study, anthropologist Edward C. Green.
Smaller but similar declines in male promiscuity were reported as well. At the same time, while the average Ugandan girl becomes sexually active at the age of 17--about one year older than was the case a decade ago--the rate of marriage among girls aged 15 to 19 is 76 percent, compared with 37 percent in neighboring Kenya.
In short, Uganda's experience suggests that abstinence and fidelity may be the keys to whipping aids in Africa. It's an idea with dramatic implications. According to a study presented to the United States Agency for International Development (usaid) this February by former Centers for Disease Control and Prevention and World Health Organization (WHO) epidemiologist Rand Stoneburner, Uganda's prevention model has the potential to reduce the AIDS rate in Africa's worst-stricken countries by 80 percent--the same level of efficacy one might expect from an HIV vaccine. Put another way, if South Africa had employed Uganda's approach from the moment the virus began showing up there roughly one decade ago, its epidemic "would have turned the corner in the year 2000 and started going down," says Stoneburner, who is advising South Africa's leading prevention program. "According to the modeling we've done, 3.2 million lives would be saved between 2000 and 2010."
The implications are not only epidemiological; they're political as well. During a U.N. General Assembly Children's Summit last week, Ugandan First Lady Janet Museveni spoke out against condom use at a forum sponsored by the religious right. Meanwhile, George W. Bush hosted her husband at the White House, part of the president's apparent effort to make abstinence promotion a centerpiece of America's development efforts in the Third World. "It's fortuitous common ground," says Jeff Spieler, chief of the research division in usaid's population office. "We're not really influenced by the Bush administration's line on abstinence. It just happens to be where the evidence is pointing." Adds Green: "I'm a flaming liberal, don't go to church, never voted for a Republican in my life. But if you say the things I've said ... the religious people love you and the people in public health get suspicious."
To be sure, there are populations in which condom promotion has produced impressive results. In Thailand, where prostitutes are strongly urged to use condoms, an estimated 30,000 people were infected with HIV last year, down from 140,000 in 1991. But that success is largely due to the fact that when Thailand began its prevention program, HIV was generally limited to an extremely high-risk pool: gays and prostitutes. By the time prevention programs had begun in most of Africa, by contrast, the epidemic had already entered the general population. And while condoms work well when used correctly and consistently--as one might expect they would be in the routinized world of prostitution--they work less well, if at all, in countering epidemics. (A recent study in Uganda led by Ronald Gray, a physician-researcher at Johns Hopkins University, confirmed that while consistent condom use worked in slowing HIV transmission, inconsistent use had no effect whatsoever.)
The experiences of Botswana and Zimbabwe provide further evidence that condom use alone is not the answer. The two nations rank first and second worldwide, respectively, in HIV prevalence. Yet by African standards, they are relatively modern states in which condoms are freely available. In a 1999 survey, more than 70 percent of adult men in Zimbabwe said they had used condoms in their last high-risk sex act, making Zimbabwe possibly the most condom-friendly country outside Asia. And while a leading usaid contractor, Population Services International (PSI), has marketed condoms heavily in Zimbabwe and Botswana, they haven't stemmed the aids epidemic. "Both countries are basket cases," says Green, who is writing a book about failures and successes in the fight against aids. "Condoms are marketed as if they are one hundred percent safe; but there is leakage, breakage, slippage, improper usage.... If condoms fail or aren't used correctly or consistently just twenty percent of the time, if you don't change your behavior and keep running around, it may be just a matter of time before you'll get infected."
All of which helps explain why even PSI--the McDonald's of the family-planning world, with six billion condoms sold worldwide--has been moving into the "A" and "B" elements of prevention as well. Currently the materials available on PSI's website stress the distribution and marketing of condoms. Recently, however, PSI joined a usaid-funded study with the Harvard School of Public Health and others to determine how Uganda's ABC program worked, with an eye toward including more abstinence and zero grazing in its anti-HIV campaigns. "If everyone used condoms, there wouldn't be transmission of aids," says John Berman, who heads PSI's aids program. "But we probably need to ramp up our investment in behavioral changes generally."
Researchers working in Uganda have suspected that abstinence and fidelity were contributing to declining infection rates for close to a decade. In 1993 Green wrote in a report for World Learning Inc., a usaid contractor: "If a high aids-prevalence country like Uganda shows a significant decline in STDs (sexually transmitted diseases) in the absence of a male condom prevalence rate over 5 (percent), it might suggest that other types of behavior change (premarital chastity, 'zero grazing' or marital fidelity, abstinence, non-penetrative and other safer sexual practices) can significantly affect STD incidence if not HIV incidence." Stoneburner, then a WHO official, came to a similar conclusion two years later. But their message didn't exactly catch fire. And while it is difficult to separate political differences from scientific ones, both Green and Stoneburner complain of difficulty publishing studies that point to the importance of fidelity and abstinence. In 1998 Green wrote an article about the apparent success of what he calls "primary behavior change"--more abstinence and fewer partners, as opposed to condom use and STD treatment--in slowing HIV transmission in the Dominican Republic, only to have it turned down by four academic journals. (He eventually published it as a brief letter in the journal Sexually Transmitted Infections.)
One prominent example of the public health establishment's preference for condoms over abstinence and fidelity in the 1990s was aidscap, a large usaid-funded "Behavior Change Communication" program run by Family Health International from 1991 to 1997. Aidscap simultaneously offered STD treatment and HIV testing in African clinics. But its prevention guidelines for health workers mainly encouraged them to talk about condom use and treatment of other STDs that make people more vulnerable to HIV. "It was considered too moralistic to stress abstinence and fidelity," recalls David Wilson, a leading usaid consultant from the University of Zimbabwe in Harare.
Officials at usaid say fidelity and abstinence--"delayed sexual debut" and "partner reduction," in public health speak--have always been part of their message. But Paul R. DeLay, acting director of usaid's Office of HIV-aids, acknowledges that "there was a tendency to focus on what we were most familiar with: condoms. Other parts weren't ignored, but were they applied to the extent they could have been?"
Today, however, there is mounting evidence that Uganda's lesson is catching on. Green notes that usaid has been more receptive to his and Stoneburner's research since Daniel Halperin--an academic medical anthropologist from outside the Beltway--joined usaid's office of HIV-aids last year. That office--which, like the rest of the government, has traditionally been hobbled in its support of religious groups by the prohibition on U.S. funding of activities that could be construed as proselytizing--is likely to boost assistance to a $1 million pilot project, begun last year, to provide small grants to African faith-based and community groups that primarily promote abstinence and fidelity. (So far, most of the grants have been for treatment rather than prevention.)
How such efforts fare may go a long way toward determining the future success of aids prevention in Africa. "What happened in Uganda," says Jim Shelton, senior medical scientist in usaid's Office of Population, "is that a lot of forces at one time were promoting more responsible sexual behavior, so you get to a social norm, a tipping point kind of thing. At some point all these messages, plus seeing people dying, get people to change their sexual behavior.... And I guess this has reinforced and awakened us to the virtue of emphasizing more the A and B in the ABC strategy." For the millions infected with HIV in the countries to Uganda's South and East, the awakening hasn't come a moment too soon.
I think that's it in a nutshell. When people get tired of burying their relatives and friends, they'll change their behavior. In many countries the people haven't reached that point.
The President and First Lady of Uganda are both Christians who have been praying for the US since 9-11 and led a national assembly praising God. Awesome courage and faith following Idi Amin's murderous rule. Then to tell the UN point blank that condoms aren't the answer...pray for Uganda. (^:
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