peripheries

Clash of the Titans: Abstinence vs Condoms

July 3rd, 2008 | by User Image

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Ivory Coast Campaign
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A few days ago Elizabeth Pisani commented on her website on how the Cambodian government caved in to US pressure. US pro-abstinence ideologues were meddling with a recognised efficacious HIV prevention intervention in exchange for economic advantages.

This was an interesting post and it fitted with one of the main theme explored in Elizabeth’s book, i.e. how ideology can take over epidemiology and surveillance data when it comes to designing HIV prevention programme.

Interestingly, in a Washington Post column, Rev. Sam L. Ruteikara, co-chair of Uganda’s National AIDS-Prevention Committee blew the wind the other way round.

Starting by commenting on a theme Elizabeth would probably agree with, Rev. Ruteikara laments on how economic interests and AIDS have been going hands in hands for quite a while now.

“In the fight against AIDS, profiteering has trumped prevention. AIDS is no longer simply a disease; it has become a multibillion-dollar industry”

And then turn his ire on Western experts driven more by ideology than by evidence-based data meddling with the Uganda HIV prevention programme.

“In the late 1980s, before international experts arrived to tell us we had it all “wrong,” we in Uganda devised a practical campaign to prevent the spread of HIV. We recognized that population-wide AIDS epidemics in Africa were driven by people having sex with more than one regular partner. Therefore, we urged people to be faithful.”

This time it is a different kind of Western ideologues that meddled with what was an effective prevention strategy, the “zero-grazing” campaign of President Museweni. By then, Uganda was not preaching abstinence only, but a reduction in multiple concurrent partners that was later identified as the driving force behind the epidemic and the best target for intervention (See Helen Epstein book: Africa: The Invisible Cure).

“Repeatedly, our 25-member prevention committee put faithfulness and abstinence into the National Strategic Plan that guides how PEPFAR money for our country will be spent. Repeatedly, foreign advisers erased our recommendations. When the document draft was published, fidelity and abstinence were missing.”

I am not convinced by Rev. Ruteikara’s argument that this was because of potential profit from “condoms, testing, anti-retroviral treatment, and assorted other drugs and devices [...] that must be transported, stored, distributed, advertised and resupplied endlessly” or because “casual sex is dear to [Westerners]”. But he has a point when observing that condom failed in Africa, not because they are not efficient but “mostly because fewer than 5 percent of people use condoms consistently with regular partners.”

When HIV infections in Africa are mostly spread by sex outside of marriage, which does equate with promiscuous behaviour, efficacious prevention, that is evidenced-based prevention, should address the issue. Fifteen years later the epidemic may be different and “zero-grazing” may be as useless as improperly used condoms, but if it is not the case then one can only agree with Rev. Ruteikara that “if the share of men having three or more sexual partners in a year drops from 15 percent to 3 percent, as happened in Uganda between 1989 and 1995, HIV infection rates will plunge. It is that simple.”

Elizabeth observed that “the most solid data we have suggest that by age 23, the early abstainers [in Uganda] had caught up with their peers in terms of infection rates” though at the time HIV rate plunged in Uganda, there was not many condoms around.

It is certainly not about promoting abstinence-only in Uganda but about facing ideologues in both camps.

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