Condom promotion in Uganda not reducing HIV risk, study shows

A study of condom distribution and promotion in Uganda has found that whilst education in condom use increased uptake, it did not lead to consistent use in the following six months. Men in the intervention group went on to have a larger number of sexual partners and were somewhat less likely to use condoms with casual sex partners than the control group. The findings are published in the September 1^st edition of the Journal of Acquired Immune Deficiency Syndromes.

The findings are unlikely to be welcomed by those who argue that the Ugandan government is deliberately turning its back on condom promotion in order to please US funders and evangelical Christians, and raise uncomfortable questions about the evidence base that informs the current international orthodoxy in HIV prevention.

The study compared two groups recruited from poor urban communites in Kampala. It was designed to overcome barriers to condom access and a lack of skills in condom use identified in Uganda. The authors note that improved availability of condoms in Uganda has had only a modest effect on condom uptake.

One group of men (n=213) was invited to attend a workshop on condom use, which explained the aims of the study, demonstrated how to use condoms, discussed how to negotiate condom use and gave participants general information about HIV in Uganda. Participants were also given vouchers that could be redeemed for condoms at local outlets, and the vouchers were used to monitor the uptake of condoms in the intervention group.

The control group was invited to attend to a workshop which gave general information about HIV in Uganda and provided vouchers for condoms.

All participants were asked about their sex partners and condom use at baseline and after six months. Seventy-seven per cent of the intervention group actually attended a workshop.

Members of the intervention group were more likely to be married and a larger proportion were aged 25 to 30 years (although this difference was not significant).

Men in the intervention group redeemed significantly more condom vouchers during the follow-up period (mean 110 vs 13 in the control group, p=0.002). However, whilst the proportion in the control group reporting unprotected sex during follow-up declined, it remained stable in the intervention group.

The proportion reporting inconsistent condom use with all sex partners did not change in either group, but inconsistent condom use with casual sex partners fell substantially in the control group at follow-up (from 7.3% to 0.6%). The reduction in inconsistent condom use with casual partners was less profound in the intervention group (7% to 3.8%) but this difference was not statistically significant.

Men in the intervention group reported a significantly higher number of partners during the six month follow-up period when compared with the six months prior to joining the study, and the intervention group also reported a non-significant increase in the number of occasions of unprotected sex with casual partners (there was a median difference of 0.65 unprotected casual partners between the groups). This was despite the fact that the intervention group reported a decline in the overall number of casual partners.

Men in the control group on the other hand reported a significant decline in the total number of casual partners.

The authors note that whilst the uptake of condoms was much higher among the intervention group, proving that the intervention had overcome barriers to access, this improvement in uptake actually appeared to be associated with an increase in behaviour that may paradoxically increase the rate of HIV transmission in sexual networks with high levels of partner change.

A larger and more expensive study that can measure actual rates of HIV infection would be needed to prove that condom promotion and distribution is less effective at reducing HIV transmission than education on partner reduction and sexual abstinence.

These findings are likely to add to the growing controversy over condom supply and distribution in Uganda. There has been a shortage of condoms since late 2004 in Uganda, when the government recalled its own Engabu brand following a loss of public confidence in the reliability of this brand. At the same time, argue advocates such as UN AIDS Envoy Stephen Lewis, the focus of free condom distribution in Uganda has shifted from generalised availability through family planning clinics and other social marketing outlets to more targeted distribution to high-risk groups.

The move is part of what advocates charge is a growing politicisation of HIV prevention through the emphasis of the President’s Emergency Plan for AIDS Relief (PEPFAR) on programmes that focus on sexual abstinence rather than condom use.

However, a 2004 Cambridge University study published in the journal Science found that a reduction in sexual partners and later age of sexual debut were the factors responsible for a reduction in HIV incidence in Uganda, not condom use. Furthermore, a study by the Columbia University expert Maria Wawer, presented at the Twelfth Conference on Retroviruses and Opportunistic Infections in February 2005, found that in Uganda’s Rakai district's increased condom uptake had nothing to do with the reduction in HIV prevalence, and that reductions in incidence pre-dated the promotion of condoms by Uganda’s government.