A consensus statement signed by over 140 HIV/AIDS experts from 36 countries has called for ideological disputes over HIV prevention programmes to be replaced by a consensus based on the best available scientific evidence. The statement is published in the November 27th edition of The Lancet.
Notable signatories include Archbishop Desmond Tutu, President Museveni of Uganda, Special UN Envoy Stephen Lewis, and representatives from the World Bank, Global Fund for AIDS/TB/Malaria, and five UN agencies, the heads of the HIV-AIDS programmes in several countries including Ethiopia, India, Jamaica and Uganda, as well as prominent technical, religious and other organizations working on HIV-AIDS.
The statement is a clear attack on the pronouncements of the Roman Catholic church and US politicians, who have attempted to undermine confidence in the reliability of condoms and divert money away from condom provision towards abstinence-based approaches to HIV prevention.
The signatories agree that programmes must be based on epidemiological evidence and should target where the risk is highest – commercial sex workers and injecting drug users in less mature epidemics, multiple concurrent partnerships in more mature epidemics.
The ABC (Abstain, Be faithful/reduce partners, use Condoms) approach has an important role to play in generalised epidemics, such as Uganda. All three elements have a role to play, according to the target population.
When targeting young people, for those who have not started sexual activity the first priority should be to encourage abstinence or delay of sexual onset, hence emphasising risk avoidance as the best way to prevent HIV and other sexually transmitted infections as well as unwanted pregnancy.
The statement also emphasises the role of condom use, and the need for accurate information on the subject to be given to young people. “For those young people who are sexually active, correct and consistent condom use should be supported. Young people and others should be informed that correct and consistent condom use lowers the risk of HIV (by about 80–90% for reported “always use”),” the authors state. Condom use should also be encouraged where partners do not know each others’ HIV status, as should testing and counselling of partners.
Amongst those at highest risk of infection (those with multiple sexual partners), promotion of condom use should be the highest priority, together with evidence-based strategies to promote behaviour change in these groups.
However the statement also explains why the “Be faithful” approach has an important part to play in HIV prevention. “When targeting sexually active adults, the first priority should be to promote mutual fidelity with an uninfected partner as the best way to assure avoidance of HIV infection. The experience of countries where HIV has declined suggests that partner reduction is of central epidemiological importance in achieving large-scale HIV incidence reduction”.
Prevention programmes need to work with marginalised communities where the epidemic is concentrated, and with community organisations to effect changes in community norms.
Halperin DT et al. The time has come for common ground on preventing sexual transmission of HIV. The Lancet 364: 1913-4, 2004.