What is the importance and place of promoting abstinence from sex and illicit drug-taking, as distinct from harm-reduction measures like condom promotion and clean needle provision? Although a debate at the Fifteenth International AIDS Conference in Bangkok was described publicly by UN Secretary General Kofi Annan as “irrelevant”, it still drew a substantial audience on the meeting's first day. The billing, “CNN vs ABC”, implied a clash of US broadcasters and was deftly mediated by an anchor from CNBC Asia, Bettina Chua, who presents a programme called Squawk Box from her base in Singapore.
In the red corner, CNN stands for “Condoms, Needles and Negotiation skills” and was championed for the International Planned Parenthood Federation by its US-based Director General, Dr Steven Sinding, and a young woman, Arushi Singh, from Chandigarh in India.
Dr Sinding observed that he found himself in agreement with much of what Dr Green had written on HIV prevention, in contrast to the original speaker he had been asked to debate with, Congressman Chris Smith, a “stalwart of the Christian Right from the United States.”
Dr Sinding argued that while the “ABC” approach as implemented in Uganda and other countries was admirable and deserved support, it had been “severely twisted” and even perverted by religious reactionaries who influence the US Administration and the Vatican into something extreme. This misrepresented condoms and sought to deny that choice to people, which represented a “serious setback to efforts to bring HIV/AIDS under control.”
Dr Sinding said that the 2003 analysis by Hearst and Chen for UNAIDS had found condom promotion had been most effective where commercial sex had been important in HIV transmission, notably in Thailand and Brazil, but did not have as much impact where widespread heterosexual transmission was taking place. He argued that condom promotion is as much about behaviour change as any other HIV prevention strategy, and required a great deal of effort to educate people in effective use of condoms. Experience with condoms as contraceptives was that “compliance in its use is difficult to achieve with consistency over extended periods of time.”
Abstinence-only education lacked clear evidence that it works: a recent review of US programmes containing abstinence messages found no difference in pregnancy rates among the partners of young male participants compared to those who had not been on any programme. Abstinence pledgers broke their pledges [to abstain from sex until marriage] in over 60% of cases and 55% who reported keeping their virginity had “risky forms of non-vaginal sex.”
Dr Sinding concluded with a defence of needle-exchanges, insisting that rehabilitation and detoxification efforts, while essential, are not a substitute for clean needles. Empowering individuals to make informed choices was the only approach that worked.
Ms Singh spoke of an adolescent health care clinic in her city where programme staff refused to answer her questions about sex and STIs, telling her to ”wait until you are married, and you will find out!”
Girls could be married from the age of 14 to older husbands, to whom they could not say “no,” she noted. Ms Singh described the experience of a friend who had been forcibly married at the age of 20 to a man whose positive HIV status was not revealed to her. After her husband’s death she was thrown out of her home by her in-laws, but has now become an effective and committed educator of young people, as the organiser of a positive women’s network.
She questioned the practicality of ABC approaches and asked whether abstinence-only campaigns could really be empowering in this context. Young people had the right to knowledge and empowerment that came from education, “telling us the complete story … in all its loud and glorious detail.” The ABC approach excluded males who had sex with males, sex workers and drug users, which was a human rights issue.
In the black and white corner, ABC stands for “Abstain, Be faithful, or (use) Condoms” – Uganda’s famous recipe for reversing the tide of HIV and AIDS. It was advocated by Dr Edward C Green, a self-described liberal Democrat from Harvard University’s Center for Population and Development Studies and a member of the US Presidential Advisory Council on HIV and AIDS. He was joined by Simon Peter Onaba, who spoke from his experience of committing himself to sexual abstinence for the past three years through a group he joined at Makerere University, Uganda, having been sexually active in his teens.
Dr Green stressed that he was advocating for the ABC strategy as implemented in Uganda, which was clearly not the ideologically-driven abstinence-only approach attributed by Dr Sinding to the Vatican and elements of the Bush administration.
Dr Green argued that condom use and harm-reduction using needles had developed in the USA in working with populations of gay men and drug users who were seen as either unable to make greater changes in behaviour or at risk of being driven away from services. Dr Green had himself been involved in the social marketing of condoms in Africa and continues to support condom use, but now believes that other modes of HIV prevention are of greater value against AIDS in Africa.
There was no evidence from Africa that more condoms had led to less AIDS. Botswana, South Africa and Zimbabwe now have exceptionally high rates of condom use, but also continuing high HIV prevalence. Consistent use of condoms could indeed give substantial protection against HIV but most condom use is inconsistent, and this does not protect, according to Hearst and Chen’s review for UNAIDS.
In Uganda, most of the change in HIV incidence took place between 1986 and 1991 before condom social marketing really started in the mid-1990s and was clearly linked to delayed sex among young people and reductions in extramarital relationships.
Up to 11% of sexually active Ugandans would now say they had used condoms when they last had sex. Perhaps more helpfully around 95% of the small number of men who admitted paying for sex reported that they had used condoms when they did so.
He concluded that where epidemics are concentrated among commercial sex workers and/or injecting drug users, then the “CNN” approach could be more “effective, appropriate and realistic”, but where epidemics are more generalised, then ABC is more effective, with an emphasis on abstinence and behaviour change, despite its limitations in respect of inequalities of gender and other power difference, since there had been such limited success in promoting widespread use of condoms.
Simon Peter Onaba, a 22-year-old from Uganda, spoke of his experience of having decided to stop having sex and remain abstinent, having had sex from the age of 16, sometimes with condoms but increasingly without, until at university he had been challenged by others about his behaviour. He was now committed to abstinence until he married.
From the audience, Dr Geeta Rao Gupta asked Mr Onaba what choices he would offer to a young woman who did not have the same freedom to abstain that he described for himself. He replied that political leadership to change social structures was essential. This was reinforced by Dr Green who observed that Uganda had enacted and was increasingly enforcing laws against “defilement” of girls and young women.
The real question, as raised by a South African member of the audience, was why the Bush administration had placed “abstinence only” conditions on a proportion of US international aid for HIV prevention. Dr Green explained this as a reaction to the experience that all money was going to condom promotion despite evidence that this was not the most effective means of HIV prevention in Africa. Dr Sinding argued that it was pandering to a religious constituency in the USA.
Dr Sinding observed that the only real difference he had with another member of the panel was with the implication by Mr Onaba that abstinence was a better choice than the choice to use condoms. This was a question of values, which was at the heart of the issue, and could not be resolved by evidence.
However, Ms Singh insisted that the status of women, education and poverty were in fact the main reasons that people do not have the choice to protect themselves.
Ms Chua had the last word, concluding that different messages are needed by different people, and the only thing that stood in the way of getting this was “politicisation of the AIDS dollar.”