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Condoms or abstinence: providing choices is key to HIV prevention

Condoms are an integral and essential part of comprehensive HIV/AIDS prevention and care programmes, and their promotion must be accelerated,” read a position statement issued by a couple of United Nations agencies, at the end of XV International AIDS Conference (IAC) Bangkok. Earlier, nearly 20,000 delegates who participated in six-day IAC held in July this year witnessed a passionate debate amongst advocates of US Agency for International Development (USAID) sponsored “ABC Approach to HIV Prevention” and dissenters who called it “paternalistic and prescriptive”.

“ABC” approach builds upon three fundamental prerequisite that can prevent or reduce the likelihood of sexual transmission of AIDS virus; A-for abstinence, B-for being faithful and C-for consistent condom use, especially for casual sexual activity and other high-risk situations.

Uganda is considered one of the world’s earliest success stories in confronting AIDS pandemic using “ABC” approach. According to estimates by UNAIDS and U.S. Census Bureau, the national prevalence (of HIV) peaked at around 15 percent in the early 1990s and fell to 5 percent by 2001 in Uganda. According to USAID this decline in prevalence was associated with a positive change in all three “ABC” behaviors. The country indeed reported a 60% decline in casual sex encounters, with Ugandan men and women exhibiting faithfulness or partner-reduction behaviour. The highest reduction was in the 15 - 29-year age group.

The scenario in nearby Botswana, where 58% of adult population was HIV positive in 2002 is gloomy. Ms Serea Mogwe of the School of Nursing at the University of Botswana, who was in Bangkok to participate in IAC, speculated over the reasons of failure of AIDS prevention programme in her impoverished country. She recalled that when in 1986, first person tested positive for HIV in Botswana, the government launched a massive education campaign with emphasis on condoms promotion. The slogan of the campaign was, “lock out AIDS with condoms". Ms Mogwe wonders if this was not a grave mistake. People seem to have developed "take the condoms and have fun" attitude. The onus of HIV prevention was apparently transferred from community to condoms, she lamented. She believes that her country should have placed equal stress on behaviour change, but this was missing from the programme.

A number of AIDS activists and experts fear that “ABC” does not offer a holistic approach to HIV prevention especially for women and young people.

Zeda Rosenberg in an impassioned presentation at the conference stated, “For women worldwide, being young and married are most significant risk factors for acquiring HIV infection. Married women or women who do not have control over if they have sex cannot choose abstinence. And many women who have contracted HIV infection from their husbands or long-term partners were faithful”.

Dr. Quarrisha Abdool Karim who addressed one of the plenary sessions at the IAC said, “Abstinence and life-long mutually faithful monogamous relationships are critical to reduce the number of discordant sexual acts, and should be promoted as part of any comprehensive prevention strategy”. But she also said that condoms, when used properly are 97 percent effective in preventing transmission of HIV through sexual contact.

Raoul Fransen of Young Positives said, ” The “ABC” approach, simply does not fit into the worldview or actual life of so many young people. It does not recognize our sexual or reproductive rights and does not provide workable options for women in particular, and even less for young women”.

“Rather than being taught not to have sex, young people-with or without HIV-should be enabled to make the choice-be this abstinence or partner reduction or having access to condoms-that is right for them” he adds.

Ms. Thoraya Ahmed Obaid, Executive Director of United Nations Population Fund in an effort to tread the middle path pleaded “It is time for leaders and policymakers to stop arguing about the merits of condom versus abstinence, because both are options for young people in different settings.”

USAID itself recognizes the need for balance of A, B and C interventions. It agrees that in Southeast Asia HIV is still largely confined to high-risk populations, in which correct and consistent use condom use is easy to implement.

Dr. Malcolm Potts of University of California talking to the author explained that active promotion of condoms amongst commercial sex workers and men having sex with men could play a key role in reversal of AIDS epidemic in India.

“ABC” approach nevertheless addresses one hitherto neglected element in HIV prevention strategies that is partner reduction and fidelity. Amid debate over abstinence versus condoms, “B” could become centerpiece of unifying evidence based ABC approach as suggested by experience in countries like Uganda and Thailand.