HIV prevalence has now declined in seven countries hit hard by AIDS, and two experts from Harvard University in Cambridge, Mass., attribute the progress to behavioral changes such as an increase in abstinence and partner reduction rather than to widely touted condom distribution.
“In every case, a few years before we notice prevalence going down, we see that the proportion of men and women who report having more than one sex partner in the past year goes down significantly,” said Edward Green, a senior research scientist at the Harvard School of Public Health.
“In almost all cases, we’ve seen the rate of premarital sex going down significantly. And condom use can either go up or down or stay the same. It doesn’t seem to make much of a difference,” he said.
The seven countries that have shown signs of declining infection rates include Uganda, Kenya and Zimbabwe and urban Zambia, Ethiopia, Haiti and Malawi, Green said.
ABC method successful
Foreign donors continue to push condom distribution and AIDS testing as prevention methods while disputing the effectiveness of the ABC method that has seen so much success, he said. The method teaches abstinence, being faithful to one partner and using condoms in high-risk situations.
“The sad thing is that even in Uganda, the national AIDS program has been largely redesigned by foreign donors to no longer emphasize the messages that were successful in reducing Uganda’s epidemic — faithfulness and partner reduction, and abstinence for young people.
“Condoms have had impact in certain high-risk groups, such as prostitutes in Thailand and Cambodia. But condoms have not had an impact in any general population or in any country where HIV is mostly in the general population, such as most of those in sub-Saharan Africa,” Green said.
Lack of awareness
Allison Herling Ruark, a research fellow with the AIDS Prevention Research Project at the Harvard Center for Population and Development Studies, said foreign donors often refuse to believe that abstinence and faithfulness messages work and instead contend that behavior is ingrained and efforts to change it are futile.
“I think people just aren’t aware that there’s good evidence of behavior changes,” Ruark said. “Even in Uganda where those changes happened 20 years ago and they’re so well-known, they’re not always as well known as they should be.
“People often think it’s difficult to measure behavioral changes, but we really don’t think it is. You can ask people questions about their sexual behavior, and you can look at trends over time,” she said. “We have been doing this for condom use for many years.”
Organizations that distribute condoms or provide treatment for sexually transmitted infections are easily able to keep a numerical tab of their efforts, Ruark noted, whereas the links between informational messages and behavior change are more challenging to substantiate.
Green, director of the AIDS Prevention Research Project, said the continued mainstream push for condom distribution and HIV testing and treatment also is fueled by an industry built around such services. But as Green’s colleague Daniel Halperin wrote in a Washington Post op-ed Oct. 22, there is little evidence indicating that testing for HIV alters behavior.
Most studies show that people continue their risky behavior after being tested and some worsen their behavior if they learn they’re not infected.
“HIV testing, in fact, does not appear to have played a crucial role in the declines in HIV rates observed in a number of countries and settings …,” Halperin wrote. “[V]irtually everywhere in Africa where HIV rates have fallen, these declines were preceded by steep declines in multiple partnerships.”
Halperin went on to conclude that the “most rigorous evidence suggests that there needs to be a vigorous expansion in Africa of behavior-change programs.”
Green pointed to Uganda as evidence that an ABC-type campaign works. “There was a lot of behavior change in Uganda, and it became the world’s great success story in AIDS, bringing down infection rates by two-thirds,” Green, a medical anthropologist, said.
“You couldn’t call it an abstinence-only program,” he added. “For example, the schools taught all the different ways one could prevent AIDS. They talked about condoms, but what most people don’t usually do is be candid about condoms.
“Condoms, if you use them each and every time, are about 80 to 85 percent effective in reducing HIV transmissions,” Green said. “But they’re rarely used each and every time, particularly in Africa where they’re hard to get and people run out and they’re not handy.”
Green said the rates of casual and multipartner sex have been on the rise for about 10 years in Uganda.
“The men and women who report more than one sex partner in the last year has gone up pretty steadily since the mid-90s,” he said.
Ruark said the change may be due to feelings of fatigue. “When AIDS was first perceived as a crisis in Uganda, people were really scared and willing to make changes in their behavior,” she said. “Now we’re 20 years on in the epidemic and people are not dying as frequently. There are drugs now that keep people alive, which is a wonderful thing but it does lead to some complacency.”
There’s a tendency for a perception of reduced risk to make risk-taking more attractive, Ruark said, referring to a public health term called disinhibition.
“People adjust their behavior in response to the increased sense of personal safety that comes with protective behaviors such as wearing a seat belt or using a condom,” she said, adding that when treatment is available, “suddenly people feel that AIDS is not such a death sentence.”
Still, Ruark is optimistic as she has found that peer groups in which teens could encourage each other not to have sex are thriving.
She also emphasized that AIDS prevention is not just a youth problem. It depends largely upon adults changing their sexual behavior, she said. “I think at times, especially for faith communities, there’s a tendency to just focus on youth and abstinence, which is important, but actually, epidemiologically, it’s adult behavior that’s more important.
“What’s really fueling HIV in sub-Saharan Africa is not young people having sex. It’s adults having sex with multiple partners and the creation of sexual networks where HIV can spread like wildfire,” Ruark said. (BP)
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