[afro-nets] Condoms in Thailand and in Africa

[Edward Green <EGreendc@aol.com>]

Condoms in Thailand and in Africa
---------------------------------

Condom use in commercial sex is credited with reducing national
HIV prevalence in Thailand. But we have not found similar sto-
ries in Africa. Here is an interview with one of the authors of
the 2003 UNAIDS condom effectiveness review (OK, this was in the
Baptist Press, but mainstream media are still very nervous about
publishing findings that raise questions about the global AIDS
prevention paradigm, a paradigm based on the premise that there
is no prevention unless it involves drugs & medical devices).

Lest there be any doubt, I completely support condoms, and I
spent years working as a condom social marketer, but let's not
leave behavior change out of prevention. I believe in ABC, espe-
cially for Africa, where most HIV infections are not found in
commercial sex.

AIDS researcher: No good evidence condoms work against broad
epidemic
http://www.bpnews.net/bpnews.asp?ID=20471

Mar 30, 2005

By Erin Curry NASHVILLE, Tenn. (BP) -- No good evidence exists
to prove that condoms are the most effective method to curb the
spread of AIDS in most societies, Norman Hearst of the Univer-
sity of California, San Francisco told Baptist Press.

Hearst has been involved in AIDS research for more than 20
years, and two years ago he was commissioned by UNAIDS -- the
joint United Nations program on HIV/AIDS -- to conduct a review
of what's known about how well condoms work for AIDS prevention.

The medical doctor and professor of family and community medi-
cine and epidemiology and bio statistics concluded that condoms
are not the answer to stopping the worldwide AIDS epidemic.

Hearst found good evidence that condoms have been effective in
certain settings, such as the commercial sex business in Thai-
land.

"Generally speaking, where they have been most effective is
where transmission tends to be concentrated in certain settings
and it's possible to get very high rates of condom use in those
settings," he said.

"However, we really couldn't find good evidence that condoms
have been effective as a public health measure for generalized
epidemics, the type that you see particularly in parts of Africa
where the epidemic is the worst. That strategy has been employed
for many years now and just has not produced the results that
were hoped for," Hearst said.

Maria Wawer, a professor at Columbia University, presented a
study at an AIDS meeting in February that said abstinence and
sexual fidelity have played virtually no role in reducing the
AIDS rate in Uganda. Instead, she said, the deaths of previously
infected people are responsible for the reduction in overall
rates.

Hearst told BP he could not assess the study itself because it
has not been published yet and he did not attend Wawer's presen-
tation.

"But I am familiar with their study and with their data, and
there is no way to correctly draw the conclusions from their
data that have shown up in the press," he said. "Absolutely no
way. Either they themselves are drawing incorrect conclusions
from their data or the press is drawing incorrect conclusions
from what they presented. Again, because there is no written re-
port of this, there is really no way for me to tell those two
apart."

Wawer presented data starting in 1994, Hearst said, which cannot
accurately determine what worked in Uganda because the success
there was in the late '80s and early '90s.

"So their data first of all are irrelevant to what caused the
big decline in AIDS infection rates in Uganda," he said. "There
are data from before 1994, and what those clearly show are that
these declines were due to behavior change, mainly to people re-
ducing their numbers of partners. If you're talking about ABC --
abstinence, being faithful and condoms -- it was almost all the
B, some of the A and very little C at that point. So it was
aBc."

The Columbia study focused on the district of Rakai, and Hearst
said the data from that community shows that incidence rates
have been stable since 1994 and if anything may be starting to
increase slightly.

"The data, as I've heard second-hand that they've presented,
show that since 1994, condom use has gone up and there has been
a little bit of backsliding in terms of abstinence and number of
partners," Hearst said. "In other words, these things have got-
ten a little worse. So basically what has happened since 1994 is
Ugandans in this district are relying a bit more on condoms and
a bit less on abstinence and being faithful than they were 10
years ago and as a result of this, if anything, the infection
rates are going up slightly. How anybody can take this data and
twist it into saying A and B don't work and C does is beyond me.

"I think the tremendous publicity that this has received shows
the incredible eagerness of many people to try to latch on to
anything that might prove that condoms are the answer," he said.

Hearst has noticed that some members of the public health estab-
lishment have been reluctant to embrace abstinence and faithful-
ness as an effective strategy compared to condoms in the quest
to reduce AIDS rates, particularly because they may appear to be
embracing an agenda pushed by the religious right. He noted that
USAID has been ahead of most international organizations in
terms of advocating a more balanced ABC approach rather than C
only.

"Nevertheless, there remain many individuals in USAID and most
other organizations operating internationally that are very com-
mitted to the condom strategy," Hearst told BP, adding, "I
should make clear that I am in no way opposed to promoting con-
doms, however I think that needs to be part of an ABC strategy.
In generalized epidemics in Africa, if you look at what has
worked, there's much better evidence for especially the B of ABC
than there is for condoms."

The time that USAID became more open to promoting the ABC method
roughly corresponded to the time the Bush administration came to
power, Hearst said, which causes some people to believe the two
are intertwined.

"I think many people assumed that this was purely politically
driven. In a way that's unfortunate because while that may have
had something to do with it, it was based on sound scientific
evidence. And because of this assumption that it was all politi-
cally driven in many quarters, particularly international quar-
ters, people perhaps paid less attention to the scientific basis
for it than they would have otherwise," he said. "If this policy
had come out a few years earlier, say during the Clinton admini-
stration, I'm just speculating, but maybe people would been more
inclined to give it a fair hearing."

--
Edward Green
mailto:egreendc@aol.com