[afro-nets] CNN and ABC

[Claudio Schuftan <claudio@hcmc.netnam.vn>]

CNN and ABC
-----------

Steven Sinding is the Director General of the International
Planned Parenthood Federation. Before moving to IPPF, he had
worked for many years for USAID and has deep understanding of
the political link between the White House and Vatican as well
as the politics behind the US's government health-related poli-
cies.

This article is well-written and provides also a number of good
references for those who are interested in the "CNN" and "ABC".

Alan Guttmacher Institute has generously given permission to
post articles from its journals.

Claudio Schuftan
mailto:claudio@hcmc.netnam.vn


--
International Family Planning Perspectives
Volume 31, Number 1, March 2005
VIEWPOINT

DOES "CNN" (CONDOMS, NEEDLES, NEGOTIATION) WORK BETTER THAN
"ABC" (ABSTINENCE, BEING FAITHFUL AND CONDOM USE) IN ATTACHING
THE AIDS EPIDEMIC?

By Steven W. Sinding

After more than two decades of HIV/AIDS, we have learned a great
deal about how it is transmitted, care and treatment options,
its global impact, its developmental roots, and what preventive
measures are most feasible and effective. Yet it sometimes seems
as if these science-based lessons are lost in the cacophony of
ideological, religious and political rhetoric that surrounds
discussion of HIV/AIDS today. The uproar about ABC (abstinence,
being faithful, condom use) is an excellent case in point, for
the narrow manner in which this model of prevention is being in-
terpreted may be undermining the global response.

On the face of it, few would argue with the basic premise of
ABC. It is epidemiologically and programmatically sound-a tiered
approach to prevention that is appropriately calibrated to lev-
els of risk. Indeed, as implemented in Uganda and other places,
the ABC approach has been successful and effective in reducing
the rate of new infection and deserves the support and the
praise it has received.

But it's not that simple.

Marriage as a Risk Factor

The reality of AIDS in Sub-Saharan Africa-still the region bear-
ing the overwhelming share of the global AIDS burden-is that
marriage (and the illusion of fidelity among supposedly HIV-
negative couples) is increasingly seen as a risk factor. As
health providers, we see that married, monogamous women are
highly vulnerable to HIV infection due to their lack of rights
within marriage, difficulties negotiating safer sex, extended
partner absence and domestic violence.

In Sub-Saharan Africa, the majority of newly HIV-positive women
are contracting the virus within marriage from their husbands.1
This pattern is reflected around the world. In Cambodia, preva-
lence is falling among sex workers but rising rapidly in married
women: Fifty percent of all married women who contracted the vi-
rus in 2002 were infected by their husbands.2 Furthermore, in
one recent study, more than 80% of HIV-positive women were mo-
nogamous,3 and in a study in Rwanda, 25% of women who were HIV-
positive said they had had only one sexual partner in their
lifetime.4 These women had complied with the prevention messages
they were given, and yet doing so failed to protect them. Pro-
moting abstinence or faithfulness as the only ways to prevent
HIV transmission will leave millions of people without the abil-
ity to protect themselves from infection.

Improving women's status and negotiating skills are thus key ar-
eas for any prevention strategy. Women are increasingly vulner-
able to HIV infection.5 In 1997, women made up 41% of people
living with HIV; by 2002, this figure had risen to almost 50%.
In 2003, UNAIDS estimated that five million people were newly
infected and 40 million people were living with HIV/AIDS. Half
of those infected were women.

Condom Stigma

Another critical issue is condom stigma-the association in many
people's minds between condoms and illicit sex. Many women and
men feel shame about using-and frequently refuse to use-condoms
within marriage. A tremendously important goal must be the de-
sensitization of condom use, the removal of the taboo on this
method and, indeed, on communication between partners about con-
dom use. The genius of Senator Mechai in Thailand and, early on,
President Museveni of Uganda was their ability, as political
leaders, to create an environment in which open discussion of
HIV transmission permitted discussions about sexuality-at the
community, family and couple levels. Once options were dis-
cussed, real behavior change occurred. In Thailand, this re-
sulted in phenomenal changes in condom use, and in Uganda it re-
sulted in a more multidimensional, but nonetheless highly effec-
tive, behavioral response.

Indeed, effective condom use is real behavior change. It has
been said that past programs were primarily focused simply on
providing condoms and hoping people would use them correctly.
But for many years, IPPF has been teaching people how to use
condoms correctly and serious efforts have been under way for
several years to help young people understand how to use condoms
properly. By promoting condoms as part of a standard package of
prevention measures, we can help to destigmatize and normalize
their use.

It comes down to this: Serious efforts at behavior change commu-
nication may succeed in delaying sexual debut and limiting the
numbers of partners. But among HIV-positive people-the majority
of whom may be unaware of their status-sex is an undeniable re-
ality and, in the absence of any other technology to protect
sexually active people from the risk of infection, prevention
messages must stress correct and consistent use of condoms.

Evidence That Condoms Work

What is the evidence that condoms are an essential part of the
battle against AIDS? First, a recent position statement from
WHO, UNAIDS and UNFPA reads, in part:6

"The male latex condom is the single most efficient available
technology to reduce the sexual transmission of HIV and other
sexually transmitted infections... Condoms will remain the key
preventive tool for many, many years to come..."

According to a meta-analysis commissioned by UNAIDS, condom use
is 90% effective in preventing transmission, and condom use has
been a key element in reductions in HIV prevalence in many coun-
tries.7 In Thailand and Brazil, for example, where transmission
has primarily been within the commercial sex trade, condom pro-
motion has been especially effective.

But, where the epidemic is largely heterosexual and widespread,
evidence on the effectiveness of condom programs has been more
mixed and less clear. In Uganda, while it is clear that condoms
have played a role in lowering infection rates, reducing the
number of sex partners appears to have played at least as large
a role. In other words, condoms should not be seen as distinct
from other strategies but as an integral part of comprehensive
strategies that also counsel abstinence and reducing the number
of sexual partners. This view is also expressed in the 2004 UN-
AIDS Report on the Global AIDS Epidemic.8

Furthermore, the effectiveness of condoms in preventing disease
transmission (and unwanted pregnancy, for that matter) lies not
in the inherent quality of the product but in its effective use.
Evidence from family planning programs over many years makes it
abundantly clear that the condom is a safe and relatively effec-
tive method, but that compliance in its use is difficult to
achieve with consistency over extended periods of time. For this
reason, family planning fieldworkers often recommended other
methods of birth control over condom use, although condoms were
always known to be the best and, indeed, one of the only forms
of prevention of STIs.

Needle Exchange

There is a good analogy between moralizing against condoms and
moralizing against needle exchange programs. In both cases, the
moralizers wish to deny human nature and behavior. A 2004 evi-
dence assessment by the Cochrane Collaborative Review Group on
HIV Infection and AIDS shows that clean needles, methadone sub-
stitution for injecting drug use, and condom use by injecting
drug users are effective in reducing the spread of HIV.9

Of course, rehabilitation and detoxification efforts must con-
tinue, and we must search for ways to make them better. One way
to do this is by providing not just one, but a suite of care
services that recognize the reality of injecting drug users'
lives. Just as abstinence and fidelity are not substitutes for
condom use, so rehabilitation and detoxification are not substi-
tutes for clean needles.

Distorting the ABC Model

Abstinence for younger adolescents, faithfulness in marriage and
condom promotion have a place in international HIV/AIDS pro-
grams. Unfortunately, by twisting the ABC concept important in-
ternational voices-the U.S. government and the Vatican, in par-
ticular-have made ABC controversial. The actions of these major
political actors are not only regrettable; given their influence
over millions of people around the world, they represent a seri-
ous setback to efforts to bring HIV/AIDS under control.

Conservative U.S. government officials have made clear the Bush
administration's preference for abstinence-only approaches and
have registered strong misgivings about the moral and ethical
advisability of providing condoms as part of AIDS prevention
programs, arguing-incorrectly-that condoms may encourage early
sex and sexual promiscuity. In addition, U.S. officials have re-
moved scientifically accurate information about condom use ef-
fectiveness from the Web sites of several federal agencies and
have questioned whether or not condoms provide protection
against STIs, including HIV.

This issue of abstinence-only programming needs to be addressed
head on. Not only are there question marks over exactly what de-
fines abstinence and what makes it sustainable; there is no
clear evidence that it works.

As the largest international funder of HIV/AIDS programs, the
attitude and recommendations of the U.S. government have far-
reaching consequences for the health of people across the world.
The "ABC" approach is a central prevention component of the new
U.S. Global AIDS Strategy, yet the government channels one-third
of all HIV prevention funding to abstinence programs, particu-
larly those that counsel abstinence until marriage.10

To date, however, there is no conclusive proof that abstinence-
only programs have been successful in any country in the world
in reducing HIV transmission.11 In a recent review of abstinence
programs in the United States by DiCenso and colleagues, preg-
nancy rates among the partners of the young male participants
were no lower than those among the partners of nonpartici-
pants.12

Similarly, the effectiveness of abstinence as a long-term strat-
egy-particularly for young people-was refuted by a study pre-
sented at the annual meeting of the American Psychological Soci-
ety that reported that not only was the "virginity pledge" bro-
ken by more than 60% of the pledgers, but 55% who reported keep-
ing their virginity admitted to engaging in risky forms of non-
vaginal sex.13

For its part, the Vatican has conducted a global campaign of
disinformation about condoms. Not only has the Vatican echoed
the Bush administration's concerns about the effect of condoms
on Christian morality, but many in the church hierarchy have
denigrated condoms as flawed products.14 In 2003, the president
of the Vatican's Pontifical Council for the Family, Cardinal Al-
fonso López Trujillo, told a BBC Panorama program, "the AIDS vi-
rus is roughly 450 times smaller than the spermatozoon. The vi-
rus can easily pass through the 'net' that is formed by the con-
dom."15 In countering the Vatican's claims, WHO and IPPF were
supported by research from the U.S. National Institutes of
Health, which concluded that "intact condoms are essentially im-
permeable to particles the size of STD pathogens, including the
smallest sexually transmitted virus."16

In other words, the HIV prevention approach we are talking about
here is not ABC in its pure form but rather ABC as it has been
perverted by the religious conservatives who wield such strong
influence within the Bush administration and the Vatican.

Science, Not Ideology

We live in a world that is complex and diverse. Many things in
addition to the ABC approach are necessary to control the epi-
demic: Voluntary counseling and testing-a cornerstone of the WHO
"3 by 5" initiative-needs to be linked to treatment access; des-
tigmatization campaigns are required to promote a better envi-
ronment for those seeking prevention and treatment; and in-
creased efforts need to be made to improve the status of women
and young girls. The UNAIDS Global Coalition on Women and AIDS
provides an excellent platform to revitalize our global preven-
tion agenda. And while the ABC approach will form part of the
response, it should be firmly grounded in science, not ideology.

Instead of debating CNN vs. ABC, we must recognize the complex-
ity of sexual relations, which embrace every facet of our lives,
including issues of culture, tradition, power and status. We
must acknowledge the unequal power relationships between men and
women, especially older men and younger women, and we must de-
sign interventions that provide realistic choices. Above all, we
must resist efforts to impose a particular morality on individu-
als. We must respect the individual and find ways of giving peo-
ple realistic and effective options. We must not deny men and
women access to information or technologies that enable them to
protect their health and even their lives. Forty years of ex-
perience in family planning and reproductive health has shown us
that empowering individuals to make informed choices is the only
approach that really works.

REFERENCES

1. Stanecki K, The AIDS pandemic in the 21st century, U.S. Bu-
reau of the Census, July 2002,
http://www.dec.org/pdf_docs/PNACP816.pdf, accessed June 2004.

2.Nakamura S et al., Projections for HIV/AIDS in Cambodia: 2000?
2010, Phnom Pen, Cambodia: National Centre for HIV/AIDS, Derma-
tology and STDs, 2002.

3. Newman S et al., Marriage, monogamy and HIV: a profile of
HIVinfected women in South India, International Journal of STD
and AIDS, 2000, 11(4):250?253.

4. Allen S et al., Human immunodeficiency virus infection in ur-
ban Rwanda: demographic and behavioral correlates in a represen-
tative sample of childbearing women, Journal of the American
Medical Association, 1991, 266(12):1657?1663.

5. UNAIDS, 2004 UNAIDS Report on the Global AIDS Epidemic, Ge-
neva: UNAIDS, 2004.

6.World Health Organization, UNAIDS and United Nations Popula-
tion Fund (UNFPA), Position statement on condoms and HIV preven-
tion, July 2004,
http://www.who.int/hiv/pub/prev_care/statement/en, accessed July
2004.

7. Hearst N and Chen S, Condom promotion for AIDS prevention in
the developing world: is it working? Studies in Family Planning,
2004, 35(1):39?47.

8. UNAIDS, 2004, op. cit. (see reference 5).

9. Cochrane Collaborative Review Group on HIV Infection and
AIDS, Evidence assessment: strategies for HIV/AIDS prevention,
treatment and care, July 2004, http://www.igh.org/Cochrane, ac-
cessed July 2004.

10. Sexuality Information and Education Council of the United
States (SIECUS), Bush visits Uganda and praises ?ABC? approach
in spite of administration?s preference for abstinence-only-
until-marriage, Policy Update, July 2003,
http://www.siecus.org/policy/PUpdates/arch03/ arch030065.html,
accessed Feb. 11, 2004.

11. Dailard C, Understanding ?abstinence?: implications for in-
dividuals, programs and policies, Guttmacher Report on Public
Policy, 2003, Vol. 6, No. 5, pp. 4?6.

12. Di Censo A et al., Interventions to reduce unintended preg-
nancies among adolescents: systematic review of randomized con-
trolled trials, BMJ, 2002, 324(7351): 1426

13. Lipsitz A, Bishop PD and Robinson C, Virginity pledges: who
takes them and how well do they work? presentation at the annual
convention of the American Psychological Society, Atlanta, GA,
USA, May 31, 2003.

14. Bradshaw S, Vatican: condoms don?t stop AIDS, Guardian, Oct.
9, 2003,
http://www.guardian.co.uk/international/story/0,,1058966,00.html, ac-
cessed Oct. 10, 2003.

15. Ibid.

16.National Institutes of Health, Workshop Summary: Scientific
Evidence on Condom Effectiveness for Sexually Transmitted Dis-
ease Infection, July 20, 2001,
http://www.niaid.nih.gov/dmid/stds/condomreport.pdf, accessed
Mar. 30, 2004.