Uganda holds a unique place in the history of the AIDS epidemic in sub-Saharan Africa. Uganda was the first African country in which the AIDS threat was immediately recognized at the highest political levels, the first in which civil society was genuinely mobilized in the fight against HIV/AIDS, and one of the very few countries in sub-Saharan Africa in which the spread of the epidemic seems to be slowing down.
Part of the Ugandan success story has been attributed to what has become known as the ABC approach to AIDS prevention: Abstinence is best, Being faithful to your partner is second best, and when all else fails, use a Condom. Over the years, the ABC approach has not been without its critics in both developed and developing countries. Some have objected that promoting abstinence is simply unrealistic given the universal human appeal of sex. Others have pointed out that be faithful is an especially unhelpful prevention message for women with unfaithful male partners. But opponents of ABC were often stopped cold in their tracks with the very mention of Uganda. The facts seemed to speak for themselves: Uganda strongly promoted ABC, and the adult HIV prevalence rates dropped from a peak of 18% in 1995 to around 5% in 2001.
The ABC (or at least the AB of ABC) approach has strongly appealed to conservative tastes among US government officials and influential religious groups, and many US-funded AIDS prevention programs around the world are roughly based on the Ugandan model. The approach seems to merge conservative views about the sanctity of marriage and sexual temperance with sound public health policy. The case of Uganda has been predictably invoked by conservatives to argue that the promotion of ABC prevention programs abroad is justified by scientific study and actual outcomes, and is not simply the imposition of a puritan sexual morality.
This use of Uganda as poster child has recently been challenged. A study presented at last months CROI conference in Boston indicated that the drop in HIV prevalence in Uganda was not due to A, B, or C, but rather a combination of C and D, where D stands for Death. Maria J. Wawer, a physician at Columbia Universitys Mailman School of Public Health, presented data that suggested the rate of HIV prevalence between 1993 and 2004 in Uganda has declined due to increased condom use and the deaths of HIV positive persons, rather than abstinent and faithful behaviors. While HIV prevalence decreased, the Ugandans studied were not more abstinent or faithful than before. To the contrary, the percentage of men reporting one or more sexual partner rose during this period, the percentage of non-sexually active young men between 15-19 years old fell, and the median age for first sexual intercourse for both sexes declined. So much for A and B.
As access to AIDS treatment in Uganda increases, the Grim Reaper will stop holding down the HIV prevalence rates. Besides death, the recent Columbia University study suggests that the most effective way to reduce transmission of HIV is what many have said all along: promotion of condom use.
Only time will tell how conservative backers of AIDS prevention programs in the developing world will respond to this news about their beloved ABC approach. Will there finally be a pro-life embrace of the condom?
Link, More, and Still More. – Stuart Rennie