Thursday, February 24, 2005

Abstinence and AIDS in Africa

The AIDS epidemic in Africa is unbelievable. Millions and millions of people infected, more than two million per year dying from AIDS. As you know, the big thing is for missionary-types to go over there and teach the locals to practice sexual abstinence and sexual fidelity, good old-fashioned family values.

And, wow, since they've been doing that, the number of Ugandans with AIDS has dropped drastically. The Family Whatever groups are happy to take the credit for this, as it proves that their values are most excellent.

Then, yesterday, The Post had this: Uganda's AIDS Decline Attributed to Deaths:
Abstinence and sexual fidelity have played virtually no role in the much-heralded decline of AIDS rates in the most closely studied region of Uganda, two researchers told a gathering of AIDS scientists here.

It is the deaths of previously infected people, not dramatic change in human behavior, that is the main engine behind the ebbing of the overall rate, or prevalence, of AIDS in southern Uganda over the last decade, they reported.

The findings, not yet published, contradict earlier evidence that attributed Uganda's success in AIDS prevention largely to campaigns promoting abstinence and faithfulness to sex partners. Much of the prevention work in the Bush administration's $15 billion global AIDS plan is built around those two themes, and Uganda is frequently cited as evidence that the strategy works.

If the report here stands up to scrutiny -- and, more important, is borne out by surveys elsewhere in Uganda -- it will deflate one of the few supposed triumphs to come out of AIDS-battered Africa in the last decade. The success of Uganda's ABC strategy -- the letters stand for "abstinence," "be faithful" and "(use) condoms" -- has been widely touted and is on the verge of being exported to neighboring countries with the help of American money.

I admit, it surprised me. I hadn't thought of that. I'd seen that the rates were dropping, and I thought, well, we do know that abstinence is the only sure method to avoid sexually transmitted infection, maybe a liberal dose of that Olde Thyme Religion actually changed their behavior enough to stop the epidemic. Uh, I didn't mean "liberal," really.
"There is an urgent need to assess abstinence and monogamy in other parts of Uganda," said Maria J. Wawer, a physician at Columbia University's Mailman School of Public Health who presented the data at the 12th Conference on Retroviruses, the annual mid-winter AIDS meeting in the United States.

Ironically, she and her colleagues found that the one prevention technique whose use did increase between 1994 and 2003 was condoms -- the part of the ABC triad that has been relatively de-emphasized in the Bush plan.

"Abstinence and monogamy are very good behaviors," she said in a press briefing after her presentation. "On the other hand, the data support that in this setting, the behavior that seems to have been the easiest to increase over time is condom use."

It wouldn't be right to gloat over the failure of ABC in Uganda, it's not a good thing, and this news is actually terrible, people are dying so fast that the proportion with the virus is decreasing.

But there is a lesson to learn here. Mmm, several lessons.

First of all, don't let anybody interpret the statistics for you. The rates went down after this program was started, and so the people running the program -- the Bush administration, basically -- attributed the decline to their work. It doesn't not appear that that was the cause; at the least, there is good reason to look at other explanations.

Second, this does, in fact, greatly diminish the credibility of abstinence education. Telling people to abstain did not result in abstention, even when sex was likely to kill them. Look:
In the Rakai district, the percentage of women infected with HIV fell from 20 percent in 1994 to 13 percent in 2003. For men, the rate of infection declined from 15 percent to 9 percent, a decline of roughly one-third.

Over that same period, however, the fraction of men reporting two or more sexual partners in the previous year rose from 28 percent to 35 percent. The fraction of young men ages 15 to 19 who were not sexually active fell from about 60 percent to just under 50 percent. For women that age, the proportion not having sex remained at about 30 percent through the decade.

The median age of first intercourse for men fell from 17.1 to 16.2 years, and for women from 15.9 to 15.5 years.

Telling people not to have sex, even when it's literally a life-or-death decision for them, just plain doesn't work. These Ugandans started having sex earlier, and had more partners, after being taught to practice abstinence ... exactly what you don't want in Uganda, and what we don't want in Montgomery County.

2 Comments:

Blogger Isabel Manuela said...

Jim, and take a look at the statistics of women. This is a major issue in Africa: women start having sex BEFORE men -obviously, WITH men.
About half of male teens have sex, but 70% of female teens have sex WITH OLDER MEN, which is known to be a major form of spreading STIs in general, HIV in particular. As we know, young women in that situation have little or no control over their partners and over the conditions of the intercourse in general. On the other hand, older men have sex with several women (young and old), prostitutes, etc. Of course, being faithful would do wonders, but since people are dying NOW, there is no time to wait till they change their behavior.
That's why we need to convince men to use condoms ALL THE TIME, unless they will remain totally faithful. This may help lower the rate of AIDS among teens. We need to insist in faithfulness, and other things, but if in societies with such a strong feminist sentiments such as US, we have still many issues of male controlling the conditions of sexual intercourse, what to expect of those societies in which we have very undereducated populations, and women in very dependent situations, women being sold/exchanged, etc.
The logic of "if you mention condoms they will not be faithful, because they think that's a safe alternative" just don't work at least in two counts:
1. I thought people should be faithful out of love, and out of compliance with their own religious and/or moral views, not out of fear of disease. Fear has hardly ever work as a good deterrent for changing (sexual) behavior. If it works, Africa would not have more AIDS cases, because people there are literally dying on the streets every single day.
2. If you don't mention condoms, they won't be any more faithful and abstain, they will just get sick and die... after having unprotected sex.

February 25, 2005 11:42 AM  
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