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Prepared Witness Testimony The House Committee on Energy and Commerce
HIV/AIDS, TB, and Malaria: Combating a Global Pandemic.
Subcommittee on Health
Mr. Edward C. Green Ph.D.
Thank you, Chairman Tauzin and distinguished members of the Health subcommittee. I am a senior research scientist at the Harvard School of Public Health. For most of my professional career, I have not been an academic. I have worked in less developed countries as a behavioral science researcher and as designer and evaluator of public health programs. I have worked extensively in Africa and other resource-poor parts of the world. A good deal of my work has focused on reproductive health, some of this including the social marketing of condoms and oral contraceptives. In view of all the sad news we hear about AIDS,
especially in Africa, it is my pleasure to share some good news. There are
several bright spots in the world when it comes to AIDS. The brightest spot of
all may be Uganda, where infection rates have declined from 21% to 6% since 1991
[Fig. 1]. The Government of Uganda, led by President Museveni, developed a distinctive approach to AIDS prevention known as the ABC approach: Abstain, Be faithful, or use Condoms if A and B are not practiced. The abstinence message for the most part took the form of urging youth to delay having sex until they were older, and preferably married. Many of us in the AIDS and public health communities didn't believe that abstinence or delay, and faithfulness, were realistic goals. It now seems we were wrong. Uganda's program began in 1986, the year President Museveni became head of state. Since the rate of new infections began to decline in the late 1980s, it becomes important to know what programs were in place in the latter 1980s and what behaviors changed, in order to account for the decline of infection rates. The standard programs we associate with AIDS prevention were not in place in the 1980s. We now know that there were significant changes in sexual behavior between 1989 and 1995. And these were most pronounced among youth, the very age group primarily targeted in AIDS education. And the behaviors that changed the most were the ones emphasized in Uganda's AIDS prevention efforts. Let me share with you some World Health Organization data we have on some key measures of sexual behavior. The first pertains to premarital sex. The proportion of young males age 15-24 reporting premarital sex decreased from 60% in 1989 to 23% in 1995. For females, the decline was from 53% to 16%. Next, looking at all age groups, 41% of males had more than one sex partner in 1989. This declined to only 21% by 1995. For females, the decline was from 23% to 9%. Furthermore, the proportion of males reporting three or more sex partners fell from 15% to 3% between 1989 and 1995. Now we can compare this with data on condom use. In 1995, about 6% of sexually active Ugandans, used a condom with some regularity, according to the US-funded Demographic and Health Survey. By 2000, this rose to 11% of sexually active Ugandans, or 8% of all Ugandans. However these low figures obscure the fact that condom use has become quite high among those who need them most, namely those relatively few who are still having multiple partners The ABC approach recognizes that some people cannot or will not avoid risky sex, and so they need reduce their risk with condoms. What prevention programs existed in the latter 1980s? There was a deliberate attempt to fight stigma and discrimination associated with AIDS, and to generate open and candid discussion about the epidemic everywhere, down to the village level. There was AIDS education in the primary schools. The faith-based organizations were involved from the beginning of the national response and they were particularly adept at promoting abstinence and faithfulness. The AIDS message was not soft-pedaled. People
were made to fear HIV infection, but not to fear people with AIDS. People were
also told clearly what to do to avoid infection. It may be noted that condom user rates in Uganda are not higher than those of other countries, as can be seen in Fig. 2. Condom use with Last Non-Regular Partner Never Married
Married
Sexual Partnerships with Non-regular Partners
Female
Some in the West have expressed skepticism about the ability of African women to abstain or be faithful, since women often have little power to negotiate sex. Yet look at the data we have. By 1995, the great majority of Ugandan women, 98.5%, were reporting either abstinence or no sex partner outside their regular partners. Along with the ABC approach, the Ugandan government took various steps to raise the status of women. One measure of the success of these efforts comes from the Demographic and Health survey, which asks women if they believe they have the power to refuse unwanted sex, or insist upon condom use. Uganda ranked first among all African nations. AIDS prevention is largely a behavioral problem that requires a behavioral solution. I believe that AIDS prevention programs in Africa and the developing world generally have become too focused on medical technology and drugs, and not enough on behavior. Evidence from Uganda and some other countries, show that when faced with a life-threatening danger, people can and will modify their behavior, once they are given the right information, in the right way. Uganda's ABC approach, especially as it was implemented in the early years of that country's epidemic, has proven to be an effective model that has worked in Africa and beyond. There are other countries that have implemented ABC approaches, and they have also achieved measures of success: Senegal, Zambia, Jamaica, and the Dominican Republic. What are the implications for US policy, at least in Africa? It must be acknowledged that program emphasis on condom provision and promotion alone does not seem to have paid off. A 2003 UNAIDS review of condom effectiveness (Hearst and Chen 2003) concluded, "There are no definite examples yet of generalized epidemics that have been turned back by prevention programs based primarily on condom promotion." Correct and consistent condom use surely averts infections, but after many years of effort, most condom use in Africa remains inconsistent. In the words of the UNAIDS review, "There is little convincing evidence that inconsistent condom use provides any protection." In fact, the countries in Africa which have the highest levels of condom availability relative to male population (Zimbabwe, Botswana, South Africa, Kenya) have some of the highest HIV prevalence rates in the world [fig. 4].
I am not saying that the two are causally connected, only that we probably need to be thinking of interventions in addition to condom social marketing, since we do not yet see national-level results in Africa. And I say this as someone who has worked in condom social marketing. Meanwhile, evidence is accumulating that reduction in numbers of sexual partners, which can result from abstinence and fidelity interventions, can reduce national HIV prevalence levels. So this is not to argue against a continuing role for condoms. Rather it is to argue that the US should put some real efforts and resources into promoting balanced ABC programs, especially in generalized epidemics. Condoms in fact seem to have played a significant role in impacting national HIV infection rates in countries like Thailand, where infection are concentrated in high-risk groups. Yet even in Thailand, there was a significant decline in premarital and extramarital sex in the general male population shortly before Thailand's prevalence decline of the mid-1990s. In sum, AIDS prevention works when done in the right way. I hope a substantial proportion of the new funds for AIDS will be allocated to effective prevention programs. References: USAID (2002). The "ABCs" of HIV prevention: Report of a USAID technical meeting on behavior change approaches to primary prevention of HIV/AIDS. Washington, D.C.: "ABC" Experts Technical Meeting, September 17, 2002.
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