….I am sure you are aware that at times help comes with strings attached. We received US $10 million aid, but it had to be only condoms. We had two option:  to accept all the US$10 million worth of condoms or refuse. If it was our choice we would have spread this help to other forms of prevention as well and particularly advocacy for behavior change in schools. The Ministry of Education is looking for help to print its syllabus and book aids to help the teachers and the children to learn about HIV infection and how to prevent it. No one wants to help to print books and teaching aids….So you can see the mismatch in emphasis between the needs perceived by locals and those of our collaborators. We have adopted an attitude that anything that helps is welcome, even if it is not priority, since we may not get what we call priority if we insist on having it our way.

-Mohamed Abdullah, Chairman, Kenya National AIDS Council

Introduction

No one today would question that HIV/AIDS is the world’s leading health problem. UNAIDS has recently released the estimates that at the end of 2002 there are 42 million persons infected with HIV, 29 million of whom are in Africa. This prevalence makes AIDS the fourth leading cause of death worldwide, and the leading cause of death in Africa.

We know well the major causes of HIV transmission in the population. There are two high risk behaviors – multiple sexual partners and intravenous drug use (IDU). And following from these are mother-to-child transmission (MTCT) and infections inadvertently acquired from contaminated blood products in medical procedures.

Because HIV is sexually spread, the immediate response in most populations has generally been to stigmatize people with HIV/AIDS (PWAs), irrespective of how the infection was acquired. Regrettably, this has at times been reinforced by moral condemnation by some religious leaders who are against any form of sexual behavior outside of marriage. Their conservative viewpoint is commonly tied to an opposition to the promotion of condoms, which is considered as only accommodating, if not openly promoting, immoral behaviors. Many public health professionals are also not open minded, believing that sexual behaviors in populations are essentially not malleable, and that their only role is to reduce the risks, not change lifestyles. Unfortunately, these conservative viewpoints by both sides too often lead to a lack of cooperation and even antagonism between two of the groups that together could make the greatest contributions towards abating the HIV/AIDS epidemic – the public health professionals and the faith-based communities. And this lack of a concerted approach, coupled with other social, cultural and political factors, has often discouraged political leaders from stepping forward and aggressively addressing the HIV/AIDS epidemics in their countries.

 

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Many public health professionals believe 

their only role is to reduce the risks,

not change lifestyles.

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Over the past 15 years, faith-based organizations (FBOs), building on their calling for compassion to the suffering, have addressed the issues of stigma and been leaders in providing care to AIDS victims and their families. They have also developed effective education programs directed towards encouraging sexual abstinence among unmarried youth and fidelity among couples. Correspondingly, while holding to their principles regarding abstinence and fidelity, many FBOs have come to recognize the ethical obligation of informing people about condoms for the prevention of HIV transmission in high-risk situations, for example, where multiple partners or commercial sex workers are involved. And, at the same time, public health professionals have begun to promote partner reduction, especially among men having sex with men and situations involving multiple partners.

 “Evidence-based” and “what is true” as shared values in prevention

 While the antipathy between the FBOs and public health professionals has been eroding as each has learned to work with the other, still there is not a full partnership in all cases. Yet there should be, on the basis of certain shared principles. First, both groups share a concern for the social, economic and physical well being of every person, and they work to combat injustices in these areas. Second, both groups should respect the autonomy of individuals to make their own choices and would want to see that every individual has all of the information and opportunities needed to make the best choices for themselves and their loved ones. Third, both groups should have a common commitment to seeing reality objectively and acting accordingly. In public heath, this is referred to “evidence-based” practice; among FBOs, this is a commitment to knowing “what is true.” (The modern scientific revolution began, after all, by a search for God’s Laws in the natural order of the universe.)

 Starting with the principle of evidence-based/what is true, what do we actually know about heterosexual transmission of the HIV virus and about the potential efficacy and the use-effectiveness of the leading interventions being promoted, now often referred to as “ABC”: 

 A – Abstinence (until marriage); 

B – Be faithful (to one partner); and

C – Condom use (whenever engaging in sex with “non-regular” partners).

Efficacy refers to the maximum potential protection possible while use-effectiveness is the protection observed among ordinary users of the method.

First, regarding heterosexual transmission, the evidence is clear that the more sexual partners a person has, the higher the risk of acquiring HIV infections (and other sexually transmitted diseases as well). Also, it has been observed that the younger a person is when initiating sexual activity, the more lifetime partners the person is likely to have.

In this context, regarding the efficacy of A and B, it should be intuitively obvious that if young persons abstain from sexual activity until establishing a permanent partnership, and if both partners are faithful in their sexual union, the risk of sexually acquiring HIV is zero. Thus efficacy will be 100%, and this will be the same for use-effectiveness as well. The problem, of course, arises in a sexual union if only one partner is faithful. In this case, the faithful partner essentially shares the risks of the partner having multiple outside relationships unless some other risk reduction behavior is adopted, such as the use of condoms (or else breaking the relationship).

Regarding the efficacy of C, in the family planning literature there are estimates that the potential could be as high as 98%; and it is probably reasonable to apply this to the risk reduction for HIV infection.  The maximum potential efficacy is less than 100% because of intrinsic problems with use like putting it on too late, slippage, breakage, etc. Use-effectiveness in protecting against HIV infection, however, is substantially lower. In 2001 the US National Institutes of Health published a comprehensive review of condom studies, which concluded that “always” use of condoms could reduce the risk of acquiring HIV infection by 85%. Similarly, the Cochrane review of the literature on condom effectiveness reached the conclusion that “consistent” use of the condom reduces the risk of acquiring HIV infection by 80%. In essence, these analyses indicate that “consistent” users of condoms still have a 15- 20% risk of acquiring HIV infection compared to never users. Consistent with these conclusions are the results of a 2002 report of a prospective community-based field study from Uganda that showed the reduction in risk of HIV infection to be 63% with “consistent” use. Noteworthy, with “inconsistent” use there was no reduction at all in the risk of HIV infection in this study population.

So, while A and B will fully “protect” from HIV infection individuals and couples who share these practices, condom use does not fully “protect” those persons having sex with multiple partners; it only reduces the risks.  And, most importantly, this risk reduction only occurs if condoms are used “always” or “consistently,” that is, 100% of the time.  While there is evidence of risk reduction with “inconsistent” use of condoms, it is significantly lower than provided by “consistent” use. 

With these facts, in individual counseling sessions or media campaigns, one can only truthfully say that with “consistent” condom use, sex is “safer” than without use; but by no means is the individual fully “protected” or “safe” from the risk of acquiring HIV.  On the other hand, there is no need to qualify the protective efficacy of A and B, if people choose this option.  The challenge any program faces, of course, is getting populations to adopt these practices; and evidence is beginning to emerge indicating that these behavioral changes can be promoted with substantial impact on HIV transmission. 

 

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Even “consistent” users of condoms still 

have a 15-20% risk of acquiring HIV infection,

i.e., “safer” sex, but not “safe” sex

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 Experiences with A, B and C interventions

Studies of effectiveness of A, B or C in isolation from a specific epidemiological situation have little meaning in public health and cannot distinguish what interventions are important under what circumstances for disease control. However, some culturally and epidemiologically specific evidence has accumulated over the past several years.

Condom promotion for “safer sex” and as a risk reduction strategy has, in fact, been reasonably successful in developed countries, where overall HIV/AIDS prevalence is low and largely concentrated in selected high-risk populations (core groups) like men having sex with men (MSM) and commercial sex workers (CSWs), where vigorous promotion (and enforcement in some cases) can result in almost 100% condom use. Likewise, aggressive condom promotion achieving close to 100% use has been shown to be effective in reducing infection rates among CSWs and their clients in selected “hot spots” in Asia (Thailand and Cambodia), Africa (Uganda and Senegal) and Latin America (Dominican Republic). Most notably, in Thailand, where CSWs were a major source of HIV dissemination, strict regulation and enforcement of the practices of CSWs, along with popular education campaigns, have resulted in a substantial decline in HIV prevalence rates in recent years.

On the other hand, in most countries in sub-Saharan Africa (SSA), where heterosexual transmission of HIV/AIDS is widespread in the general population, condom promotion programs have seemed to have had little or no effect in slowing the progression of the epidemic. One major reason is that condoms have not been widely accepted by the general population in most SSA countries. “Ever use” rates reported by reproductive-age women generally only range at levels of 20-35%, while “consistent users” represent only a small fraction of these users.

In spite of the limited effect of condom promotion in slowing the onslaught of AIDS in much of SSA, a few countries like Senegal and Zambia have shown a plateau in the HIV prevalence; and Uganda, in particular, has shown a dramatic decline over the past 10 years. A number of investigators began to examine the Ugandan experience, and a summary case study of some of their work was recently published by USAID in a monograph titled: What Happened in Uganda? Declining HIV Prevalence, Behavior Change and the National Response. The principle findings in Uganda are that the decline in HIV prevalence (which began in the early 1990s) could be associated with a high level of political commitment, starting with the president and the mobilization of all sectors of society to address the AIDS problem, beginning in the mid 1980s. This led to a highly decentralized planning and implementation of behavior change communication focusing on abstinence for unmarried young people and partner reduction for married persons that reached the entire population. There was a grass roots approach involving the training of thousands of community-based AIDS counselors and peer educators, who provided culturally appropriate, face-to-face communication. Noteworthy was the active involvement of religious leaders and faith-based organizations (FBOs) in this process. Reports of the impact of localized behavior change interventions as well as national surveys taken over time indicate that the greatest impact of this national HIV/AIDS control effort has been in the delay of initiation of sexual behavior among youth and the reduction of sexual partners among both unmarried and married men and women. As a result of these efforts, Uganda’s adult HIV prevalence has declined from a high of over 20% to the current rate of about 6% at a time when prevalence has been increasing in most other African countries.

In this context, the USAID report commented on the potential impact of the behavioral change that occurred in Uganda (particularly partner reduction) if it had been applied to South Africa. This was based on a model by R.L. Stoneburner and D. Low-Beer in a paper presented at the XIII International AIDS Conference, Durban, South Africa, July, 2000. The results indicated that if such a “social vaccine” had been introduced in 1990 to the population of South Africa (currently one of the most severely affected countries in the world), it would have dramatically altered the epidemic, essentially having the same disease prevention impact as a potential medical vaccine of 80% efficacy.

 “ABC” - Behavior Change for HIV/AIDS Prevention and Control

The investigations briefly reviewed above have widened the debate on the relative importance of various elements of the “ABC” behavior change approach to HIV/AIDS prevention and control. There are three key issues here:

First, there continues to be a wide range of scientific, political, social, cultural and religious viewpoints about the appropriateness, or even effectiveness, of intervention strategies addressing A or B or C, or some combination thereof (such as A and B without C, or C without A and B).

Second, given that any national intervention effort is expensive, especially for poor countries, and generally requires donor support, the question arises as to what proportion of funding should be allocated to promoting A and B versus C. This is becoming an issue now that that evidence is accumulating about the importance of A and B interventions relative to the C in sub-Saharan Africa and some other regions of the world where heterosexual transmission of HIV in the general population is dominant. To date most donor resources directed to HIV/AIDS prevention have been invested in condom supplies and promotion and related risk reduction strategies, e.g., voluntary counseling and testing (VCT) and control of other sexually transmitted diseases (STD).

Third, the question arises as to what population-based social indicators should be used to measure the progress of national HIV/AIDS prevention programs. This obviously connects to question two, since the measurable indicator(s) will drive the priorities for investments in the interventions.

 

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Given limited resources, what proportion

of funding should be allocated to promoting

A and B versus C?

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Indicators and Priorities for Prevention

Let us look at the third issue first, since over the past several months CCIH has joined in a dialogue with representatives of UNAIDS (Joint United Nations Program on HIV/AIDS) regarding the development of a concise set of indicators that are to be used by nations around the world to measure their progress towards the goals of the Declaration of Commitment on HIV/AIDS enunciated by the June 2001 UN General Assembly Special Session on HIV/AIDS (UNGASS). This work by the UNAIDS Monitoring and Evaluation Reference Group (MERG) on prevention indicators relates to the Declaration objective that: “By 2003, establish prevention targets that address factors that spread the epidemic, and reduce HIV incidence among groups with high rates or a high risk of infection (para. 48).”

In the UNAIDS MERG draft of “National Programme and Behavioral Indicators” that was available on July, 2002, the key prevention indicator is: “Young people: condom use with non-regular partners.” The draft document notes that to gather this indicator, it will require asking young people ages 15-24 if they are sexually active, and if so, have they had sex with a non-marital/non-regular partner, and if so, how many, so some information about abstinence and partner reduction are incidentally gathered. But still the priority is on measuring condom use. The rationale given for this in the UNAIDS MERG draft is that: “Consistent condom use with non-regular sexual partners substantially reduces the risk of sexual HIV transmission….Condom use is one measure of protection against HIV/AIDS; delaying age at first sex, reducing the number of non-regular sex partners, and being faithful to one non-infected partner are equally important.” (emphasis added).

As should be clear from the earlier discussion, the issue of indicators is two-fold:

First and foremost is a question of telling people “what is true” based on scientific evidence. Is the statement equating condom use as “equally important” as a “measure of protection against HIV/AIDS” as “delaying first sex, reducing the number of non-regular partners and being faithful to one non-infected partner” true? Obviously the role of condoms depends upon the context (e.g., use by CSWs or MSM, or for protecting a marital partner when one is infected), and here, of course, 100% condom use is required. But the UNAIDS statement is not referring to an indicator for these special high-risk situations. Rather the choice is being made for a single priority behavioral indicator, i.e., C - for all countries in the world, irrespective of the local context.

Second, as noted earlier, nations and donors are to use the behavioral indicators as “prevention targets” to measure progress in HIV/AIDS control programs. If the wrong target, or one that is less-than-the best, is selected, then there can be a tremendous investment of time, effort and resources in this intervention with little to show for it at the end of the day. Regrettably, for much of sub-Saharan Africa, the empirical evidence to date suggests that this has probably been the case.

The “ABC” Experts Technical Meeting

In September 2002, USAID convened a one-day “ABC” Experts Technical Meeting to critically examine the behavioral change approaches to HIV and STD prevention. There were 130 HIV/AIDS and reproductive health experts in attendance, representing major international agencies, foundations and universities in Europe and the US. CCIH also participated. The group carefully reviewed the data from intervention studies in high risk populations, most notably the risk-reduction strategy among CSWs in Thailand, and then the experiences from sub-Saharan Africa – both the failures of a condom strategy in many countries (e.g., Botswana) and the striking success story from Uganda (as briefly described above).

In Uganda, in particular, there was a careful examination of data from multiple sources over the past 15 years, ranging from national behavioral surveys to small-scale studies of the effects of specific behavioral change interventions by FBOs. Integrating all the evidence led to the conclusion that the concerted national effort by all sectors of society did indeed lead to a substantial rise in abstinence among young people and a dramatic partner reduction among men reporting multiple sexual partners, and these behavioral changes were the driving forces resulting in the turnaround of the HIV/AIDS epidemic in the early 1990s. Because there was compelling evidence of a reduction in the incidence of HIV infections, particularly among young people, before condoms were effectively introduced widely into Uganda, most of the credit for the success in Uganda could be attributed to A and B interventions and not C.

As summarized by USAID, the expert group determined that “In lower prevalence, more concentrated epidemics, such as Thailand’s, a targeted approach focusing on condom promotion to sex worker establishments (which also resulted in significantly fewer visits by men to prostitutes) has often been successful. In  high-prevalence, sub-Saharan African epidemics, much of the success in places like Uganda resulted from delay in sexual onset by youth, as well as increased condom use with non-regular partners and, evidently of greater impact, a significant reduction in multiple partnering trends.” In effect, the strategic issue is not A and B versus C, but “how to effectively promote all three approaches (A, B and C) so as to maximize total impact.”

Implications for Faith-Based Organizations

Perhaps the most articulate scientist who has explicitly addressed the role of FBOs in HIV/AIDS prevention is Edward C. Green, PhD, from the Harvard School of Public Health. In a 2001 paper on “The Impact of Religious Organizations in Promoting HIV/AIDS Prevention” presented at the CCIH Conference on Challenges for the Church: AIDS, Malaria, and TB, Dr. Green presented the evidence for the major role that religious leaders and organizations – Muslim, Protestant and Catholic – played in promoting “primary behavior change” (PBC), that is A and B, in stemming HIV/AIDS epidemics in Uganda, Senegal and the Dominican Republic. Dr. Green presented a follow-up on Uganda with at the 2002 CCIH Conference, and later a fuller exposition of these issues at the 2002 Annual Meeting of the American Public Health Association titled “Abstinence, Fidelity, and Contribution of Religious Groups to Reducing HIV Transmission” (which added Zambia as another case study).

In these papers among his conclusions are that:

·  “FBOs are best positioned of any group to promote fidelity and abstinence; this is their comparative advantage over other organizations.” (emphasis author’s)

 

·  “Religious organizations ought to be given more support in doing what they do best, namely, supporting fidelity and abstinence. If FBOs also want to promote condom use, so much the better. But they should not be forced to do so.”

 

·  “There have been few evaluations of FBO AIDS prevention programs (probably because most programs rely on the FBO’s own funds) and existing evaluations have often remained unpublished.”

 

·  “FBOs remain a great untapped potential in the global fight against AIDS.”

Returning to the issue of shared values, there should be no conflict between faith-based organizations and public health professionals in the face of the global epidemic of HIV/AIDS. Both groups sense a common bond with all humanity that is the foundation for removing the stigma from diseases and disabilities. And both groups should always be open to the scientific evidence and committed to telling the truth to people. While different persons may have different religious convictions (or none at all), if we all would be willing to make a concerted effort to “speak the truth in love,” a truly powerful force for good could be mobilized to confront not only AIDS but many other health and social problems in the world.