Abstinence and fidelity programs effective in preventing spread of AIDS, congressman says

Washington D.C., Apr 2, 2008 / 23:40 pm

Representative Chris Smith, a New Jersey Republican, reported “compelling” evidence of the success of HIV/AIDS prevention programs that emphasize abstinence and fidelity before resorting to promoting condom use. 

According to Smith, 70% of the estimated 33 million people with HIV and 90% of the two million children afflicted with the disease live in sub-Saharan Africa. 

Speaking on Wednesday on the floor of the U.S. House of Representatives in support of a 2008 bill that would renew the President's Emergency Plan for AIDS Relief (PEPFAR), the congressman said recent reports showed the effectiveness of African HIV/AIDS prevention program based on promoting positive behavioral change.

“Five years after PEPFAR first began, the efficacy and importance of promoting abstinence and ‘be faithful’ initiatives have been demonstrated. The evidence is compelling,” Smith said.

PEPFAR, he said, relies on the ABC model, which stands for “Abstain, Be faithful, use Condoms.”  Smith cited comments about PEPFAR from the U.S. State Department, USAID, and the Department of Health and Human Services that said the ABC model “is now recognized as the most effective strategy to prevent HIV in generalized epidemics…  The legislation’s emphasis on ‘AB’ activities has been an important factor in the fundamental and needed shift in USG prevention strategy from a primarily ‘C’ approach prior to PEPFAR to the balanced ABC strategy.”

Rep. Smith added that a “growing body of data” validates the behavioral changes encouraged by ABC programs.  Data from Zimbabwe and Kenya “mirrors the earlier success of Uganda’s ABC approach to preventing HIV,” he noted.

Smith further quoted the government agencies’ comments, which said, “These three countries with generalized epidemics… have demonstrated reductions in HIV prevalence, and in each country the data point to significant AB behavior change and modest but important changes to C.  Where sexual behaviors have changed, as evidenced by increased primary and secondary abstinence, fidelity, and condom use, HIV prevalence has declined.”

According to a February 2006 report in the journal “Science,” the rate of HIV among eastern Zimbabwean men aged 17 to 29 fell by 23 percent between 1998 and 2003.  Among women aged 15 to 24, the infection rate dropped by 49 percent.

The percentage of eastern Zimbabwean men aged 17 to 19 who had engaged in sexual activity dropped from 45 percent to 27 percent, and among women aged 15 to 17 the rate dropped from 21 percent to 9 percent.

The report apparently also showed progress of the “Be faithful” aspect of the ABC model.  The percentage of sexually active men who reported a casual partner fell by 49 percent.

According to Smith, the Kenyan Ministry of Health estimated that HIV prevalence in the country dropped from about 10 percent in 1998 to approximately 7 percent in 2003.

Smith also referred to the September, 2007 testimony of Dr. Norman Hearst before the Foreign Affairs Committee.  Hearst said, “Five years ago, I was commissioned by UNAIDS to conduct a technical review of how well condoms have worked for AIDS prevention in the developing world.”  After he and his associates collected “mountains of data,” he said, “we then looked for evidence of public health impact for condoms in generalized epidemics.  To our surprise, we couldn’t find any.  No generalized HIV epidemic has ever been rolled back by a prevention strategy primarily based on condoms.  Instead, the few successes in turning around generalized HIV epidemics, such as Uganda, were achieved not through condoms but by getting people to change their sexual behavior.”

Hearst also referenced a consensus statement in the Lancet endorsed by 150 AIDS experts that said the priority for adults should be limiting one’s sexual partners, while the priority for young people should be avoiding early sexual activity.

Smith then cited a March 2, 2007 Washington Post article by Craig Timberg that noted the negative effect of certain cultural habits in sub-Saharan Africa.  “Researchers increasingly attribute the resilience of HIV in Botswana – and in southern Africa generally – to the high incidence of multiple sexual relationships.  Europeans and Americans often have more partners over their lives, studies show, but sub Saharan Africans average more at the same time,” the article said.

“Researchers increasingly agree that curbing behavior is key to slowing the spread of AIDS in Africa,” the Washington Post article continued.  The article quoted Serara Selelo-Mogwe, a public health expert and retired nursing professor at the University of Botswana, who said, “If you just say use the condom… we will never see the daylight of the virus leaving us.”

The article said that Botswana used programs favored by Western AIDS experts whose experience had been shaped by their study of the epidemic among American homosexuals and Thailand brothels.  The anti-AIDS partnership between the Bill and Melinda Gates Foundation and the drugmaker Merck dedicated $13.5 million to condom protection, more than 25 times the amount dedicated to changing dangerous behavior.  Botswana’s HIV infection rates continued to rise, and are now among the highest in Africa.

Representative Smith also cited a U.S. Government’s 2008 Annual Report to Congress, which said, “perhaps the most important [development] in recent years is the growing number of nations in which there is clear evidence of declining HIV prevalence as a result of changes in sexual behavior” and “behavior change will remain the keystone of success.”

Smith’s remarks about the successful results of ABC models of HIV/AIDS prevention were made on the House floor as he spoke in favor of the “Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008,” which would renew the PEPFAR program and change some of its policies.

The bill, Smith said, would require the Global AIDS Coordinator to provide “balanced funding for sexual transmission prevention including abstinence, delay of sexual debut, monogamy, fidelity and partner reduction.”  If less than 50 percent of prevention funds are spent on the Abstinence and Be Faithful sections of the ABC model, the bill requires the Coordinator to provide written justification.  At present, Smith said, the Coordinator can waive requirements without notifying Congress.

Smith claimed that the bill would likely prevent 12 million new HIV infections worldwide and support 3 million people, including an estimated 450,000 children.  He said the bill would also provide care for 12 million individuals with HIV/AIDS, including 5 million orphans, while helping train and deploy 140,000 new health care professionals and workers for prevention, treatment, and care of the disease.

Representative Smith also said the conscience clause in the bill “restates, improves, and expands conscience protection” for organizations so that they are not discriminated against in fund distribution.  Smith specifically mentioned Catholic Relief Services as one agency covered by the conscience clause.