Cover Story

Condom crazy

The UN pushes contraception to fight AIDS, ignoring Uganda's successful abstinence-preferred strategy

Issue: "AIDS: Africa's affliction," Sept. 9, 2000

Country by country, the percentage of HIV-positive people in Africa is horrifying. In Congo, 7.5 percent are infected; in Kenya, 12 percent; in Mozambique, 14.5 percent; in Zambia, 20 percent; in Botswana, 29 percent. More than 30 UN agencies operate anti-AIDS programs in Africa; a few even educate people on the need to avoid high-risk behavior such as prostitution, drug use, and multiple partners. But the UN shows the greatest steely eyed determination in trying to make condoms available to every man, woman, and child in Africa. Africa's religious community has raised sporadic objections, but the UN has made it clear that it believes condoms are the best weapons in the fight against AIDS. UN Secretary General Kofi Annan has set the ambitious goal of making contraceptives, and especially condoms, available to 95 percent of the world's young people by 2010. Objecting to condom use on moral or religious grounds, he said, "won't do." The UN's operatives in Africa have responded wholeheartedly to Mr. Annan's directive. Peacekeeping troops in Sierra Leone and Congo now receive a condom a day along with their other rations; a spokesperson for Mr. Annan said that in military situations, condoms "have the same value as flak jackets." UN agencies also handed out condoms at New Year's celebrations across the continent. With condom distribution comes sex education. UNAIDS has printed hundreds of thousands of "How to Use a Condom" instructional sheets in the continent's major languages. Written in explicit tones, the instructions end on the cheery note, "If you are going to have sex again, use a new condom and start the whole process over again!" Sex educators have fanned out across the continent, teaching local women how to use male and female condoms and urging them to refuse to have sex with their husbands or boyfriends unless they use one. The programs are successful by a certain standard: Condom use in Africa is up, and in polls more than three-quarters of the continent can identify the sort of high-risk behavior that causes AIDS. Despite this widespread familiarity with the causes of AIDS, however, the crisis shows no signs of abating, and is in fact gaining steam. Why? Far from preventing or slowing AIDS, new evidence suggests that condoms may actually spread the disease. A recent report in the British medical journal The Lancet suggests that "increased condom use will increase the number of [HIV/AIDS] transmissions that result from condom failures." More importantly, Dr. John Richens and his colleagues at the University College London conclude, condom use discourages the sort of lifestyle changes that are essential to stopping the spread of AIDS. They warn that a "vigorous condom promotion policy could increase rather than decrease unprotected sexual exposure if it has the unintended effect of encouraging a greater overall level of sexual activity." One bright spot in Africa's fight against AIDS is Uganda, where the government was one of the first in Africa to admit publicly that it had a problem, declaring the disease a national crisis in 1986-10 years before most countries-and adopting a vigorous national plan to combat AIDS in 1992. These efforts have yielded results: a 30 percent reduction in the rate of infection in rural areas, a 50 percent reduction in urban areas. Uganda's unparalleled success in fighting AIDS comes from the nation's focus on changing behavior. Top government officials speak out frequently during rallies and through advertising campaigns on the need to refrain from high-risk sex. The government has disseminated the message through Christian churches and Muslim mosques, bringing religious leaders on board to work in their communities. Essentially, the Ugandan people have been told that if they don't go looking for the disease, they won't get it. "The message we've tried to give people is that AIDS kills, so what do you do to avoid getting it?" said Ugandan health official Tayebwa Katureebe. "First, abstain from sex. If you cannot abstain, stick to one partner. If you can't stick to one partner then you have to use a condom. But be sure that condoms are not 100 percent effective." Condoms play a part in Uganda's efforts, but far more important is the message of abstinence and monogamy-the message that people can change their destructive behavior. Has the United Nations trumpeted Uganda's successful strategy? No, and as AIDS epidemics perhaps emerge in India, southern Russia, Southeast Asia, and the Caribbean, the UN is gearing up to duplicate its anti-AIDS efforts in those nations. That raises the specter of even more infections and even more deaths.

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