Uganda's Decline in HIV/AIDS Prevalence Attributed to Increased Condom Use, Early Death From AIDS, Study Says

Increased condom use and premature deaths from AIDS-related diseases might be playing more of a role in declining HIV prevalence in Uganda than abstinence and fidelity, according to a study presented Wednesday at the 12th Conference on Retroviruses and Opportunistic Infections in Boston, the San Francisco Chronicle reports. Supporters of Uganda's ABC method -- which stands for Abstinence, Be faithful, use Condoms -- have "widely credited" the approach with lowering the country's HIV prevalence rate from 30% of adults in the early 1990s to under 10% currently (Russell, San Francisco Chronicle, 2/24). However, the results of the unpublished study -- which was conducted by researchers at the Columbia University Mailman School of Public Health, Johns Hopkins University and several Ugandan organizations -- "contradict" previous findings that attribute Uganda's declining HIV prevalence to initiatives promoting abstinence and faithfulness to one sexual partner, according to the Washington Post. According to study co-author Maria Wawer of Mailman School of Public Health, the researchers interviewed over a period of 10 years 10,000 people ages 15 to 49 living in 44 villages in the Rakai district of Uganda. They also collected blood and urine samples and asked about participants' health and behavior. Approximately 85% of Rakai's residents cooperated with the study, which also included treatment and prevention services (Brown, Washington Post, 2/24).

Methods, Findings
The researchers found that although fewer people are sexually abstinent or monogamous, the "expected" increase in the number of new HIV infections resulting from such behavior has not occurred, according to the Chronicle (San Francisco Chronicle, 2/24). From 1994 to 2003, the number of men reporting two or more sexual partners increased from 28% to 35%, and the percentage of teenagers who were not sexually active declined from approximately 60% to around 50%. For young women in the same age group, the percentage who were not sexually active remained at around 30% over the 10-year period. However, the HIV prevalence rate among women in the district fell from 20% in 1994 to 13% in 2003, and the prevalence rate for men decreased from 15% to 9% over the same time period, the Post reports. At the same time, HIV incidence has increased slightly among men and women. For men ages 15 to 24, HIV incidence rose from 0.7 infections per 100 men annually to one infection per 100 men annually, and for women in the same age group, incidence rose from just below to just above 1.5 infections per 100 women annually. Therefore, the district's declining prevalence is not attributable to a decrease in the number of new infections, the Post reports (Washington Post, 2/24). The researchers found that the "single greatest factor" in Uganda's declining HIV prevalence rate is premature death among HIV-positive people who died of AIDS-related causes during the study, according to the Chronicle (San Francisco Chronicle, 2/24). The number of HIV-positive people who died each year of the study was about 70% more than the number of people newly infected with HIV annually, the New York Times reports (Altman, New York Times, 2/24).

Condom Use
According to Wawer, increased condom use also might be "offsetting other high-risk behaviors" in the district (San Francisco Chronicle, 2/24). In 1994, about 10% of men reported that they consistently used condoms with nonmarital partners, compared with 50% in 2003. Reported condom use among women in the same age group increased from 2% to 28% in 2003 (Washington Post, 2/24). However, Uganda "[o]minously" is "in the midst of an acute condom shortage" after the government determined that condoms provided by an unnamed foreign supplier were "substandard," according to the Chronicle. The government currently is reviewing the condom quality control standards of all its suppliers, including the United States. According to Wawer, the shortage has reduced the availability of condoms in the country by 50% and driven up the cost to consumers (San Francisco Chronicle, 2/24).

Reaction
The study's findings suggest that Uganda's "much-lauded success" in reducing its HIV prevalence has "little to do with" the abstinence and monogamy programs emphasized by the Bush administration under the President's Emergency Plan for AIDS Relief, Reuters reports (Fox, Reuters, 2/24). PEPFAR is a five-year, $15 billion program that directs funding for HIV/AIDS, tuberculosis and malaria to 15 focus countries (Kaiser Daily HIV/AIDS Report, 2/16). The law (HR 1298) authorizing PEPFAR endorses the ABC model. The measure also specifies that one-third of the bill's HIV/AIDS prevention funding be used for abstinence and monogamy programs (Kaiser Daily HIV/AIDS Report, 4/22/04). President Bush and administration officials "frequently" have cited Uganda as "evidence" that abstinence and fidelity are effective in curbing the spread of HIV, according to the Post (Washington Post, 2/24). Wawer and Ronald Gray of JHU were "reluctant to address directly" how their findings "mes[h]" with the administration's policies, according to the Times (New York Times, 2/24). However, Wawer said that the findings do not mean that the promotion of abstinence and fidelity should stop, according to Reuters. "None of us would in any way denigrate or knock down the abstinence and monogamy message," she said (Reuters, 2/24). A spokesperson for U.S. Ambassador Randall Tobias, head of the State Department's Office of the Global AIDS Coordinator, said that OGAC could not comment on the report because they had not seen it (San Francisco Chronicle, 2/24). Dr. Chris Beyrer, director of the Fogarty International AIDS Training & Research Program at JHU's Bloomberg School of Public Health, said that the study's findings emphasize that "condoms are the main preventive tool against HIV," adding that they should be "everywhere alcohol and sex are sold" (New York Times, 2/24).

NPR's "Morning Edition" on Thursday reported on the study. The program included comments from Wawer and Edward Green, a senior research scientist at the Harvard School of Public Health (Knox, "Morning Edition," NPR, 2/24). The complete segment is available online in RealPlayer.

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