At best, condoms are only part of the solution to AIDS and HIV

THE Ugandan President, Yoweri Museveni, has a rather forthright way of warning young people about AIDS.

At a recent youth conference in Kampala, he held up two bottles of Coca Cola. One was fresh, unopened and just taken from the fridge. The other had been opened the day before. Museveni asked two youths which they would like and not surprisingly both chose the unopened bottle. In the same way, Museveni told them, keep yourselves 'closed' until ready for marriage. "Don't open yourselves up," he implored.

Listening to Tom Kitt, the Minister for Overseas Development Aid, speaking at an Aids conference in Dundalk Institute of Technology last Friday, I wondered what the Irish Government would have offered those young people. A cloth to wipe the bottle, perhaps?

Kitt's speech was one of the worst I have ever heard from a government minister. It was boring, self-congratulatory and 100% vision-free. The minister listed all the things the Irish Government was doing to combat AIDS, eg spending about e40 million each year on HIV/AIDS programmes and organising lots of conferences. But there was no evidence of fresh thinking.

Kitt noted that in recent years Uganda has reversed the spread of AIDS/HIV thanks to high-level political commitment, allocation of resources, a focus on prevention, raising awareness of HIV, targeting high-risk groups such as prostitutes (he calls them 'commercial sex workers') and supporting organisations providing care for people living with HIV. Right so far. But he explained AIDS prevention to mean 'condom promotion and distribution', nothing more.

Anybody reading international newspapers or medical journals knows that it was not primarily condoms which turned the tide in Uganda but a strategy known as ABC abstain, be faithful and condomise. This approach encourages young people to delay their sexual debut and urges sexually-active people to reduce their number of sexual partners. Condoms are a third choice, not the first.

Remarkably, Kitt's speech contained no reference to ABC. And we must assume he is no wiser today since he legged it from the hall immediately after he finished speaking. Had he stayed on, he would have heard from an AIDS expert Dr Miriam Duggan, a religious sister and gynaecologist who has worked in Uganda for 30 years and on AIDS programmes since 1997.

Duggan was in Uganda when people on the Tanzanian border first began to get a peculiar sickness causing intermittent fevers, rashes, chest infections and weight-loss. Local people gave it the name 'slim'. Some thought it was a Tanzanian bewitching disease because people in the area had plundered Tanzanian villages across the border a few years previously. Now the gods were punishing them, they thought.

Within a few years, Uganda became the AIDS capital of the world. By 1991, 22% of the population had contracted it. It was 28% in Kampala. The country was shocked into action. The Ugandan AIDS commission was established in 1991 and Duggan was on its board from the start.

Ten years later by 2001 Uganda's infection rate had fallen from 22% to 6.1%. It was a unique success story for African countries. How did they do it? Duggan credits the partnership between the state, the churches and non-governmental organisations in fighting the disease. Policies which attacked the root causes of AIDS instead of just managing the crisis. And positive peer pressure generated by the Churches and young people.

Both Duggan and Kitt mentioned the high-level political commitment that had brought about change in Uganda. But to listen to Kitt, you would think it was all about condoms. In fact President Museveni criticised the promotion of condoms and 'safe sex' as a magic bullet against AIDS.

"In countries like ours where a mother has often to walk 20 miles to get an aspirin or five miles to get water, the practical question of getting a constant supply of condoms or using them properly may never be resolved," he told a conference in 1991.

This is the nub of the issue where condoms and AIDS are concerned. There is no evidence that condom promotion actually works in areas with a high prevalence of AIDS. Perhaps if you could guarantee that there was access to condoms all of the time, that they were correctly stored and correctly used, you would get a high level of protection. But how realistic is that? Condoms are supposed to be stored in a cool, dry place. Try finding one of those in Africa when you need it.

ANOTHER problem with the condom-mainly approach is that it fails to promote respect for women. So much of Africa's AIDS problem is rooted in prostitution, unfaithfulness, polygamy there is even the myth that sleeping with a virgin will cure the AIDS virus and condoms will do nothing to solve these problems. And it is difficult to imagine that people engaging in these sexual practices will bother themselves too much over condom use.

Not surprisingly then, President Museveni chose not to be fatalistic about people's sexual behaviour but encouraged people to change their habits.

"Sex is not a simple manifestation of a biological drive; it is socially dictated. I believe the best response to the threat posed by AIDS is to reaffirm publicly and forthrightly the reverence, respect and responsibility that every person owes to his neighbour. "Young people must be taught the virtues of abstinence, self-control and postponement of pleasure."

Despite the fact that this message delivered the goods in Uganda, a dangerous air of political correctness prevents others from taking it seriously. It seems that many people involved in the fight against AIDS simply do not believe you can get people to change their behaviour. One doctor at Friday's conference pointed out that sex is the only pleasure available to young people in Africa for free.

South Africa's Ambassador to Ireland, Melanie Verwoerd, told the conference that condoms were the best hope because it would be "unrealistic" to push abstinence too hard. Even more revealing was her attitude to the 'be faithful' part of the ABC strategy. This was all wrong because anyone who got AIDS could then be stigmatised for not having been faithful to their partner! But what if the 'be faithful' message works, Melanie?

By all means, try to prevent stigmatisation and promote solidarity with AIDS victims. But don't lose sight of the main issue, which is AIDS prevention. And the difference is this: Melanie Verwoerd's country, which throws around condoms like snuff at a wake, is not winning the battle against AIDS. Museveni's country, which put behaviour change first, is.

This month's British Medical Journal provides further proof of the virtues of the ABC approach. Reflecting on the Ugandan success story, Shelton et al argue that the 'be faithful' component, ie Uganda's campaign to promote monogamy and partner reduction, was the crucial factor in bringing down the AIDS rate in that country.

The lesson is that people are more capable of changing their behaviour than Governments are willing to believe. One newspaper in Uganda noted that "the horror of Slim [AIDS] is forcing people to change social habits... In Bugolobi, a young housewife with three children declared, with a gleam in her eye, 'My husband stays at home much more. And I encourage him to do so by enthusiastically keeping him informed of the latest gossip about Slim victims.'"

Depressing. But it works.