Sep 12, 2003   | COMMENTS     

AS A NEW member of the Presidential Advisory Council on HIV/AIDS, I want to respond to some comments fellow anthropologist Doug Feldman made about me in this publication. (“Critics say Bush choice for PACHA advocates abstinence,” news, Aug. 22).

I have been engaged in a public debate with Feldman about AIDS for months. He recently contacted the Washington Blade to make the claim that I support “fidelity only” programs and that I dismiss condom promotion as “a waste of time and money.” I have never said anything like this.

My research findings from Africa have been very unpopular among American condoms-only advocates. What I found in Uganda, for example, is that HIV-infection rates were already declining before American-supported programs of condom social marketing and treatment of STDs had begun. That means something other than the standard package of interventions was probably responsible for declining infection rates.

Those who work in the AIDS prevention industry did not want to hear this. And because there is a highly political debate in America over condoms vs. abstinence, Feldman thought he could do damage if he accused me of pushing “abstinence only,” even though I never promoted this nor have most Ugandans been abstaining.

In fact, anticipating the wrath of colleagues, I almost kept silent about Uganda. But then HIV-prevalence rates kept rising in most countries, while they continued to fall in Uganda.

WHAT WAS GOING on there? What I and a few other researchers willing to speak out found is that Ugandans were having fewer sexual partners, and teenagers were waiting until they were a bit older to initiate sex. Indeed, the early national response to AIDS in Uganda emphasized, “Stick to one partner,” and “Love faithfully.”

Yet Americans and other foreign experts had begun advising Africans that condoms were the “only proven intervention.”

Reacting to Western advice, Ugandan President Museveni said in 1990, “We are being told that only a thin piece of rubber stands between us and the death of our continent. I feel that condoms have a role to play as a means of protection, especially in couples who are HIV-positive, but they cannot become the main means of stemming the tide of AIDS.”

Condom use in Uganda’s general population today is about as low as it is throughout Africa, but condom user rates are quite high (59 percent) among those men who still report having causal sex.

Let me emphasize that I am simply reporting what occurred in Uganda.

Before I first went to Uganda, I also shared the view of most my colleagues that a strategy based on reduction in numbers of sexual partners was unrealistic in poor countries where women have little power, there is a transactional dimension to sex, and polygamy abounds.

Yet when people are facing the possibility of dying, they can do remarkable things. “Love faithfully” was the main message and the main behavioral response in Uganda, and HIV prevalence fell by 66 percent, whether or not Americans approve of the way this came about.

NOW WHAT DOES this have to do with America and with gay men? I am not sure, to tell the truth.

It appears from recent surveys and op-ed articles by gay journalists and scientists that there is quite a bit of casual sex and barebacking these days, more than there was in the latter 1980s. Infection rates seem to be rising again.

What to do? Urge more condom use? This cannot be the whole solution. We now know condoms are not as protective as we once thought they were. A recent meta-analysis of many studies found that HIV seroconversion occurred in approximately 20 percent of couples who used condoms consistently in vaginal sex. And if anything, “condom integrity” is more challenged during anal sex.

Whatever we say about condoms, it is safer to have fewer sexual partners. There are many monogamous gay couples.

I think we all know from common sense and from personal experience that those people, gay or straight, who have less casual sex are less likely to become HIV infected.

This should not be about moralizing or curtailing anyone’s sexual or political freedom. This is just the epidemiology of an infectious disease. I believe in giving people all the facts, and then letting them decide what to do.

Edward Green, a D.C. native, is a senior researcher at the Harvard School of Public Health and was recently appointed to the President’s Advisory Committee on HIV/AIDS (PACHA). He can be reached through this publication.