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HIV prevention conundrum: Did the Pope have a case?
By Christopher West

  We consider the statements  Pope Benedict XVI made on the AIDS scourge1 at the press  conference granted to journalists during the papal flight en route to Yaoundé,  Cameroon, realistic, reasonable and scientifically sound.

“I would say that this problem of AIDS can't be overcome only with  publicity slogans. If there is not the soul, if the Africans are not helped,  the scourge can't be resolved with the distribution of condoms: on the  contrary, there is a risk of increasing the problem. The solution can only be  found in a double commitment: first, a humanization of sexuality, that is, a  spiritual and human renewal that brings with it a new way of behaving with one  another; and second, a true friendship, also and above all for those who  suffer, the willingness -- even with sacrifice and self-denial -- to be with  the suffering. And these are the factors that help and that lead to visible  progress. Because of this, I would say that this, our double effort to renew  man interiorly, to give spiritual and human strength for correct behavior with  regard to one's body and that of another, and this capacity to suffer with  those who suffer, to remain present in situations of trial. It seems to me that  this is the correct answer, and the Church does this and thus offers a very  great and important contribution. We thank all those who do this.”

As Benedict XVI affirmed,  there is evidence in Uganda and in most African countries that “the most  efficient reality, the most present at the front of the struggle against AIDS,  is precisely the Catholic Church, with her movements, with her various organizations”.  There is no need of documenting the extraordinary contribution of Sr Miriam  Duggan, Nsambya hospital, Kitovu hospital, Youth Alive, Meeting Point groups,  Lacor hospital, Reach Out Mbuya, and many other realities of the Catholic  Church to the successful response Uganda made to the epidemic.

It is equally true that as  the Pope reiterated “this problem of AIDS can't be overcome only with  publicity slogans”. Uganda with the leadership of President Museveni and  the brave participation of the people at all levels including religious and  cultural leaders, did not indulge in asking for help. Ugandans acted with a  clear and determined strategy based on abstinence (delay of sexual debut) and  fidelity (zero grazing). Moreover it is not even a matter of level of funding:  in the crucial years when prevalence declined from 15% in 1992 to 6% in 2004,  the Uganda AIDS Control Programme cost was 23 cents of dollar per person.2

Indeed the “the scourge (of  AIDS) can't be resolved with the distribution of condoms: on the contrary,  there is a risk of increasing the problem.”

Our experience demonstrates  that the Church’s position on condom and AIDS is the most reasonable and  scientifically sound for the prevention of AIDS epidemics. Uganda has a record  of success in the fight against HIV/AIDS.3 4. Some went  to the extent of labelling the Ugandan experience as “social vaccine”5. The  comprehensive approach to prevention that would later be defined “ABC”, though  initially a truly indigenous and locally developed response to the pandemic has  become an inclusive evidence-based approach to prevent sexual transmission of  HIV. For many years we have been part of the struggle against the disease, and we acknowledge that  the Church and religion at large have had a strong impact in slowing down the  spread of the epidemic, through a work of education of the youth and of the  population to a responsible use of their sexuality. We know how important  condoms can be in focal epidemics among high-risk-groups; there is limited or  no direct evidence, however, that the common and popular prevention measures  (including condom social marketing, VCT, syndromic or mass treatment of STIs)  have contributed to the reduction or slowing down of HIV in generalised  epidemics.6  7 8 9.

Leading scientific journals published  studies showing that the major factor for the decline of prevalence of HIV in  Uganda was the reduction in casual, multi-partners sex (the B of ABC). Since  then, evidence for a pivotal role for partner reduction, complemented by  decline in premarital sex, has emerged for more recent HIV declines in Kenya,  Zimbabwe, Ethiopia and Malawi. In Uganda, Kenya, and Zambia, increases in  abstinence behaviours have been associated with declines in HIV prevalence10. In Uganda the percent  of youth 15 to 24 years reporting pre-marital sex in the past year declined  from 53% to 16% for females and 60% to 23% for males between 1989 and 1995. 11 In Kenya, similar  declines in pre-marital sexual activity in the past year were seen, from 56% to  41% for males and from 32% to 21% for females 15 to 24 years, between 1988 and  1993. 12  All  successful stories in Africa have been preceded by declines in casual sex and  in premarital sex, in general registered over 5-6 years before the evidence of  decline.13

Again in Uganda, prevalence of HIV was  lower (6.4%) among people who had never used condoms compared to 9.3% among those  who had ever used condom14.  Use of condom was associated with higher prevalence among both men and women.  The same survey showed that the West Nile and North-eastern regions of Uganda  that had the lowest prevalence of HIV (2.3% and 3.5% respectively) had some of  the lowest levels of knowledge about condom in the country, some of the lowest  sexual activity in the past 4 weeks (41.5% and 50.4% respectively), some of the  lowest number of lifetime sexual partners (mean of 1.7 and 1.8 respectively for  women and 5.2 and 4.0 respectively for men). The percent of people aged 15 to  59 engaging in “higher-risk” sex was also among the lowest in these two  regions. For women it was 5.5% (the lowest) in West Nile and 8.6% in the  North-east while for men it was 29.4% and 18.5% respectively. The percentage of  youth aged 15-24 years who had had sex before age 15 was also among the lowest,  being 9.6% and 5.2% respectively for women and 12.0% and 7.1% respectively for  men. Moreover, and interestingly, HIV prevalence was lower (1.6%) among  uncircumcised men than the circumcised ones (2.4%) contrary to the general  picture in the country. The West Nile region is not isolated from the rest of  the country, with heavy movement of people by buses and aeroplanes to and from  Kampala everyday. Many people travel from the Democratic Republic of Congo and  the Southern Sudan through West Nile to Kampala daily. In addition, the West  Nile is one of those in a post-conflict period, having seen long post-Amin era  conflict. All these point to the fact that high use of condom was not the real  factor that kept prevalence of HIV low in those two regions. Rather it was  behavioural.

The drivers of the changes happening in  several African countries are behaviours so clearly in line with the Catholic  teaching, behaviours that scientists, sociologists and cultural leaders should  be working on to identify and help to preserve to help avoid HIV.

Moreover the recent levelling trends of  HIV prevalence in Uganda can be attributed to the ‘moving away’ from the  original and verified indigenous Ugandan strategy. There is indeed an  unacceptable pressure by western experts and organisations to change the focus  from the effective A and (especially) B to the debatable C. This is mainly due  to the western taboo about the impossibility of changing sexual behaviour and  interfering with personal behaviours. This is simply hypocrisy as in the case  of smoking, alcohol and drug addiction, different approaches are implemented.

The Pope’s message should, instead of being  criticised, be a wake up call to the proven realities regarding the dynamics of  HIV transmission not only in Uganda but in sub Saharan Africa. After all, it is  universally acknowledged that the principal driver of the epidemic in the sub  region is people having multiple and concurrent sexual relationships. Any  solution that does not embrace this reality and the necessary risk avoidance  strategies is certainly bound to fail. We caution against an interpretation of  Catholic religion and of the Pope’s teaching as prejudicially against science,  because this is simply against evidence.

Sam Orach - Uganda  Catholic Medical Bureau, Kampala - Uganda
George William Pariyo –  Makerere University School of Public Health, Kampala – Uganda
Rose Busingye – Meeting  Point International, Kampala – Uganda
Ronald Kamara – Uganda  Catholic Secretariat, Kampala – Uganda
Filippo Ciantia – AVSI,  Kampala – Uganda
Lawrence Ojom – St  Joseph’s Hospital, Kitgum – Uganda
Thomas Odong – AVSI,  Kitgum – Uganda
Joseph Lokong Adaktar - Uganda Martyrs  University - Faculty of Health Sciences, Nkozi – Uganda


1 Press  conference on route to Cameroon “Our Faith is Hope by definition” http://www.zenit.org/article-25405?l=english
2 Low-Beer,  Daniel, 'This is a routinely avoidable  disease.” Financial Times (Nov 28, 2003)
3 Edward C.  Green, Daniel T. Halperin, Vinand Nantulya, and Janice A. Hogle. Uganda’s HIV  Prevention Success: The Role of Sexual Behavior Change and the National  Response. AIDS and Behavior 2006; Volume 10, Number 4: 347-350.
4 USAID. What  happened in Uganda? – Declining HIV Prevalence, Behavior Change and National  Response http://www.synergyaids.com/Documents/WhatHappenedUganda.pdf
5 Stoneburner  RL, Low-Beer D. Population-level HIV declines and behavioral risk avoidance in  Uganda. Science 2004; 304: 714–18.
6 Gregson S;  Adamson S; Papaya S; Mundondo J; Nyamukapa CA; Mason PR; Garnett GP; Chandiwana  SK; Foster G; Anderson RM. (2007) Impact and process evaluation of integrated  community and clinic-based HIV-1 control: A cluster-randomised trial in eastern  Zimbabwe PLOS MED. 4: 545-555; UNAIDS (1999) Trends in HIV incidence and  prevalence: Natural course of the epidemic or results of behaviour change?.  Geneva: UNAIDS. 36 p.; Stephenson JM, Obasi A (2004) HIV risk reduction in  adolescents. Lancet 363: 1177–1178; Kamali A, Quigley M, Nakiyingi JS, Kinsman  J, Kengeya-Kayondo J, et al. (2003) Syndromic management of STIs and behaviour  change interventions on transmission of HIV-1 in rural Uganda: A community  randomised trial. Lancet 361: 645–652; Quigley M, Kamali A, Kinsman J,  Kamulegeya I, Nakiyingi JS, et al. (2004) The impact of attending a behavioural  intervention on HIV incidence in Masaka, Uganda. AIDS 18: 2055–2063; Sherr L et  al. Voluntary HIV testing in rural Zimbabwe - what is the uptake, impact on  sexual behaviour and HIV incidence 3 years later? Third South African AIDS  Conference, Durban, abstract 46, 2007; Matovu JKB et al. Voluntary HIV  counselling and testing acceptance, sexual risk behaviour and HIV incidence in  Rakai, Uganda. AIDS 2005, 19: 503-511; Padian NS et al. Diaphragm and lubricant  gel for prevention of HIV acquisition in southern African women: a randomised  controlled trial. The Lancet (online edition), July 13th, 2007; Gray RH et al.  Randomised trials for HIV prevention. The Lancet (online edition), July 13th,  2007.
7 Shelton, James D. Ten myths and one truth about generalised HIV  epidemics. The  Lancet 2007; 370: 1809-1811
8 David  Wilson. Partner reduction and the prevention of HIV/AIDS: the most effective  strategies come from communities. British Medical Journal 2004; 328: 848-49.
9 Shelton,  James D. Confessions of a condom lover. The Lancet 2006; 368: 1947-1949.
10 Bessinger R,  Akwara P, Halperin D. Sexual Behavior, HIV and Fertility Trends: A Comparative  Analysis of Six Countries; phase I of the ABC Study. Chapel Hill, NC: Measure  Evaluation, 2003.
Cheluget B, Baltazar G, et  al. Evidence for population level declines in adult HIV prevalence in Kenya. Sexually  Transmitted Infections 2006 82; Suppl 1: i21-6.
11 Bessinger et  al, 2003.
12 Kenya DHS.  Available at www.measuredhs.com.
13 DHS.  Available at www.measuredhs.com.
14 Uganda MoH.  Uganda HIV/AIDS Sero-behavioural Survey 2004-05

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