A Plague on the Nation

February 24, 2005

Study Challenges Abstinence as Crucial to AIDS Strategy

OSTON, Feb. 23 - A new study in Uganda challenges the importance of abstinence as a centerpiece of the Bush administration's international AIDS prevention strategy. The study was conducted by Ugandan scientists in collaboration with researchers from Columbia and Johns Hopkins Universities.

Health officials around the world have pointed to Uganda's success in reducing the prevalence of infections with H.I.V., the virus that causes AIDS, in recent years. President Yoweri Kaguta Museveni of Uganda, the Bush administration and some public health experts have credited the decline largely to a policy known as ABC, for abstinence, be faithful (monogamy) and condom use.

Although educational campaigns promoting abstinence and monogamy may have been effective and contributed to the decline, the study found no evidence that abstinence and monogamy explained the overall decline in H.I.V. prevalence, said the lead author, Dr. Maria J. Wawer of the Mailman School of Public Health at Columbia.

Partial explanations for why abstinence and monogamy did not play a bigger role in the decline include fatigue among residents in the Rakai district of Uganda in responding to educational messages and false expectations of the effectiveness of the antiretroviral drugs that are slowly becoming available in Africa, Dr. Wawer said.

She said that the number of men in the study who had two or more nonmarital sex partners increased significantly over the last decade. Condom use by men with their most recent nonmarital partner also increased substantially during the same period. Sexual abstinence remained constant.

The study did show evidence that condom use increased, particularly in nonmarital relationships, Dr. Wawer said, adding that "condoms are essential" in preventing AIDS.

The number of deaths among H.I.V.-infected people in Rakai each year was about 70 more than the number of newly infected people.

The researchers conducted the study in 44 communities in Rakai from 1994 through 2002. Team members went door to door to ask residents about their sexual histories and to obtain blood and urine samples for testing. The survey, conducted annually, included 10,000 people, ages 15 to 49, each year - from 85 percent to 90 percent of those asked to participate.

The findings apply strictly to Rakai and cannot be extrapolated to other areas of Uganda for many reasons, Dr. Wawer and a co-author, Dr. Ronald Gray of the Johns Hopkins Bloomberg School of Public Health, who is also her husband, said in interviews with reporters. One reason is that the age of first sexual intercourse varies in different areas of Uganda.

Dr. Wawer and Dr. Gray also said that their findings, from the same district over the study period, differed from three earlier Ugandan national surveys that suggested that many Ugandans were delaying the time they first had sex. The national surveys were conducted at five-year intervals and involved a smaller sample and people living in districts that varied with each survey, limiting the accuracy of direct comparisons.

Dr. Wawer and Dr. Gray seemed reluctant to address directly how their findings meshed with the Bush administration's ABC policy.

Roslyn Matthews, a spokeswoman for the federal Agency for International Development, which supports international AIDS prevention and treatment programs, said her agency had not seen or heard of the report and could not comment at this time.

Dr. Chris Beyrer, who directs the Fogarty International Training and Research Program at the Johns Hopkins Bloomberg School of Public Health, but was not part of the study, said the findings underscored the point that "condoms are the main preventive tool against H.I.V."

"Condoms have to be everywhere alcohol and sex are sold," Dr. Beyrer said.

But Dr. Beyrer, Dr. Wawer and Dr. Gray said there was now a condom shortage in Uganda because officials had found defects in condoms imported from a country that they did not identify. The Ugandan government has stopped distribution of that country's condoms and is testing all foreign-made condoms, including those made in the United States, they said, adding that the price of condoms in Uganda has risen.

In October 2004, the Bush administration announced $100 million in new grants focusing on abstinence.

In announcing the program, the international development agency quoted President Bush as saying, on June 23: "I think our country needs a practical, effective and moral message. In addition to other kinds of prevention, we need to tell our children that abstinence is the only certain way to avoid contracting H.I.V. It works every time."

Warren E. Leary contributed reporting from Washington for this article.