FRIDAY, April 30, 2004 (HealthDayNews) -- Adding a new perspective to the ongoing debate over the best way to prevent AIDS in Africa, two British researchers say statistics prove a national emphasis on less casual sex, not more condom use, explains the stunning decline in cases in Uganda.
Their findings, published in the April 30 issue of Science, won't end the ongoing battle over the roles of abstinence, monogamy and safer sex in AIDS prevention in Africa and elsewhere. In fact, one critic says the research makes large leaps of faith. But study co-author Daniel Low-Beer hopes his work will help spread the details of Uganda's success story.
"Uganda had one of the worst African AIDS epidemics (in the early 1990s), but it reduced HIV by 70 percent," said Low-Beer, an epidemiologist at Cambridge University. The country's progress is "the clearest example of behavior and communication change reducing HIV."
AIDS has ravaged central and southern Africa since the mid-1980s, and now an estimated 28.5 million Africans are infected with HIV, the virus that causes the disease. In Uganda, however, AIDS rates dropped in the late 1980s and early 1990s. An estimated 5 percent of adults were HIV-positive in 2001, a lower number than some neighboring countries.
In their study, Low-Beer and colleague Rand Stoneburner examined studies that explored HIV rates, sexual behavior and government actions in Uganda over the past two decades. They compared the statistics to those from other nearby countries.
According to the researchers, Uganda's approach to AIDS prevention was unusual. Instead of being limited to the media, anti-AIDS campaigns worked their way into communities through "local networks of village meetings, chiefs, musicians, churches and care groups," Low-Beer said. "The population was mobilized directly to confront AIDS and avoid risk, and must take much of the credit."
Ugandans also emphasized abstinence and monogamy. The approach seemed to work -- surveys suggest that casual sex dropped by 60 percent between 1989 and 1995.
"They avoided AIDS in the best way they could, by reducing casual sex," Low-Beer said. The decline in casual sex, he contends, led to lower HIV rates. "This turned out to be an African success equivalent to a highly effective vaccine."
The researchers found HIV rates remained high in countries that weren't able to reduce casual sex rates, even if they emphasized condom use. The study suggests that one challenge may have been that fewer people in those countries reported knowing people who have died of AIDS. As a result, the researchers say, they may have been less likely to be afraid of the disease.
Not everyone agrees with the findings of the new study. David Gisselquist, an AIDS consultant based in Pennsylvania, said the study authors can't assume changes in sexual behavior and HIV rates are linked. He contends that unsanitary medical practices, such as the repeated use of dirty needles, have helped spread AIDS in Africa and may have played a role in Uganda.
"There is good information that there were also changes in blood exposures in health care, including government training of health workers in universal precautions, efforts to test blood and perhaps, most importantly, public awareness of risks from injections and other health-care exposures."
The World Health Organization, meanwhile, also attributes other factors to the decline in AIDS cases in Uganda. It points to an emphasis on safer sex and a push to delay sexual activity among teenagers. According to the agency, condom use has grown from 7 percent nationwide in 1990 to more than 50 percent in rural areas and 85 percent in urban areas.
Regardless of which specific prevention message reached Ugandans, the study's major message is that communication across the entire society is important, said Nancy Padian, director of international programs at the University of California, San Francisco AIDS Research Institute. "From the top down, religious leaders and government leaders were involved, and people on the ground were involved. Everybody was increasing awareness about HIV and really getting people to talk about it."