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Health Policy and Development Journal, Vol. 3, No. 2, August, 2005, pp. 114-115 LETTERS "SAFER SEX"…. MAY BE, "SAFE SEX": NEVER Filippo Ciantia Code Number: hp05016 Dear Editor, I would like to comment on the Editorial published in Volume 3 number 1 of April 2005 of your journal Health Policy and Development, entitled "Pragmatic safe sex, not abstinence or faithfulness, was key in Uganda's HIV decline". First of all from a Public Health point of view, I think we should only talk about "safer" sex since there is no "safe" sex. In addition, we should only talk about "safer" behaviors, unless you refer to abstinence, the only safe behaviour. Secondly, in Uganda actually we have a two-decade old epidemic, with different epidemiological profiles. The first decade (1985- 1995) was characterized by the dramatic decline in prevalence. No matter its nature and relevance, one cannot deny that the most important message was the famous "zero grazing" which, translated into medical language, has been later renamed "AB". One could argue that the word was used in its literal sense and in its agricultural sense. In the literal sense, "zero grazing" could mean "grazing on nothing" (abstinence) and in its agricultural sense, the term means "grazing on restricted ground" (being faithful). Back in 1992 when the A-word, abstinence, was not yet used by western AIDS professionals, Ugandans themselves were already promoting & studying abstinence (Rwabukwali et al., 1992). The second decade (1996 -2005) has instead shown a stagnation of prevalence rates. This is the main fact that the Columbia research has corroborated with the recent study the Editorial mentions (Wawer et al, 2005). It should be noted that it is actually in this second decade that the public health message has been much more on condom promotion. Contrary to some recent publications, public policy documents in Uganda seem to indicate a shift from ABC. The Uganda AIDS Commission recently outlined what it sees as the lessons learned in the fight against HIV/AIDS. It outlines them as (a) a policy of openness (b) political will (c) a multi-sectoral response and (d) resource mobilization (UAC, 2004). The trouble with these "lessons" is that they have also been learned by other countries, which mobilised even more resources than Uganda but did not achieve the same results. Therefore, the explanation for Uganda's success must lie elsewhere. Even the elements of prevention in the current national policy (more or less in order here) are: use popular media, promote condoms, encourage Voluntary Counseling and Testing (VCT), ensure gender equality, target the youth, involve Field-Based Organisations (FBOs), treat Sexually Transmitted Diseases (STDs), do prevention of mother-to-child-transmission (PMTCT), and target prison inmates. There is less mention of ensuring safe blood supply. Certainly, the "AB" is missing in the frontline. When the Commission sets forth "principles" or "core values" to be followed or pursued in the country, these include the fight against stigma, involving people living with HIV/AIDS (PLWHAs) and openly acknowl-edging bisexuality and homosexuality. There is only one passing mention of "ABC", in the context of "going beyond ABC". Those familiar with the global ABC debate will immediately recognize in this Commission document all the content that ABC-rejectors have been fighting for. Whereas I do not think a lot of this dismantling of Uganda's initial program has been necessarily conscious, I think most AIDS experts (particularly western experts) think we are doing the right thing fighting for ever-greater supplies of condoms, fighting stigma, testing everyone etc. All this is great, but recent evidence published last year shows that monogamy or fidelity (and some partner reduction) was the major behavior change accounting for Uganda's success. Most of this occurred before 1995. Yet, the language has changed thereafter. What matters in behavior change is the social environment, which supports positive choices particularly by young people and this has been shown to exist in Uganda, especially through the government and the churches (Stoneburner, RL, Low-Beer, D, 2000). The impact of a social vaccine promoted by a clear message by the government, the Ministry of Health and the Churches cannot, therefore, be denied in the actual content and composition (at least for the first 10 years) of the struggle against AIDS. The Editorial's argument that "a moralistic abstinence-until-marriage message could be disastrous" is not only debatable from a Public Health point of view, but also regrettable for your respectable journal. The example of the disaster in Swaziland actually indicates the contrary. It is the loss of the traditional pragmatic safer sex practice of the Swazi people that caused the disaster the King is addressing. Moreover the process in Uganda has been far more complex and comprehensive. Actually, in Uganda the initial strategy against AIDS was accompanied and supported by a fierce fight against stigma, promotion of education, particularly girl education, empowerment of women and youth, young girl protection, involvement of religious leaders and PLWHAs. I think the authors have been much more convincing on other occasions and issues but not on this one. Filippo Ciantia AVSI - Uganda References:
Copyright 2005 - Department of Health Sciences of Uganda Martyrs University |
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