Uganda Study Found That Death Reduced HIV Prevalence; Did the Public Take Home the Wrong Message?

by John S. James

Summary: Uganda has had a remarkable decline in HIV prevalence, and the question of what caused this decline is controversial. An intensive study of the Rakai region of Uganda from 1994 - 2003 found that much of the decreased prevalence resulted from death of people with HIV. But the incidence of new HIV infections was low throughout this study and did not change greatly, suggesting that the real cause of the success was a large reduction in new infections before the study began. The early data presented at the February 2005 Retroviruses conference also showed increasing use of condoms, and some backsliding on reducing the number of sexual partners. But neither change was big enough to greatly affect the incidence of new infections, at least in the aggregate data across the 50 villages studied. In summary, the big reduction in HIV prevalence occurred because of changes that happened before this study, not those measured within it. Therefore the new information does not contradict reduction in the number of sexual partners as a major cause of Uganda's success.

Bill Weintraub:

Why do Rakai and ABC matter to us?

Because, like the ABC people in Uganda and elsewhere, we advocate a type of "primary behavior change" -- in our case, Frot and partner reduction -- as a superior and more effective alternative to condom campaigns, which among "men who have sex with men" (MSM) have been failing miserably.

What the data from Uganda demonstrates and what we know from our own lives is that people can and routinely do change their sexual behavior when faced with life or death consequences.

And that the assumption made by the condom campaigners -- which is that gay men and Africans are essentially children, too impulsive to control their sexual appetites -- are patronizing, racist, and false.

So Rakai matters, and what's important to understand if you've been following this story in the news is that, as reported, the Rakai data were deeply misleading.

ABC works.

Abstinence -- or delayed age of sexual onset; Being faithful -- or partner reduction; and Condom use only when necessary -- substantially reduce HIV prevalence.

That's a lesson well understood in Uganda.

The question is when, if ever, our own American AIDS Inc. will acknowledge that a similar approach here emphasizing non-anal alternatives and fidelity would substantially reduce new MSM HIV infections and effectively end the epidemic in America.

Once again, Chuck Tarver's formulation of ABC for men who have sex with men is:

"Avoid anal, Be faithful, use a Condom only if you won't do the first two."

That formula, properly promulgated, would wipe out AIDS in America.