Promoting safe sex is not a waste of time nor money

by Alisa Alvis, BSc. Hon., MSc. 18.JULY.08

I have no interest in arguing with Mike Edwards about his opinion piece on safe sex. It is an “opinion” and he is entitled to it. But in the interest of balance and preventing the dissemination of inaccuracies I feel compelled to offer a few facts.

First of all, this is true: the surest way to avoid transmission of sexually transmitted diseases is to abstain from sexual intercourse, or to be in a long-term mutually monogamous relationship with a partner who has been tested and you know is uninfected. That being said, this does not justify the non-provision of other methods of disease prevention or HIV/AIDS and STI awareness.{{more}} Abstinence and delay of first sexual intercourse was a part of the campaign used to dramatically decrease HIV infection rates in Uganda. The method used is called “The ABC Approach” and was first seen in Botswana in the late 1990’s. The billboards used would say “Abstain, Be Faithful, Condomise”. This method was taken and adopted by other organizations such as PEPFAR (President Bush’s Emergency Plan for Aids Relief) and UNAIDS. Under UNAIDS the ABC’s stand for:

• Abstinence or delaying first sex

• Being safer by being faithful to one partner or by reducing the number of sexual partners

• Correct and consistent use of condoms for sexually active young people, couples in which one partner is HIV-positive, sex workers and their clients, and anyone engaging in sexual activity with partners who may have been at risk of HIV exposure.

Risk reduction strategies are extremely important for decreasing the transmission of HIV and other STIs but complimentary testing, stigma reduction, educational campaigns and condom distribution are just as important. You cannot force people to abstain and many will not. Also marriage or monogamy do not ensure safety. Some people are faithful to persons who are not faithful to them, or are unsure of their partner’s status. In these situations testing and condoms are of great importance.

“Condoms, when distributed with educational materials as part of a comprehensive prevention package, have been shown to significantly lower sexual risk and activity, both among those already sexually active and those who are not.” – UNAIDS, October 2004.4”

Mr. Edwards accuses the AIDS Secretariat of wasting money with ineffective electronic billboards and condom campaigns, and that a message of abstinence is what needs to be taught because that is what was effective in Uganda. What he fails to mention is the multi-faceted interdisciplinary approach used by the government and NGO’s in Uganda. This is an excerpt from an article which can be found at www.avert.org/abc-hiv.htm:

“Uganda’s response was powerful and wide-ranging. The government launched an aggressive media campaign involving posters, radio messages and rallies; they trained teachers to begin effective HIV and AIDS education; and – most importantly – they mobilised community leaders, churches and indeed the public in general.

The government worked alongside many independent organisations, using different messages to address different groups of people according to their needs as well as their ability to respond. Young people were encouraged to wait before first having sex, or to return to abstinence if they were not virgins. All sexually active people were given the message of “zero grazing”, which meant staying with regular partners and not having casual sex. Those who did not abstain were encouraged to use condoms, which were promoted to the population as a whole.

In order to encourage people to take up such strategies – and to make them effective – action was taken to encourage candid discussion of HIV and AIDS, to reduce stigma, to better the status of women, to improve testing facilities, to treat other sexually transmitted infections and to provide better care for those already infected.

What appears to have worked in Uganda was a combination of risk avoidance and risk reduction approaches. These resulted in a fall in the annual number of new infections between the late 1980s and mid 1990s, which in turn led to a reduction in HIV prevalence. In later years, an increase in the death rate probably made a contribution to further declines in prevalence, while the number of new infections remained more or less unchanged.

What has been particularly important in Uganda has been the combination of messages and approaches that have been used, including the widespread promotion and distribution of condoms. During the 1990s, schemes funded by USAID and other donors greatly increased condom use.

“The ABC approach in Uganda was and still is more than just abstinence and needs to be balanced without any emphasis on one aspect. Neither ‘A’ nor ‘B’ nor ‘C’ on its own can provide the answer to reducing risk of infection that is practical for every member of the population.” – Dr Stella Talisuna, March, 2005.”

As for the rest of Mr. Edwards’ points, I wish to briefly clear up a few misconceptions about condoms, STIs and sexual health.

1. Condoms are 98% effective in preventing pregnancy when used correctly.

2. The average failure rate for condoms is 12%: reflective of people who do not use them properly or do not use them every time they have intercourse. Demographic differences and availability of condoms are also confounding variables in ascertaining failure rates.

3. Laboratory tests show that neither sperm, which has a diameter of 3 microns, nor STD-causing organisms, which are a quarter to a ninth the size of sperm, can penetrate an intact latex condom. Condoms effectively prevent the transmission of Hepatitis B which is much smaller than HIV.

4. If there is a leak in more than 4 per 1,000 condoms, the entire lot (approximately 5,000) is discarded.

5. Recent studies provide compelling evidence that latex condoms are highly effective in protecting against HIV infection when used for every act of intercourse. Some of these studies used “discordant couples”. These are couples where one person is infected with HIV and the other is not. One such study featured 124 couples who reported consistent use of latex condoms during sex. After 2 years, none of the uninfected partners became infected.

A study cited by the University of California, San Francisco, in an HIV Prevention Fact Sheet supports this finding. The study focused on 245 heterosexual couples where one partner was HIV infected and the other wasn’t. None of the 123 male or female partners who consistently used condoms became infected. In contrast, 12 of the 122 partners who either didn’t use condoms or used them inconsistently became infected.

6. A number of studies show an association between condom use and a reduced risk of HPV-associated diseases, including genital warts, cervical dysplasia and cervical cancer. The reason for lower rates of cervical cancer among condom users observed in some studies is unknown. HPV infection is believed to be required, but not by itself sufficient, for cervical cancer to occur. Co-infections with other STDs may be a factor in increasing the likelihood that HPV infection will lead to cervical cancer.

Finally, Mr. Edwards claims that non-use or inconsistent use of condoms has nothing to do with lack of knowledge or availability. On this point I will argue with him because he could not be more wrong. The UNFPA (United Nations Population Fund) is the lead organization for the procurement of condoms and other reproductive health commodities. They note that condoms are more than a commodity and ensuring supply does not ensure use. For effective condom programming you must have a supportive environment which we do not. Without a supportive political, legislative and community environment, condoms are unlikely to get to those that most need them. There are attitudinal barriers to condom use by both providers and users. People would prefer to quote you a bible verse than have a frank discussion about sexuality and how to manage one’s sex life in a healthy way. Of course people use condoms incorrectly and inconsistently – they are not taught to use them effectively. Sexual education belongs in schools, starting at the primary level. At the secondary level condoms should be available to students as well as information about abstinence, STIs, pregnancy and sexuality as a whole. In this country we have wrapped sex up in so much myth and taboo that young people cannot get any information except what they glean from their peers and the media.

Mr. Edwards prefers that we deal in fear, moralizing and uselessly wishing for the “good old days” when people, especially teenagers, were supposedly not having casual sex. We will never reduce teenage pregnancy and STI and HIV transmission until we stop dancing around the issue of sexuality. Consider this: in Massachusetts they have been distributing condoms in high schools for 11 years. They have a teenage pregnancy rate of 22 per 1000 teenage girls, far below the U.S. national average of 80 per 1000 girls. The Centre for Disease Control found that teenagers who had frank discussions with their parents about condom use and sex were 3 times more likely to use condoms and less likely to contract and STI or have an unwanted pregnancy. However, the timing of these conversations was crucial – they had their greatest effect when they preceded the teenagers’ first sexual experience.

Dealing in fear does not help. When people are afraid they avoid the truth, they do not embrace it. All of the statistics that Mr. Edwards’ quoted are designed to inspire fear. I don’t need to convince him of anything, he already believes he is right. But what I do need is for someone to read this and know that you can equip yourself to have a healthy sex life. There are measures you can take to have safer sex. You are not some sort of social deviant for being sexually active. You are capable of being responsible about your sexual health.