The XIX International AIDS Conference took place in Washington, DC, July 22–27. The meeting occurs biennially, bringing together scientists, experts, and civil society actors in the largest conference on any health or development issue. The official theme of this year’s conference was “Turning the Tide Together.” However, it was the “Condomize!” campaign sponsored by UNFPA and the Condom Project in collaboration with Durex, UNAIDS, and several other organizations that set the predominant tone for the six-day event.
The Conference heralded many remarkable successes in the fight against HIV/AIDS, including an overall decrease in transmission of HIV, improved access to antiretroviral therapy, and a significant reduction in mother-to-child transmission. These advances point to the promise of an evidence-based response to HIV/AIDS and demonstrate the power of human ingenuity in the fight against the disease. However, advancements in science must go hand-in-hand with a culture that affirms the critical importance of responsible choices.
The overwhelming prevalence of the Condomize! campaign palpably undermined the value of building such a culture. With over one million condoms dispensed at the conference and the constant loudspeaker announcements encouraging participants to “Live, Love, Condomize,” it was readily apparent that the message of the International AIDS Conference could be boiled down to one word—condoms. If we are to truly “turn the tide together” we need to do more than ensure that condoms are available in every corner of the world.
Condom promotion is not an effective response in generalized epidemics, like those in Africa, where HIV is spread through heterosexual sex (and not primarily by sex workers, men who have sex with men, and injecting drug users, like it is in the United States and other countries that have concentrated epidemics). Evidence shows that people in long-term relationships do not use condoms consistently, and in many African communities it is a sign of lack of trust if a partner demands condom use. The international AIDS community needs to understand the contexts and cultures in which HIV ravages communities.
It also needs to accept the science behind HIV transmission. When a person is first infected by HIV, his viral loads are extremely high and he is very infectious, yet because there are often no immediate symptoms, he is not aware he has it. If he has multiple concurrent partners—that is, more than one sexual partner around the same time—those partners are at risk of contracting HIV. And if those partners have other partners, those additional partners are exposed to the risk of contracting HIV. Even a monogamous partner is at risk if her partner is not faithful. These concurrent relationships are not uncommon in many parts of Africa, due to migrant labor, transactional sex, and polygamy.
It is therefore critical that people reduce the number of concurrent partners that they have. An emphasis on mutual fidelity works: In Uganda in the 1990s, the famous “zero grazing” and “love faithfully” messages broadcast through all forms of media, by religious leaders, and by the president himself were culturally relevant and effective. Ugandans reduced the number of partners they had, and HIV prevalence declined.
Another necessary form of behavior change is delay of sexual debut. By delaying sexual activity, young people delay their exposure to the virus. This is particularly important for women, who are biologically and behaviorally more susceptible to contracting HIV. This was another component of Uganda’s successful campaign to decrease HIV prevalence.
Both of these prevention strategies are person-centered. They understand the capacity of the person to make responsible decisions, and thus they get at the underlying behavior that puts a person at risk of contracting HIV. A person-centered response to HIV/AIDS also understands the needs of the person who has already contracted HIV, and treatment with antiretroviral drugs (ARVs) is an essential component of this. ARVs keep viral loads down so low that an HIV-positive person has a much longer lifespan than he would otherwise. ARVs are also the key component of preventing transmission of HIV from an HIV-positive mother to her child during pregnancy, childbirth, and breastfeeding.
Unfortunately, attendees of the AIDS Conference did not hear about the importance of evidence-based, risk avoidance prevention strategies. Instead, they were blasted with promotion of condoms and sterile needles, which is the global health policy community’s intervention of choice for injecting drug users.
The body that should be leading the charge for evidence-based and person-centered solutions is UNAIDS, the United Nations body charged with addressing the HIV/AIDS epidemic. Yet UNAIDS documents repeatedly tout harm reduction strategies that do not work in generalized epidemics. Although UNAIDS rightfully promotes ARVs for all infected by HIV, its person-centered approach ends there. UNAIDS does recognize the importance of partner reduction and delay of sexual debut in preventing the transmission of HIV, yet it fails to prioritize these strategies. It is time for UNAIDS to lead with evidence-based and person-centered solutions to end the spread of HIV.
Elyssa Koren, J.D., is the Director of Advocacy at the World Youth Alliance. Meghan Grizzle, J.D., is the Research and Policy Specialist at the World Youth Alliance.
World Youth Alliance HIV/AIDS White Paper
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