San Francisco Chronicle - February 23, 2005
Sabin Russell at srussell@sfchronicle.com.

Research from the heavily studied Rakai district in southern Uganda suggests that increased condom use, coupled with premature death among those infected more than a decade ago with the AIDS virus, are primarily responsible for the steady decline in HIV infections in that area.

Uganda's "ABC" prevention formula -- standing for Abstinence, Be Faithful, and use Condoms -- has been widely credited with lowering that nation's infection rate from 30 percent in the early 1990s to below 10 percent today.

The Bush administration has embraced ABC, including promoting condom use when necessary, as the primary prevention tool to be applied in the president's $15 billion emergency plan for AIDS relief.

In the Rakai district, however, researchers found that abstinence and fidelity have actually been declining, but the expected rise in HIV infections stemming from such behavior has not occurred.

"Condom use may be offsetting other high-risk behaviors,'' said Maria Wawer, a professor at Columbia University's Mailman School of Public Health, who presented the study at a session of the 12th Annual Retrovirus Conference in Boston.

Ominously, Uganda is now in the midst of an acute condom shortage, according Wawer, who conducts research in the Rakai district, one of the earliest locations of the AIDS epidemic in Africa.

The Ugandan government, after determining that condoms provided from an unidentified foreign supplier were substandard, is reviewing condom quality control from all suppliers, including the United States. Wawer said that move has cut the African country's inventory of condoms in half, while driving up the price.

Uganda's ABC program has been showcased frequently by Ambassador Randall Tobias, the U.S. AIDS coordinator in charge of the president's overseas program. A Tobias spokeswoman noted that he has frequently stressed the importance of "evidence-based prevention strategies" and the importance of the ABC approach.

She said no one from the office could comment on the Rakai study, because they had not seen the report.

The U.S. researchers found that the single greatest factor lowering the percentage of Rakai people infected by HIV was the premature deaths of those who were infected earlier with HIV and subsequently died of AIDS. As the number of AIDS patients decreased, the percentage of those who remained infected or became newly infected decreased in the late 1990s.

Dr. Ronald Gray of Johns Hopkins University, co-author of the Rakai study, said that much of Uganda's early bout with high rates of HIV infection coincided with a period of war in the 1980s. By the 1990s, the country was settling down to a period of relative peace and a return to normal sexual behaviors.

A rebel insurgency continues, however, in northern Uganda, and there are no data to determine whether the nation's AIDS prevention efforts are succeeding or failing in those areas marked by violence.

The push for abstinence until marriage, and the so-called "zero-grazing" policy discouraging sex with multiple partners, does not appear in the Rakai study to have made an impact, according to Gray.

"Over the past decade, we're just not seeing it," he said.

The Rakai findings are based on an extensive and continuing process of interviewing 10,000 adults each year -- a so-called population-based survey that is considered the gold standard for this kind of epidemiological research.

One piece of good news is that, despite indications of slippage in both sexual abstinence and efforts to limit the number of sexual partners, the HIV rate in Rakai continues to drop.

But the percentage of men aged 15 to 49 who reported in 2002 having more than one nonmarital sex partner each year has risen to 50 percent from less than 30 percent in 1995, according to the report.

The decline in abstinence was most pronounced among teenagers. The proportion of sexually inactive girls has fallen from 60 to 50 percent since 1995; among boys it has fallen from about 32 percent to 28 percent.

The median age for girls to have their first sexual encounter -- another marker of successful abstinence education -- dropped to 16 in 2002 from 17 in 1995.

Reports of consistent condom use by men rose to more than 50 percent by 2002, compared with 10 percent a decade earlier. Among women, reports of condom use rose from virtually zero to 25 percent.

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