US eyes limits on AIDS education

As HIV infections start to climb again among gay men and young adults, the federal government is moving to impose restrictions on AIDS education that would require campaigns to discuss the "lack of effectiveness" of condoms and subject explicit materials to high-level scrutiny from state public health authorities -- measures that critics argue would impede efforts to prevent the disease.

Executives and physicians from AIDS agencies, which rely heavily on federal money to subsidize their education campaigns, contend that the new rules would sow confusion and reduce the impact of HIV prevention materials.

They point to research showing that consistent use of condoms reduces the spread of the virus by at least 87 percent, while public health authorities add that two decades' worth of prevention efforts have demonstrated that frank, sometimes graphic materials on sexual behavior are necessary to connect with teens and other groups at highest risk of contracting the disease.

"In the absence of an HIV vaccine, really the most effective method we have for preventing HIV is the condom," said Dr. Elizabeth Miller, who takes care of adolescents in Revere at a clinic run by Massachusetts General Hospital. "To obfuscate that and to make the issue cloudy really is of no benefit for prevention efforts."

Authorities at the Centers for Disease Control and Prevention, which introduced the proposed rules with little fanfare in June, said the regulations aim to ensure that appropriate prevention messages reach people who need to hear them most and to increase accountability over the $227 million a year given to community organizations, schools, and local and state health departments for AIDS education.

"We want to make sure our dollars really contribute to preventing HIV infections," said Dr. Ed Thompson, chief of public health practice at the CDC.

Those infections appear to be increasing, and even the number of patients developing full-blown AIDS is rising again after having declined precipitously with the arrival in 1996 of potent drug cocktails, CDC figures show. A survey of 29 states and the US Virgin Islands indicated that from 1999 to 2002, the number of men contracting HIV through sexual activity with other men increased 17 percent, while infections climbed by 11 percent during the same period in adolescents and young adults.

The battle over the guidelines is viewed within the ranks of the CDC as emblematic of a broader struggle for the soul of the agency, according to a former CDC official who spent 17 years working for the agency.

Dr. Margaret Scarlett, who worked on HIV policy, programs, and research at CDC until she left in 2001, said efforts to introduce political and social ideology into public health initiatives have roiled the agency during the past three years.

"In conversations with friends and colleagues, they're saying the distinctions between science and ideology are not being made," Scarlett said. "It's discouraging for seasoned public-health officials who are trying to serve the public's interest who find themselves in a position now where they can't, and it's created a level of frustration for friends and colleagues that for some is untenable."

The proposed rules are the legacy of little-noticed legislation championed by an Oklahoma congressman who maintains that HIV-infected people should refrain from all sexual activity and that abstinence should be the centerpiece of education campaigns because it is the only 100 percent effective method of stopping the spread of sexually transmitted diseases.

That lawmaker, Dr. Tom Coburn, left Congress in 2001 and later became cochairman of President Bush's Advisory Council on HIV and AIDS. "If there's a duty of the federal government to inform, to provide for health, decreased risk of disease, and longevity, why would we have any other health policy than abstinence?" said Coburn in an interview from Oklahoma, where he is the Republican nominee for a US Senate seat.

A dozen years had passed since CDC last issued guidelines governing the content of AIDS education materials paid for with federal money. Changes in technology, especially the increasing use of the Internet for education purposes, along with the condom law backed by Coburn combined to prompt the agency to embark on a review of the rules, Thompson said.

The condom provision was passed in 2000 by Congress and included as part of the Public Health Service Act.

The law requires education campaigns targeting sexually transmitted diseases to provide "medically accurate information regarding the effectiveness or lack of effectiveness of condoms in preventing the sexually transmitted disease the materials are designed to address."

A CDC fact sheet on condoms and their ability to prevent sexually transmitted diseases, which was based on a 2001 report from the National Institutes of Health, concludes that "latex condoms, when used consistently and correctly, are highly effective in preventing transmission of HIV."

The agency's newly proposed guidelines make no mention of that finding, but they do stress the importance of abstaining from sex. The condom fact sheet also highlights abstinence, listing it as the first recommendation, in bold-face type: "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."

Research has yielded conflicting findings about the effectiveness of abstinence campaigns. Studies have suggested that pledges taken by teens to abstain from sex before marriage have contributed to lowering teenage pregnancies. But other studies have concluded that teens who take abstinence pledges end up developing sexually transmitted diseases at a rate comparable to teens who do not make such a commitment.

The other provision in the rules that has generated the most concern among AIDS organizations is CDC's desire to increase oversight of the money it devotes to AIDS education and prevention. Already, CDC requires that agency-funded materials be approved by a local panel familiar with the transmission of HIV and audiences targeted by education campaigns.

Now, the agency is proposing that the materials also receive the express blessing of state or local public-health authorities, and AIDS organizations fear that elected or appointed government officials will be reluctant to approve explicit materials.

"When you're talking about a disease transmitted through sexual activity and the use of drugs, some of the materials used to reach folks will be a little bit edgy, will need to be very direct," said Rebecca Haag, executive director of AIDS Action Committee of Massachusetts, New England's largest private HIV education and counseling agency. "The proposed regulations as currently written could have a chilling effect on our ability to prevent the spread of HIV and AIDS."

A CDC spokeswoman said that while no single event prompted the additional layer of review, the agency had received complaints about the actions of AIDS education and counseling agencies. The complaints ranged from concerns about whether prevention materials were encouraging sexual activity to whether grants for education campaigns were being used for other purposes, such as lobbying.

The acting chief of the HIV/AIDS Bureau in the Massachusetts Department of Public Health, Kevin Cranston, said that his agency has a panel that reviews government-backed AIDS campaigns and that requiring further approval from an agency executive would prove "additionally burdensome for the department."

Stephen Smith can be reached at stsmith@globe.com.