US condom policy in Africa targets 'high-risk' areas

JOHANNESBURG -- The US government has purchased more than 1 billion condoms in the past two years to help prevent HIV infections in the developing world, a significant increase from previous years, amid criticism from activists that the Bush administration isn't doing enough to make condoms more widely available.

By the end of December, US officials project that they will have shipped more than 612 million condoms this year to Africa, Asia, and Latin America, the greatest annual figure since 1991, according to the Office of the US Global AIDS Coordinator in Washington. In 2004, the United States purchased 442 million condoms.

Despite the increase, more than 60 countries around the world report condom shortages, according to the United Nations. Last week, activists, including a United Nations AIDS representative and two prominent AIDS activists in Africa, blamed US policies as playing a role in a shortage of condoms in Uganda.

The United States now is emphasizing that the two best prevention methods against contracting HIV are abstinence and being faithful to one partner. If either is not possible, officials recommend consistent condom use. Activists suggested that Uganda's president, Yoweri Museveni, who has disparaged condoms as only an ''improvisation" tool in preventing AIDS, has not been aggressive in addressing a condom shortage out of deference to US pro-abstinence policies.

But Dr. Mark Dybul, US deputy global AIDS coordinator, calls such thinking ''bizarre."

''We are still, by far, the largest supplier of condoms in the world," Dybul said by telephone last week from London. ''During the last two years, the only difference is that we recognize a condoms-only policy to prevent the spread of HIV in a generalized epidemic just won't work."

A generalized epidemic is one that has spread throughout society and is not limited to specific populations. More than 25 million people in sub-Saharan Africa are estimated to have the virus that causes AIDS. That number amounts to roughly seven of every 10 people living with the virus globally.

Dybul and several US officials working in AIDS programs in Africa said the administration's AIDS-prevention policy has shifted significantly over the last two years, broadening to put more emphasis on promoting abstinence and faithfulness within marriage. US legislation now requires that one-third of AIDS-prevention funding be spent to promote abstinence, a condition strongly supported by US religious groups but criticized by many world health authorities as unnecessarily rigid.

The distribution of US-purchased condoms, Dybul said, is now more tightly aimed at such ''high-risk activity" areas as bars, border crossings, brothels, and military bases, but does not preclude giving them to other groups at risk. He said that promoting condom use to all segments of society would send the wrong message to people who are trying to abstain from sex or stay faithful to one partner.

''In a generalized epidemic, what's lost is the true public health message," Dybul said. ''It is our duty to tell people how they can best protect themselves from the risk of infection. The best way to protect yourself from HIV infection is to abstain, or to be faithful to one partner. If you can't do either of those, then condoms are the next-best thing."

There is no doubt that condoms will remain an essential part of global AIDS-prevention efforts. The prevention policy of the Joint United Nations Programme on HIV/AIDS states that the ''male latex condom is the single, most efficient available technology to reduce the sexual transmission of HIV and other sexually transmitted infections."

But globally, donor support for condoms has dropped significantly in recent years, from $2.7 billion in 2001 to $1.8 billion in 2003, the latest figures available, according to Jagdish Upadhyay, head of commodities management branch at the UN Population Fund.

The heart of the debate over condoms focuses on how to implement the so-called ABC-prevention program adopted by all countries -- A stands for abstinence, B for begin faithful, and C for consistent and correct condom use.

''It's not just about the numbers of condoms, but it is about who can get them," said Jodi Jacobson, executive director of the Center for Health and Gender Equity, a Maryland-based group that works on AIDS issues in developing countries. ''What the [US] global AIDS coordinators office has told people is that you can distribute condoms only to sex workers, truck drivers, and people in bars."

On the Uganda shortage, Zackie Achmat, a South Africa AIDS activist, told reporters in a conference call last week that Uganda alone should be receiving 400 million condoms this year -- based on his estimate that each of the country's 6.5 million sexually active men have sex an average of five times a month. The United Nations says Uganda should be distributing 80 million to 100 million condoms free of charge, but the government had a shortfall in late 2004 and early 2005.

''A billion condoms from the US sounds like a big number, but it is relatively small for such a large area," of Africa, Stephen H. Lewis, the special representative for AIDS in Africa to the UN secretary general, said in a telephone interview from Toronto. ''When a virus has spread so widely, it is important to focus on high-risk areas, but it's important also to focus on the whole population."

In the conference call with reporters, Lewis said the ''condom crisis in Uganda is being driven and exacerbated by . . . the extreme policies that the administration in the United States is now pursuing in the emphasis on abstinence, far and away beyond that of condoms."

Beatrice Were, an AIDS activist in Uganda, said that the abstinence messages pushed by President Museveni and his wife, Janet, had created a backlash against condom use.

''There is now a stigma attached to the use of condoms," she said. ''Those of us who are promoting condoms are looked at as immoral people, those that are morally dead."

But the US global AIDS office, in an 18-page document for US staff in overseas missions that offers ''guidance" on policy in preventing HIV transmission, says that ''correct and consistent" condom use should be promoted as an integral part of the battle.

The document, which was obtained by the Globe, defines several groups as being at high risk of HIV infection, including married women.

Most importantly, the document said, the global AIDS office would fund programs that advocated condom use for ''sex workers and their clients; sexually active discordant couples or couples with unknown HIV status; substance abusers; mobile male populations; men who have sex with men; people living with HIV/AIDS; and those who have sex with an HIV-positive partner or one whose status is unknown." Discordant couples involve one person who is infected with HIV and one who isn't.

John Donnelly can be reached at donnelly@globe.com