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Abstinence - the safest or most dangerous HIV strategy?

[Uganda] Abstinence messages have replaced billboards promoting condom use along Kampala's streets. [Date picture taken: April 2006]
Les comportements qui évoluent exigent de repenser les stratégies de prévention du VIH pour mieux combattre l'épidémie (Richard Lough/IRIN)

Pumping his fists in the air, Pastor Martin Ssempa strides up and down the stage at one end of a swimming pool at Uganda's Makerere University, where thousands of students listen excitedly to the evangelist's simple message: HIV/AIDS kills - If you want to guarantee yourself 100 percent protection, abstain.

The occasion is 'Prime Time at the Pool', a weekly abstinence rally held at the country's largest and most prestigious university.

"Sex is something so sweet ... but the greatest sex can only be enjoyed in marriage," says Ssempa, insisting that abstinence has always played a greater role than condoms in the fight against HIV/AIDS.

His critics argue that there is no place for morals in the fight against AIDS - it is a straightforward health issue.

"People say remove morality from the debate, but we say take responsibility for your actions," Ssempa maintains. "Mixing religion and health is our secret."

Under the Pastor's guidance, James Okurut coordinates the activities of the NGO, Campus Alliance to Wipe out AIDS (CAWA).

"It is hard to abstain without God. When God is working with me I can overcome temptations," Okurut said. The NGO promotes behavioural change by encouraging students to believe in God and the idea that sex before marriage is immoral.

CAWA recently surveyed nearly 2,000 students at Makerere University and concluded that up to 70 percent were abstaining from sex.

However, Don, a third-year student enjoying a night out at Steak Out, a popular bar in the capital, Kampala, dismissed the findings as "total rubbish" before describing university life as "books, booze and sex". To many students, university represents freedom from parental control, and abstinence is the wrong message.

"We are hot-blooded Ugandans. Those that try to abstain end up backsliding [succumbing to temptation] and then they look for sex like there's no tomorrow," he added. "Abstinence is doing more harm than good. What we need is easy access to condoms."

Uganda once had one of the highest HIV/AIDS levels in the world, but in the early 1990s President Yoweri Museveni's administration pioneered a groundbreaking three-pronged strategy, known as 'ABC' - Abstinence until marriage, Being faithful to one's partner, and correct Condom use - which has been credited with cutting HIV prevalence from over 20 percent to a current rate of about six percent.

However, under the perceived influence of the United States and the evangelical church, the government has been criticised for shifting the emphasis of its fight against the pandemic to favour abstinence over condom use.

Sub-Saharan Africa has more than 390 million Christians, up from 117 million in 1970, a trend due mostly to evangelism, according to the Centre for the Study of Global Christianity.

Uganda's most prominent born-again Christian is First Lady Janet Museveni, an outspoken supporter of abstinence. She has led abstinence marches, and in 2004 called for a nationwide census to count the number of virgins in the country.

A programme run by the Office of the First Lady, the US-funded National Youth Forum, educates young people aged between 12 and 25 about how to protect themselves from contracting HIV.

Margaret Kiwanuka, national coordinator of the forum, said abstinence was 100 percent effective, unlike other HIV/AIDS prevention methods, and noted that virginity was traditionally considered a prised asset, especially a woman's.

One reason young Ugandans were becoming more sexually active outside of marriage, she said, was the sense of 'abstino-phobia', or fear of abstinence.

"Many youths engage in sex because of the myths and misconceptions surrounding abstinence. We tell them that it's OK to have sexual urges, and teach life skills like self-control," Kiwanuka explained.


Critics of abstinence-only programmes claim the Christian and US-backed promotion of abstinence is already having an impact in countries like Uganda.

In August 2005, the UN Secretary-General's special envoy for HIV/AIDS in Africa, Stephen Lewis, accused the US of jeopardising Uganda's struggle to curb AIDS by cutting funds for condoms in Uganda while promoting abstinence.

"To impose a dogma-driven policy that is fundamentally flawed is doing damage to Africa," he said.

Throughout 2005, the media increasingly reported shortages of condoms across the country, a claim the government denies.

"There is no condom crisis," said Elizabeth Madraa, head of the country's AIDS Control Programme. She believes the success of 'ABC' lies in targeting particular sectors of the population with specific elements of the strategy.

"You can't go to the universities and say, 'abstain'. Those that do have their own reasons, but if they were having any impact there wouldn't be people crying out for condoms," she noted.

In 2003 the US government pledged US $15 billion over five years to fight the disease. Most of this funding is channelled through the President's Emergency Plan for Aids Relief (PEPFAR), of which Uganda is one of the largest beneficiaries.

However, two-thirds of the money has to go towards the AB of the ABC strategy. The PEPFAR five-year strategy document mentions condom provision and promotion only for those who practice high-risk behaviour, and not as a general strategy for helping prevent HIV/AIDS among young people.

"For those who are infected or who are unable to avoid high-risk behaviours [such as 'discordant couples', where one partner is HIV positive and the other is not], condom use is a critical risk-reduction intervention," the plan states. "The Emergency Plan will make condoms available to reduce the risk of the spread of HIV infection among those who engage in high-risk activity."

For young people, the PEPFAR's clear preference is abstinence. "The strategies for youth ... encourage abstinence until marriage for those who have not yet initiated sexual activity and 'secondary abstinence' for unmarried youth who have already engaged in intercourse," it says.

The numerous billboards promoting condom use that once lined Kampala's streets have gradually disappeared, replaced with posters urging the youth to refrain from sex before marriage.

One poster, not far from Makerere University, displays a smiling young woman with the caption: "Somewhere out there she's keeping herself for you - what about you?" Alongside the logo of the Office of the First Lady, the poster adds: "Abstinence - Why Not?"

Sceptics argue that the Ugandan policy shift began when Bush's conservative Republican government came to office in 2000, and has been promoted by powerful Christians like Mrs Museveni and Pastor Ssempa.

"In the 1990s, the government's message was very clear: 'We have a problem, we will use every avenue available to deal with HIV'," said one NGO employee, who preferred anonymity. "But since all the PEPFAR money became available to faith-based NGOs, abstinence ideas seem to dominate AIDS education."

Mrs Museveni was elected to Uganda's parliament in February, giving her greater political leverage, which analysts say could see her lobbying to make the abstinence-only message even stronger.

The Ministry of Health maintains that the official government policy has never shifted from ABC, and says equal weight is given to all three elements of the approach.

Alex Kamugisha, Minister of Health in charge of primary health, said Uganda had adopted the ABC strategy more than 20 years ago, long before the US began funding Uganda's abstinence programmes.

"For younger primary school children, the appropriate thing is to focus on abstinence, but later we teach them all the ways to avoid contracting the disease, including the use of condoms," he commented.

HIV/AIDS education has been taught at primary and secondary school level for over 15 years, but recently the emphasis has shifted to abstinence and away from condoms.

In 2002, Museveni launched the US-funded Presidential Initiative on AIDS Strategy for Communication to Youth, to promote increased HIV education among children and the youth.

The initiative included educational assemblies and disseminating handbooks on HIV to primary and secondary schools, but by 2004 the handbooks had been altered to remove graphic information concerning condom use and included a chapter on ethics and moral values. The institution of marriage is highlighted the as the only proper avenue for sex, with some Ministry of Education documents claiming that it "protects society from sexual disease".

Beatrice Were, an AIDS activist with the international poverty NGO, ActionAid, said she had refrained from sex until marriage, but then contracted HIV from her unfaithful husband soon after their first child was born.

"We know that women are not able to have a say in their sex life - it is the men who make those decisions - so it doesn't make sense to talk about abstinence and fidelity until women's rights are equal to men's," she remarked.

The abstinence-only strategy, she added, assumed a degree of control by vulnerable groups like women and girls living in a patriarchal society.


Women and girls are not the only vulnerable groups affected by the abstinence-only campaign.
"Many young people have little or no ability to negotiate whether or not they have sex, especially those in difficult economic circumstances or in conflict situations," said Robina Biteyi, a programme coordinator with the African Medical and Research Foundation (AMREF).

According to the UN report, 'Children on the Brink 2004, A Joint Report on New Orphan Estimates and a Framework for Action', many of the 940,000 children orphaned by HIV/AIDS in Uganda are at the mercy of exploitative caregivers, heading households of younger siblings, or destitute.

"Adolescent orphans in HIV/AIDS-affected communities may be more vulnerable than young children or adults," the report said. "Psychosocial and economic distress can lead to risk-taking behaviour linked with unsafe sexual practices and substance abuse."

A brutal 19-year war in northern Uganda between the government and the rebel Lord's Resistance Army (LRA) has forced some 1.7 million people into camps for the internally displaced. In June 2005, a joint survey by the government and the UN Children's Fund, 'Suffering in Silence', found that at least 60 percent of women in the largest camp had encountered some form of sexual or domestic violence.

"Survival sex" with soldiers and civilians in exchange for food or money was also common, and the rebels have abducted thousands of children for use as sexual slaves. The HIV prevalence rate in the northern district of Gulu is 11 percent, almost twice the national average.

"Sexual coercion and exploitation in the context of this conflict is likely responsible for higher HIV prevalence rates in northern Uganda than in the rest of the country," said a 2005 Human Rights Watch (HRW) report, 'The Less They Know, The Better: Abstinence Only HIV/AIDS Programs in Uganda'.

"The increased risk of sexual violence, sexual exploitation, and heightened sexual activity among boys and girls requires a realistic HIV prevention strategy," it added.


Opponents of the abstinence-only strategy say the "no sex before marriage" message should fit into the wider, more effective ABC approach, or Uganda could risk compromising its hard-won gains.

HRW urged donors to Uganda's AIDS programmes to "ensure that funding is not provided to individuals or groups that deny young people factual information about HIV prevention ... or use HIV prevention funds to engage in religious proselytising".

"It is critical to provide comprehensive sexual health education and services to reduce the risks - often heightened for orphans - of unwanted pregnancies, coerced sex, exploitation in commercial sex and transmission of sexually transmitted infections," the UN report said.

"Abstinence is all well and good," said AMREF's Biteyi, "but people should be given all the information, so they can be properly equipped to protect themselves from contracting HIV/AIDS."

This article was produced by IRIN News while it was part of the United Nations Office for the Coordination of Humanitarian Affairs. Please send queries on copyright or liability to the UN. For more information: https://shop.un.org/rights-permissions

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