Monday, May 10, 2004

Uganda's HIV Epidemic Wanes: Word of Mouth Leads to Safer Sex

This is wonderful news, if true, and I'm chagrined that I failed to spot this article earlier.

There are 70% fewer cases of HIV in Uganda now compared with ten years ago, research reveals. It is a success story that highlights the power of local communities to initiate change and shows how prevention strategies can work.

The disease is less prevalent because people are limiting their number of sexual partners, says Daniel Low-Beer from Cambridge University, who co-authored the research. He believes this has happened because friends, family and social networks are talking about HIV, the virus that causes AIDS, and spreading the word about preventing infection.

The researchers studied the medical and behavioural records of thousands of pregnant women and army recruits in Uganda and neighbouring Malawi, Kenya and Zambia. Extrapolating from those figures to the whole population, the team report in Science that half a million Ugandans are HIV positive now, compared with 1.5 million a decade ago.

"It is a massive decline," says HIV researcher George Rutherford from the University of California, San Francisco, who was not involved in the study. "It is unprecedented in the developing world." The survey also reveals that there is 60% less casual sex in Uganda now than ten years ago.

Uganda's achievement is something of a one-off in a continent where the HIV epidemic is still growing. Success is in part due to rapid response mass media campaigns.

Twenty years ago, when infection was at its peak, billboards, radio shows and concerts shouted a coordinated anti-HIV message. Public figures, including politicians, religious leaders and health workers, promoted safe sex and people began to use condoms more often.

But similar strategies in other African countries did little to lower the prevalence of HIV. So why was Uganda so successful?


The difference is that in Uganda people became engaged with the epidemic at the community level, says Low-Beer. Local care groups, religious movements, non-governmental organisations and care networks all spread the message. Families, friends and neighbours began talking about HIV prevention and care, and sexually transmitted diseases stopped being a taboo topic.

The issue also became personal, says Low-Beer. Most people now know someone who has AIDS or has died from the disease and this has motivated people to change their behaviour.

The situation echoes San Francisco in the late eighties when HIV had a stranglehold on the gay community. The best predictor of behavioural change back then was knowing someone with HIV or AIDS. (emphases added)

Following is a critical sentence from the abstract of the actual study that I think particularly worthy of note:

The Ugandan success is equivalent to a vaccine of 80% effectiveness.

There are a few things that need to be noted here. The first is that, as wonderful as this news may seem, the methodology employed in the study is one that has had problems in the past: pregnant women and soldiers by no means constitute a random subsection of any population. One hopes that this is an issue that has been dealt rigorously dealt with by the authors of this study, but I don't have access to the full article to confirm this myself.

Proceeding for the moment on the assumption that population sampling issues aren't important, the second, and undoubtedly the most important, issue that one must pay attention to is the causal factor to which the decline in HIV-infection rates is attributed - a decline in the number of sexual partners Ugandans are having. In other words, instead of relying more heavily on condoms, people in Uganda are abstaining from sexual promiscuity.

I'm no puritan, and don't at all buy into the notion that sex is "evil", but I've always found it curious that so many supposedly "open-minded" people should be dismissive of efforts to encourage abstinence. Even if one doesn't like the people who advocate such messages for their religious and social views, that still doesn't give one licence to dismiss anything they have to say as false by definition. The empirical reality in Uganda seems to indicate strongly that a reduction in sexual promiscuity can lead to dramatic drops in HIV prevalence rates: if we were to hear on the news tomorrow that someone had come up with an HIV vaccine that was 80% effective, most of us would be jumping for joy.

The final thing I'd like to point the reader's attention to is the statement by Daniel Low-Beer about the personal impact of actually having acquaintances who are either suffering from or have died of AIDS. If Low-Beer's insight is correct, it indicates a possible silver lining: there is a chance that the HIV epidemic will become self-limiting, as increasing familiarity with the disease dispels tbe complacency that has allowed the virus to spread so widely across Africa and South Asia. Given the extremely high HIV prevalance rates in Southern Africa even under the lowest projections, I don't know to what extent such a hope will be borne out, but it does seem a reasonable enough possibility on the face of it.