''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
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