(Condoms) A strategy that works

A strategy that works
By Chris Beyrer and Voravit Suwanvanichkij
Copyright by The New York Times
Published: August 13, 2006


Thailand

Twenty-five years into the HIV pandemic, there remain few developing countries that have had success in controlling the virus. Thailand is one of them.

In the late 1980s, Thailand experienced the first HIV epidemic in Asia, and one of the most severe. By 1991, 10.4 percent of military conscripts from northern Thailand were infected by the virus, the highest level ever reported among a general population of young men outside Africa.

It became clear early on that the commercial sex industry - illegal but popular among Thai men - was at the core of the virus' explosive spread. The Thai response was the 100 Percent Condom Campaign.

As part of the campaign, public- health officials aggressively focused on bars, brothels, nightclubs and massage parlors for condom education, promotion and distribution. Sex workers were likewise offered counseling, testing and treatment. The openness of sex venues there and health officials' access to the women in them made this a relatively simple intervention.
Venues that did not agree to require condom use were shut down. Signs appeared over bar doors saying, "No condom, no sex, no refund!" And the government put resources behind the effort, distributing some 60 million free condoms a year.
A wider national effort was also under way. Condoms appeared in village shops and urban supermarkets, and frank HIV education was introduced in schools, hospitals, workplaces, the military and the mass media. Thais worked hard to reduce fear and stigma and to support those living with HIV.

This national mobilization was classically Thai - funny, nonthreatening and sex-positive. When we briefed the Thai surgeon general on an HIV prevention program for soldiers, he said, "Please be sure the program maintains sexual pleasure, otherwise the men won't like it and won't use it."

It worked. By 2001, fewer than 1 percent of army recruits were HIV positive, infection rates had fallen among pregnant women, and several million infections had been averted.

The 100 Percent Condom Campaign proves that HIV-prevention efforts can succeed by focusing on at-risk populations, providing tangible services and making healthy behavior, like condom use, social norms. Cambodia, the Dominican Republic and other countries have successfully adopted the Thai model.

It's troubling then that the United States now requires all foreign and domestic recipients of HIV and AIDS funding to pledge to oppose prostitution. After all, the 100 Percent Condom Campaign and similar efforts have been shown to decrease the spread of the epidemic through sexual intercourse; the pledge policy can make no such claim.

Quite the opposite: The policy may even limit outreach and access to sex workers, and make condom distribution more difficult. This is why Brazil rejected some $40 million in AIDS funding from the United States last year rather than take the pledge.

This is not the time for us to turn away from any approach that's proven to slow the spread of HIV, and yet the Bush administration lets its moral concerns trump the evidence. Even in Thailand, the government has refused to expand successful prevention services to include gay men and injecting drug users, leading to rising infection rates among these groups.

Still, we cannot ignore the lessons learned during the 100 Percent Condom Campaign. HIV policy should be driven by only what's been shown to work, and prevention services have to reach those most at risk, whether or not we condone their behavior.

Chris Beyrer, a medical epidemiologist, directs the Center for Public Health and Human Rights at Johns Hopkins. Voravit Suwanvanichkij, a physician in Thailand, is on the faculty at Johns Hopkins.