Can Education and Prevention Strategies Control HIV and Other Sexually Transmitted Diseases?

An Exchange of Views Between The Conant Foundation and The Beyond AIDS Foundation

The Conant Foundation was founded in 1989 by Dr. Marcus Conant, a dermatologist at UC San Francisco who identified the first cases of AIDS-associated Kaposi’s sarcoma in 1981, and ever since has been involved in key research and teaching on treatment of AIDS, Kaposi's sarcoma, and numerous complications of HIV.  He deserves the utmost respect for this work.  The Conant Foundation has shifted its focus over the years.  According to its Web site, it initially supported educational meetings held by Dr. Conant on HIV diagnosis, disease progression, treatment, and research. 

The Conant Foundation later focused on reviewing international AIDS meetings and reporting back to the community on the findings and their implications for HIV disease management, and on promoting research for an HIV vaccine.  The mission statement still posted on its Web site speaks to providing patients and their caregivers with the educational tools and information they need “to make the best possible decisions regarding diagnosis, treatment, and management of HIV/AIDS and other sexually transmitted diseases”; and working “to promote the development and utilization of effective drug treatments, vaccines, and, hopefully, cures.”

However, in the latest Winter 2003-4 newsletter, the Conant Foundation has revised its mission to finding “scientific strategies to eliminate sexually transmitted diseases.”  The statement goes on to say: "...The HIV/AIDS epidemic has taught us that education and prevention strategies, while effective in the short run, have a negligible impact on basic human behavior.  It is our contention that sexually transmitted diseases will only be conquered by science, not by behavior modification..."

To accomplish its mission, the Foundation will in part: "Educate the public that behavior modification has failed to prevent the transmission of sexually transmitted diseases, and that scientific research holds the key to disease elimination..."

In view of Dr. Conant’s stellar reputation, and the educational and research value his foundation has had up to now, some members of Beyond AIDS were distressed to learn that the Conant Foundation has given up on the possibility of controlling HIV and other STDs through longterm change in human behavior.  Dr. Ron Hattis sent Dr. Conant the following letter on January 10, 2004.

Marcus Conant, MD
President, Conant Foundation



Dear Dr. Conant:

I have had the utmost respect for your work as an HIV/AIDS researcher and clinician from the beginning of the outbreak, and have received valuable briefings from your foundation. Your energies in many different directions, particularly in testing new therapies and in educating patients and healthcare providers, have been impressive and extremely valuable.

As a public health physician (UCSF grad 1968) with experience at CDC and as a medical teacher and health officer, and inspired in part by role models like yourself, I have helped over the past 6 years to establish the Beyond AIDS Foundation.  The mission of this organization is to help reverse the course of the HIV/AIDS epidemic through sound public health policy.

I and my colleagues therefore have been profoundly disappointed by the latest emphasis of the Conant Foundation on actually discouraging reliance on behavioral change as a means of controlling the epidemic, in favor of relying on scientific solutions that may be decades away and may never come, e.g., a cure that makes people not only clinically well but also non-infectious, and/or a highly effective vaccine.  Even for diseases for which we have a cure (such as TB and syphilis) or a vaccine (such as hepatitis B), behavioral measures need to accompany the scientific solutions for optimal effectiveness.  Examples include willingness to be screened, restrictions on behavior while infectious, and adherence to treatment. Even for traditional parasitic and enteric diseases, the scientific solution of sewage treatment and water treatment had to be accompanied by the cultural change of using toilets and keeping children from defecating in water sources as frequently occurs in the Third World. 

As you know as well as anyone else in the world, for HIV/AIDS we have neither a cure nor a vaccine, and we are therefore entirely dependent for the foreseeable future on the very behavioral measures that you have so dramatically given up on.  Are we to give up on the present generation entirely while working for an elusive scientific solution?

I am attaching one of numerous articles on the Uganda success, and would appreciate your take on this phenomenon.  I would agree with you that the San Francisco model for so-called prevention and behavior change, based almost entirely on "harm reduction" such as condom advocacy, has been a longterm failure.  However, I challenge whether this is really a good example of an effort at behavioral change, and whether true behavioral/cultural change efforts that could be theoretically successful have even been seriously attempted. 

I have been seeking for years in vain, evidence that the money spent on prevention in San Francisco has really been directed toward inculcating a sense of responsibility for non-transmission among HIV-positive individuals, and changing the culture of the community to make promiscuity a disapproved practice.  The community has steadfastly opposed confidential reporting by name, consistent public-health-assistetd partner notification, true prevention case management, and commitments to abstinence or faithful relationships, and the grants have been squandered on half-hearted efforts to simply graft condom use onto the unsafe general culture. The result is that there is no effective way to even theoretically control transmission, since the average person does not know he has been exposed, let alone infected, until having already transmitted the disease. In fact, the major reason for the decrease in AIDS incidence in San Francisco and many other communities experiencing gay community HIV epidemics in the 1990s was the die-off of an entire generation of infected gay men, and the exhaustion of the pool of susceptibles among them.

In my opinion, the San Francisco model, emulated in many other cities, has been in large part an increasingly expensive misuse of prevention funding, monitoring of an ongoing holocaust without effective intervention, and the greatest missed opportunity for the saving of lives in the history of public health. It would be gratifying if the Conant Foundation would join with the Beyond AIDS Foundation in supporting a reversal of course toward truly effective prevention.  This would of course require you to reconsider your recent nihilistic rejection of behavioral change as a means of controlling the epidemic.

With great respect,
Ronald P. Hattis, MD, MPH


Forwarded Message:


Subj:

Irish Times: Ugandans show correct way to tackle AIDS 

Date:

1/7/2004 2:11:06 PM Pacific Standard Time

From:

Roland.Foster@mail.house.gov

Sent from the Internet (Details)

The Irish Times
January 5, 2004
SECTION: CITY EDITION; OPINION AND ANALYSIS; Pg. 12

Ugandans show correct way to tackle AIDS
The promotion of condoms as a means of stopping the spread of AIDS and sexually transmitted diseases is irresponsible, writes Dr Miriam Duggan

World AIDS Day has recently passed and we have been presented with the global magnitude of the AIDS pandemic. Africa has been the worst affected area, where the consequences for families, for children left orphans and for the social and economic well-being of countries at large have been devastating. Various strategies, mainly the use of condoms, have been advocated to curtail the spread of this fatal disease. However, what is needed, as has been shown in Uganda, is to address the root causes of the spread of the disease.

In 1991 at the International Conference on AIDS and Sexually Transmitted Diseases (ICASA) held in Senegal, which I attended, some representatives from several African countries met to see how best to approach the further spread of HIV/AIDS. At the end of four days of discussion the following statement was drawn up:

"We believe that individuals and whole communities have the inherent capacity to change attitudes and behaviours. The power to fulfil this capacity is often denied or is not exercised ... This power must now be recognised, called forth and supported ...We recognise that behaviour change is inextricably linked to such basic human values as care, love, faith, family and friendship, respect for people and cultures, solidarity and support ...We believe that behaviour change is the most essential strategy in overcoming the HIV pandemic."

Having worked in Uganda as a gynaecologist, serving on the Uganda AIDS Commission, and working on an AIDS prevention programme for 10 years, I can recommend this approach.

Uganda had the courage to address the attitudes and behaviours that were spreading the virus. Value-based programmes and behaviour change workshops were run throughout the country. Young people were helped to look critically at their lifestyles and attitudes, and helped to make responsible choices - choices that would promote life and health. As a result many people made commitments not to have extramarital sex, and to avoid, for example, over-indulging in drink or drugs which results in less control of their behaviour. This demanded much work. President Museveni, the First Lady, as well as many other prominent people and churches supported this approach.

A Harvard University study on the prevention of AIDS in Uganda credits abstinence education with "significant effectiveness in reducing AIDS in Uganda". The study found that from the late 1980s to 2001 the number of pregnant women infected with HIV dropped from 21.2 per cent to 6.2 per cent. By contrast in Botswana, where condoms are officially promoted as the solution, 38 per cent of pregnant women were HIV positive in 2001 (reported in Life Site Daily News, July 22nd, 2002).

The promotion of condoms as a way to stop the spread of AIDS and sexually transmitted diseases (STDs) is irresponsible. The most a condom will do is reduce the risk of infection. The medical literature clearly shows that condoms have a 10 to 13 per cent failure rate for pregnancy and a 10 to 20 per cent failure rate for the HIV virus for a multitude of reasons. Even the Durex manufacturer of condoms state on its website that: "For complete protection from HIV and STDs the only totally effective measure is sexual abstinence or limiting sexual intercourse to mutually faithful uninfected partners."

AIDS is a killer disease and to accept a 10 to 20 per cent failure rate is playing Russian roulette with people's lives. Recreational sex has many adverse side effects apart from the risk of AIDS infection; one has only to read about the increased rates of infertility due to chlamydia, the increase in syphilis, not to mention the consequences of teenage pregnancy. People have the right to be told the truth so that they can make responsible choices.

There are many voices in Ireland today advocating the inclusion of "safe sex" in sex education programmes in schools as a means of reducing pregnancy and STDs. The message being conveyed to our young people is that it's alright to have sex so long as you use a condom - this is irresponsible. Such programmes promote promiscuity, pregnancy, abortions and STDs. STDs in our country are increasing at an alarming rate among our young people. It should also be remembered that the statutory age limit for engaging in sexual intercourse is 16 for girls and 17 for boys.

At another ICASA conference in Zambia in 1999, the Youth Forum made the following recommendation: "You tell us that because 20 per cent of the youth are having sex, you provide us all with 'safe sex' education and a supply of condoms. Why not uphold the 80 per cent who are not having sex and encouraging the others to come back on board?"

In Ireland, the ministers for Health and Children and for Education and Science should take a lead from the value-based programmes promoted in Uganda and heed the Youth Forum's recommendations at the conference in Zambia. Young people have a latent idealism and are able to make responsible choices if encouraged and supported. Good sex education should include an appreciation of each individual, the wonder of the gift of procreation and the gift of life.

In an article by Dr P.B. Marwood published in the British Journal of Hospital Medicine, "AIDS a conspiracy of misinformation", states that: "Church leaders proclaim abstinence as the only real protection. I fear that they are correct. It would seem that virginity and faithfulness will again become fashionable."

Dr Miriam Duggan (FRCOG), a member of the Franciscan Missionary Sisters for Africa, is a gynaecologist who has worked in Uganda and southern Africa on anti-AIDS campaigns.

1/10/04

Dr. Conant: The Beyond AIDS Foundation may wish to publish my letter to you (see last e-mail) or excerpts thereof, and to post it on our Web site (www.beyondaids.org) and/or in our newsletter (Lifeline) with reference to the mission statement from your last newsletter.  If so, we would be pleased to include your response, or excerpts, depending on length.  I therefore would be delighted by a thoughtful response written with this in mind, and your permission for us to include your remarks.  I think that the issues raised by both sides of the debate, and a continuing dialog on the best strategies to cope with the ongoing epidemic, are valuable for others to see and consider. 

BTW, thank you for including an up-to-date list of all current HIV drugs in your last newsletter. It's very helpful to have this all on one sheet.  I have copied it for my staff and we have it available in the HIV clinic of the hospital where I work.

With appreciation,

Ron Hattis, MD, MPH
Beyond AIDS Foundation
(909) 838-4157
1233 Friar Lane
Redlands, California 92373



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