Preventing HIV with Young People: A Case Study from Zambia

Abstract

The US President’s Emergency Plan for AIDS Relief (PEPFAR) is funding thousands of community-based organisations, international NGOs and government services in high HIV prevalence countries to persuade young people to abstain from sex until marriage (Abstinence, Behaviour Change, Youth – ABY). This paper describes how this strategy is being implemented in Zambia, and community responses to it. It is derived from published information and observations and discussions in the Eastern Province in 2005–2006. A few NGOs have challenged the strategy, but many took the funds and are paying large numbers of peer educators to promote abstinence only. Messages are rife that condoms have holes or don’t work sufficiently well to make them worth using. Condom promotion materials have been replaced. Service providers refuse to give condoms to young people. Young people who had attended sexuality and life skills programmes that gave them accurate information are rejecting inaccurate messages and demanding condoms. Without this education, however, inaccurate messages will spread quickly. It is not possible to promote condoms only for high risk people without stigmatising both the people and condoms, and it also jeopardises promoting condom use for contraception. Everything possible must be done to reduce negative messages about condoms. Everyone involved in HIV/AIDS needs to reflect on their own work in relation to this new climate and ensure that all prevention options are widely available, correct information is given and condoms are available for everyone who needs them.

Résumé

Le Plan du Président des Etats-Unis pour l’aide d’urgence à la lutte contre le SIDA finance des milliers d’organisations communautaires, d’ONG et de services gouvernementaux dans des pays à forte prévalence du VIH afin d’inciter les jeunes à l’abstinence avant le mariage. Cet article décrit l’application de cette politique en Zambie, et les réactions des communautés. Il s’inspire de publications, d’observations et de discussions dans la Province Orientale en 2005-2006. Quelques ONG ont réfuté cette stratégie, mais la plupart ont pris les fonds et rémunèrent beaucoup d’éducateurs pour promouvoir uniquement l’abstinence. Des messages affirment que les préservatifs sont troués ou ne servent pas à grand-chose. Le matériel promotionnel des préservatifs a été remplacé et les pénuries de préservatifs sont fréquentes. Les jeunes ayant participé à des programmes d’éducation sexuelle et de compétences essentielles qui leur ont transmis des informations justes rejettent les messages inexacts et exigent des préservatifs. Néanmoins, sans cette éducation, les messages erronés se propageront rapidement. Il est impossible de promouvoir les préservatifs seulement pour les personnes à haut risque sans stigmatiser les individus et les préservatifs, et compromettre leur promotion pour la contraception. Tout doit être fait pour réduire les messages négatifs sur les préservatifs. Chaque acteur concerné par le VIH/SIDA doit réfléchir à son travail dans ce climat et garantir la disponibilité de toutes les options de prévention, l’exactitude des informations et l’accès aux préservatifs de tous ceux qui en ont besoin.

Resumen

El Plan de Emergencia del Presidente de EE.UU. para Combatir el SIDA (PEPFAR) financia miles de organizaciones comunitarias, ONG internacionales y servicios gubernamentales en países con alta prevalencia de VIH para persuadir a los jóvenes a abstenerse del sexo hasta el matrimonio. En este artículo se describe cómo se está realizando eso en Zambia, y las respuestas de la comunidad. Es derivado de la información publicada, de observaciones y discusiones en la Provincia Oriental en 2005-2006. Algunas ONG han cuestionado la estrategia, pero la mayoría aceptaron los fondos y les pagan a educadores de pares para promover sólo la abstinencia. Cunden los mensajes de que los condones tienen agujeros o no funcionan bien para ser dignos de usarse. Se han substituido los materiales de promoción del condón, y hay frecuente escasez de condones. Los jóvenes que habían asistido a los programas de sexualidad y formación para desenvolverse en la vida, donde se les suministró información exacta, están rechazando los mensajes incorrectos y exigen condones. No obstante, sin esta educación, esos mensajes se difundirán rápidamente. No es posible promover condones sólo para las personas en alto riesgo sin estigmatizar a las personas y a los condones, y perjudicar la promoción de su uso para la anticoncepción. Debe hacerse todo lo posible por disminuir los mensajes negativos respecto al condón. Todos los que trabajan en la lucha contra el VIH/SIDA deben reflexionar sobre su propio trabajo en relación con este nuevo clima y asegurar la amplia disponibilidad de todas las opciones de prevención, el suministro de información correcta y la disponibilidad de condones para quienes los necesiten.

Key Words:

• condoms
• HIV/AIDS
• adolescents and young people
• Zambia

Millions of US tax dollars are going through the US President’s Emergency Plan for AIDS Relief (PEPFAR) to thousands of community-based organisations, international NGOs, government services and policy-makers across high HIV prevalence countries to persuade young people to abstain from sex until marriage and have a mutually faithful monogamous marriage for life thereafter. These are entitled “Abstinence, Behaviour Change, Youth” (ABY) programmes.

Zambia has a generalised HIV epidemic, with an average prevalence of 17%. The HIV prevalence among young women aged 15–24 is six times that of young men of the same age, but the highest prevalence is in women aged 25–34 years (24–30%) and men aged 35–39 years (23%).¹ Early unwanted pregnancy is also a major problem for young women. Many factors make young people vulnerable to HIV, STIs, early pregnancy and non-consensual sex. These include earlier puberty and later marriage; sexual desire and pleasure; ignorance about their bodies and protective measures; lack of access to condoms; traditional and emerging gender and sexuality norms which encourage unsafe sexual activity among young people; and gender inequity resulting in a high prevalence of non-consensual sexual activity. In addition, poverty results in risky economic strategies including sex work, transactional sex between younger women and older men and early marriage.

This paper summarises PEPFAR’s ABY guidelines, describes how they are being implemented in Zambia, and community responses. On the basis of the findings and evidence of good practice, the authors discuss why the PEPFAR ABY concept, guidelines and implementation need to change before organisations and communities will be able to use US funds effectively to create empowered young people, health-promoting institutions and enabling environments to support young people’s sexual and reproductive well-being and prevent more infections and unwanted pregnancies.

The paper is derived from published information and observations, activities, events and discussions in which the authors were involved, one (Gordon) providing technical support to community-based programmes and the other (Mwale) as the head of an NGO working with adolescents and young people in the Eastern Province of Zambia in 2005 and 2006.

The “Abstinence, Behaviour Change, Youth” (ABY) approach

HIV prevention programmes have focused on behaviour change since the early 1990s, using “ABC” as shorthand for protective behaviours: Abstinence, Be faithful, Condoms. The majority of programmes for young people promoted abstinence and fidelity, with condoms as a fall-back option if sex happened. ABC has been criticised by many HIV prevention practitioners as being over-simplistic and a reason for limited success.²

But the US Government saw a different set of weaknesses in the ABC method. They perceived that condoms were being promoted to young and old indiscriminately, to the detriment of abstinence and fidelity messages. This was thought to be disrespectful to the values of local faiths and traditions, particularly in relation to women. Also, evidence from the high prevalence, generalised epidemics in Uganda and Botswana in the 1990s seemed to show that the impact of condoms on the epidemic, as compared to partner reduction and delayed sexual debut, was limited. This was thought to be partly because people in regular partnerships were considered to be reluctant to use condoms, and because it was logistically difficult to ensure they were widely available to enable regular and consistent use.³ There were also concerns that educating young people about condoms would reduce the power of the abstinence message and cause harm if condoms were then not consistently available.⁴ It was argued that risk elimination should be prioritised for promotion to the general population because condoms are not 100% effective and were therefore appropriate for high-risk groups only.

These concerns resulted in the emergence of the ABY approach for young people, in which abstinence and behaviour change are stressed and condoms only addressed with young people who are already sexually active.

In order to ensure that abstinence was adequately promoted, the guidelines required that 33% of all prevention funding (not just the reduction of sexual transmission) be used for activities promoting abstinence.

In 2004–2006 the PEPFAR budget increased from $207 million to $322 million, which was to be spent in 15 countries, 12 of which are in sub-Saharan Africa, including Zambia. 55% of those funds are required to be spent on treatment and 10% on orphans and vulnerable children. 15% are recommended to be spent on palliative care for HIV+ people and 20% on prevention.

Prevention must cover blood safety, prevention of mother-to-child transmission, safe medical injections, AB activities and “other prevention”. PEPFAR country teams are required to spend half of prevention funds on prevention of sexual transmission, two-thirds of which should be spent on AB (abstinence/faithfulness) activities.

ABY (also called abstinence-until-marriage) means:

•	Encourage youth to be abstinent until marriage and delay sexual activity to protect themselves from exposure to HIV and other STIs; and
•	Encourage individuals to practise fidelity in sexual relationships, including marriage, to reduce risk of exposure to HIV.
•	Condom use to those who practise risky sexual relationships such as sex workers.
•	Condoms may not be promoted to youths aged 10–14 in school.

Further limits on promotion of condoms include:

•	Any PEPFAR-funded programme that provides information on condoms must also provide AB information.
•	PEPFAR funds may not be used to physically distribute or provide condoms in school settings or for marketing efforts to promote condoms to youths, nor in any setting to promote condoms as the primary intervention for HIV prevention.5

The guidelines reflect a social marketing strategy, in which audiences are segmented and targeted with focused, persuasive messages to change individual and peer behaviours. Young people between 10 and 14 years of age should only receive information about abstinence, self-esteem and skills to avoid sex. For those between 15 and 19 years, abstinence until marriage is the primary message with information on condoms and teaching their correct and consistent use only to those who are already sexually active. The guidelines say:

“Marketing campaigns that target youth and encourage condom use as the primary intervention are not appropriate. Implementing partners must take great care not to appear to present abstinence and condom use as equally viable, alternative choices or that it is acceptable to engage in risky sex. For programs that include a condom component, information about correct and consistent condom use must be coupled with information about abstinence as the only 100% effective method of eliminating HIV risk.”

“Every effort will be made to deliver a clear message that the best means of preventing HIV is to avoid risk altogether. Condoms are an essential means of HIV prevention for populations who engage in risk behaviour. These groups include prostitutes, sexually active discordant couples, substance abusers, men who have sex with men and people with HIV. These groups must be taught how to use condoms consistently and correctly.”

“Information provided about the use of condoms shall be medically accurate and shall include the public health benefits and failure rates of condoms” ⁶

The expansion of the ABY strategy in Zambia

Under PEPFAR, 33% of all prevention funding is being used for activities promoting abstinence. Programmes must include the importance of abstinence in reducing the prevention of HIV transmission in unmarried individuals, the decision to delay sexual activity until marriage, skills development and the adoption of social and community norms that support delaying sex until marriage and that denounce forced, transactional or inter-generational sexual activity amongst unmarried individuals.⁶

Earmarking funds for abstinence in this way has forced several USAID country teams not to fund programmes with other prevention components, including condoms, in order to reach this target. They reported in 2005 that without being exempted from this target, they would have had to reduce prevention of mother-to-child transmission activities, cut medical and blood safety activities and care programmes.⁵ USAID staff are expected to exercise tight control over youth prevention programmes at all stages of the funding and implementation to ensure that the abstinence target is met. Solicitations for proposals in Chipata district made it clear that the ABY funds are meant for abstinence-only activities and not the promotion of condoms. The control includes monitoring learning materials for young people, training reports, data collection and field visits to ensure that the abstinence guidelines are met.

PEPFAR funds are paying for staff in national policy positions in Ministries in Zambia that have responsibility for young people, and who are in strategically powerful positions to promote abstinence and fidelity messages to young people.

“The fight against HIV in Zambia amongst adolescents involves a mass of often conflicting moral, religious, cultural, ideological and human rights arguments which can be broadly divided into a battle between condoms and sex vs. abstinence and virginity. The recent shift in emphasis to abstinence became apparent a year ago [in 2003] when the Ministry for Education banned NGOs from distributing condoms at or near school sites. Many programmes now promote abstinence as the only message, not only for HIV prevention but also for a ‘healthy person who values his or her body’. Other programmes restricted by beliefs or US-based funding will not distribute condoms, even in rural areas where other sources of condoms are difficult to access. Such programmes deprive Zambian youth of information about reproductive heath and their reproductive rights in general. Abstinence and fidelity may have their place in the control of HIV/AIDS, but it is already too late for the one in five youth with HIV and alternative messages need to reach the 60% of sexually active girls aged 15–19 who have conceived and the 64% who report incidents of forced sex.” ⁷

At district level in Zambia, the District Development Co-ordinating Committees (DDCC) manage all HIV prevention work with young people and disburse funds to civil society and government programmes. At DDCC meetings in Chipata district, all sectors and NGOs were informed that there was a substantial level of US funding for work with young people on condition that abstinence and fidelity should be promoted, with condoms only for “high risk” people such as sex workers.

There have always been groups who believe that young people should only have the choice to abstain until marriage even if that means that the majority risk serious illness and death when they don’t succeed. Some health workers think that girls should not “get away with” having sex by using contraceptives, but should be punished with pregnancy and unsafe abortion. In the past, however, governments and civil society organisations trained and monitored health providers to avoid allowing their own values to interfere with providing the services laid down in government policy. Today, with PEPFAR money, these judgmental attitudes are being more widely supported. Although condoms are available in Rural Health Centres, young people frequently report that they do not have the courage to ask for them or they are refused supplies because they are not married.

Condom dress, 8,500 condoms

The response of civil society organisations

A few NGOs in Chipata have challenged the ABY strategy and refused PEPFAR funding but the majority of organisations are surviving on these funds and promoting abstinence until marriage and fidelity only. These include the majority of the international NGOs who sub-grant and have a major influence on local community-based organisations. There is disagreement in the HIV community over these strategies, which has resulted in a breakdown in collaboration between the NGOs and weakened the multi-sectoral response to address causes of vulnerability. For example, Africare was a partner to the Planned Parenthood Association of Zambia, offering economic activities to young people, whilst PPAZ addressed sexual and reproductive health. This partnership ceased when Africare took ABY funds.

Organisations with ABY funds are training and supporting large numbers of peer educators to promote abstinence and fidelity and discourage condom use. Better incentives encourage peer educators to leave comprehensive prevention activities to join abstinence-only programmes. Abstinence and fidelity are no longer treated as components of a comprehensive prevention strategy for young people but a discrete intervention. Organisations are tempted to carry the guidelines to extremes to avoid risking loss of funds. Some organisations justified taking ABY funding in the expectation that other organisations would provide condoms to young people. This is no longer the case in an increasing number of settings.

Faith-based organisations have always struggled with how to marry their moral mission and the need to protect health and life, given the reality of sexual lives. Some continue to encourage condom use. For example, Christian Aid recommends open and frank education on all prevention options with young people,⁸ in response to concerns about stigma and over-simplified ABC activities.⁹ Other faith-based organisations are relieved, however, that PEPFAR allows them to have stand-alone abstinence and fidelity programmes with no condom component. Many small faith-based organisations have a low capacity to carry out HIV prevention work with young people and their behaviour change activities are often based on religious prescriptions rather than good educational practice. It is important to bring values, love and relationships into discussions of sexuality, and young people greatly appreciate these discussions. But some faith-based organisations are now being funded to promote messages about sin and fear, which increase stigma and discrimination. Also, it appears that HIV prevention messages are becoming more negative about sexuality generally and seek to repress sexual feelings rather than help young people to find safe ways to express them¹⁰. Safe sex practices such as masturbation are also being undermined, because they are condemned in the Bible and suggest that pleasure is acceptable as long as it is safe.

How PEPFAR guidelines are being translated at local level

Condoms are being hit by a double whammy in the way PEPFAR guidelines are being translated in US-funded programmes at local level. The message is that condoms don’t work and are only suitable for high risk people.

“Condoms don’t work”

The message that condoms are not 100% safe is being widely interpreted as “condoms don’t work sufficiently well to make them worth using”, as the following examples show. The majority of the educators in these events reported that their sponsors were well-known international NGOs using PEPFAR funding.

•	A young peer educator demonstrated how she tells young people that abstinence is the only answer until they are at least 20 and married, because condoms are not reliable. She hands out cards to young people with statistics explaining why condoms will not protect them. She herself did not believe or follow this advice. When challenged by a peer that she was ‘killing her brothers and sisters” she said she needed the high pay from the United States. (Observation and interview with peer educator, Chipata, 2005)
•	A youth organisation in Lusaka put condoms in the microwave and later tipped milk through them to demonstrate to young people that condoms have holes in them. (Personal communication)
•	Participants on a US-funded course were taught that condoms have holes in them which allow HIV through but are too small to allow sperm through, that this makes them suitable only for family planning for married people and that condom manufacturers put lubrication on them to cover up the holes. (Personal communication, Kate Hawkins, 2006)
•	Teaching methods used by NGOs and schools include the Russian Roulette game to teach that “if you have sex six times with a person with HIV using condoms every time, by the sixth time you will have HIV yourself”. Young people are asked to imagine putting a pistol to their heads and pulling the trigger six times.10
•	A Chichewa song being sung widely on the radio and in schools and communities has a line that “there is no point in using a condom because it is the same as not wearing one”. (Observation and discussion with primary school teachers at workshop in Chipata, December 2005)
•	A drama group in Chipangali staged a play about a drunken man with three girlfriends who was told to marry one to avoid HIV. He tested HIV-positive and committed suicide. Condoms were not mentioned in the play as the sponsors instructed the dramatists not to, on the grounds that if you have sex using a condom six times with a person with HIV, you will get HIV yourself. (Observation of drama and discussion with drama group, Chipangali 2005)
•	A local newsletter with US funding in Chipata published articles about Dr HIV, who sends sinners with HIV to live in a silent city forever; an article on abstinence vs. condoms that said that if people used condoms, in a few years everyone would have HIV; and an article blaming girls who wear short skirts for the epidemic. (Kwacha Kumawa: Newsletter, Chipata, December 2005)
•	A poster that shows someone jumping out of an aeroplane with a parachute. The question asked is: “Would you jump out of a plane if the parachute only opened 75% of the time?” (Seen in Chipata, December 2005)

“Condoms are only appropriate for high risk people”

This message is being promoted through interpersonal communication; separating sexually active young people from their abstinent peers and treating them as “special cases” for referral; separating condom messages into separate categories for contraception and HIV prevention, rather than promoting dual protection; and carrying out HIV education as if everyone in the audience were HIV negative and can abstain until marriage.

US funding has been withdrawn from social marketing agencies such as the Society for Family Health, funded through Population Services International, for condom promotion to young people in Zambia. This has resulted in the removal of all posters from health services, schools and youth clubs and other media promoting condoms, which have been replaced by posters promoting abstinence and fidelity. Many of these posters show elite young people with university degrees, saying they got there because they abstained. This must seem ironic to girls, and sometimes boys, whose only possible route to university has been via a male “sponsor”, a common occurrence in Zambia.

Failure to address gender

Women have been blamed and stigmatised more than men in the HIV epidemic, with all the negative consequences of this. The latest phrase, “the feminisation of the epidemic”, emphasises that the percentage of women with HIV in Africa is now higher than that of men (in Zambia 57% women to 43% men)¹ because women are more vulnerable to HIV infection biologically and are not able to negotiate for safer sex. Girls aged 15–24 years are popularly seen as the most vulnerable but also the “drivers” of the epidemic because they are six times more likely to be infected than boys of the same age. The high prevalence of HIV in the older men they have sex with is not acknowledged. Heterosexual men have vanished from the list of vulnerable people. This has two effects: men do not feel themselves to be very vulnerable nor do they feel themselves to be responsible for safer sexual activity.

“I didn’t use a condom because she didn’t insist on it” is a common response from Zambian men when asked why they did not use a condom. A values clarification exercise with teachers in Chipata had 50% of the men agreeing with the statement “Women have more responsibility for HIV prevention because they are more vulnerable and can more easily control their sexual feelings”. There is a proverb in Chichewa that says that in relation to sex, men are like children, they cannot be expected to control themselves. These attitudes call for a huge change in male and female sexual norms and expectations of relationships, which will require a lot of work with boys and men, not just girls and women, at interpersonal, group and societal levels. Single or married girls and women cannot be expected to abstain, be faithful or use condoms whilst for boys and men it is business as usual.

To their credit, the ABY guidelines call for activities to change gender norms, reduce gender violence and strengthen women’s status and power. However, in Chipata district, the great majority of ABY activities focus on abstinence and behaviour change in young people and often specifically girls, in spite of encouragement in calls for proposals to address the behaviour of older men, gender issues, and transactional and inter-generational sex. The US fails to insist that strategies include a substantive focus on these issues¹¹ and many organisations require capacity-building to address them.

Community responses

Young people are used to conflicting messages about sexuality from different sources. Many young people and adults appreciate condoms and are actively responding to incorrect information and restrictions on their accessibility. In places where safer sex choices have been promoted for some time, some young people are confident enough to challenge or ignore the person who says that condoms have holes in them or are only for high risk people. In the evaluation of a life-skills programme in Chipata district in 2005, for example, a young woman responded this way:

Questioner: “What would you do if someone said to you that condoms have holes in them and are not worth using and that they are only for promiscuous people?”

Young woman: “I would explain that they have been given incorrect information, that using condoms is many times safer than unprotected sex and is for anyone who is sexually active and wants to prevent pregnancy and STI/HIV, whether married or not. I would tell them about my good experiences with using condoms.”

Young people aged 17–19 attending a session on abstinence explained that:

“Abstinence is good for younger people and those who like it, but we like sex and at our age sex is a part of life. If we cannot get condoms, we will continue to have sex, and if we catch HIV and die, that’s part of life too. It has happened to many others, from AIDS and other causes and we will join them.”

Young men who cannot access condoms are wrapping cling film or plastic bags around their penises as makeshift condoms.

Community reproductive health workers have reported that both married and single men have threatened to beat them when they ran out of condoms. One couple complained to the Rural Health Centre staff and committees, saying this:

“We are now used to condoms and we need them to plan our families and avoid diseases. You can’t tell us that they are now finished.”

These people were able to reject inaccurate or stigmatising condom messages because they had attended interactive sexuality and life skills programmes that gave them accurate information and confidence about their rights, sexuality and communication skills.

Although the majority of young people already know something about condoms, if they are told that they do not work or are only for promiscuous people, that message will rapidly spread. Young people coming up to adolescence without a history of comprehensive sexuality and life skills education will know nothing else, however, and have asked: “What is the point of using condoms if they have holes in them?” and “Won’t it make us promiscuous or prostitutes to use condoms?”

ABY does not meet principles and good practice for effective youth prevention

There is now a large amount of evidence to guide good practice for youth HIV prevention and sexual and reproductive health.¹²¹³ But there are aspects of the ABY strategy which are not meeting evidence and rights-based good practice.

The ABY strategy calls for community mobilisation and engagement of young people in programmes. However, it is challenging to mobilise communities and engage young people as active participants in all stages of programming with ABY guidelines for two reasons. Firstly, the imposed prescriptions about activities and behaviour and the judgmental language of what is “acceptable” behaviour and “denunciation” of harmful practices do not sit well with notions of partnership and respect for community knowledge, culture and skills. Secondly, the short time frame of one-year rolling grants and the expectation of high coverage and rapid changes in sexual behaviour do not allow time for genuine community engagement. In many cases, only message dissemination is carried out. In our own experience of carrying out participatory assessments and planning with young people and communities, they want something different to the ABY guidelines.

Strategies for sustained behaviour change require addressing causes of vulnerability with longer-term changes in social, gender and sexual culture and economy to work. Locally approved contextualisation of activities aimed at creating enabling environments to support safer sexual behaviour, the engagement of young people and those who influence them, adequate capacity building, monitoring and sharing lessons learned are all needed to bring about sustained changes in norms and behaviours.

Sexual behaviour is complex and engaged in for a myriad of reasons. Physical health is not the only consideration in making sexual decisions. Abstaining until a person has the resources to marry or enduring an unhappy monogamous marriage for life do not add up to sexual well-being for many people. Zambian traditional counsellors have told us that young people aged 14 years who have strong sexual feelings should marry early rather than use condoms. Young people, in contrast, demand information about condoms, for example, even if they are not yet sexually active, and they want access to services as a component of protective behaviour.

15-year-old girls, Zambia, 2005

There is good evidence that teaching abstinence only until young people acknowledge their sexual activity and denying them access to comprehensive information about sexuality as they are growing up is not protective. Studies show that young people taught abstinence only may delay sexual debut for a year, but that when they do have sex, they are more likely to have unprotected sex, with negative consequences.¹⁴ Lack of knowledge about sexual practices and their safety puts young people at risk of both STIs and HIV, as well as unwanted pregnancy. In the United States, oral gonorrhoea is higher in young people who have been through only abstinence-only programmes.¹⁵ Some young people in Chipata report that they use anal sex as a way to avoid pregnancy. Boys also have anal sex together because they are attracted to others of the same sex, want to practice sexual skills or lack girlfriends. Anal sex is stigmatised and not talked about so young people have no understanding of the risk of HIV in this practice.

The promotion of condoms to high risk populations only may be effective in low prevalence settings where there are groups of high HIV transmitters who can be identified and targeted, such as sex workers, men who have sex with men, intravenous drug users and mobile populations. There is evidence that the situation is different in high prevalence settings, where a far wider population is at risk even if most people have on average only two concurrent and regular sexual partners.¹⁶

Moreover, it is very difficult and often risky to segment young people into groups for educational interventions or services on the basis of abstinence and sexual activity. Sexual activity is private in nature. If being sexually active is stigmatised, young people will not admit to having sex.¹⁷ This would put them at risk of abuse from people in powerful positions, such as teachers or religious leaders. On the other hand, flagging one’s virginity can be a powerful trigger for boys and men to seduce or rape. Young people may give gifts, money or favours in a sexual encounter but the meaning of this varies and it may not be viewed as ‘transactional’ or commercial sex. People do not necessarily have sex with partners only from their age group. Young and older people move in and out of sexual relationships and with a 17% prevalence rate, any couple who do not both know their HIV status need to use condoms.

People who are not having sex now will become sexually active. For the majority of people sexual life does not move in a straightforward way from abstinence to marriage and mutual fidelity with an uninfected person for life. The majority of people in Zambia will need to protect themselves from infection and pregnancy at some stage of their lives. If young people only receive abstinence messages they will be ill-equipped to make good decisions as they mature. Young people need key survival knowledge, positive attitudes and skills before they become sexually active so that they can make informed decisions to protect themselves in different situations. We cannot afford to wait until young people are in a risky sexual situation before giving them this capacity. Many young people go to school or are taught by traditional counsellors. This provides an opportunity to teach comprehensive sexuality education as a foundation for sexual and reproductive well-being throughout their lives.

There is considerable evidence that teaching abstinent young people about condoms does not encourage sexual activity; indeed providing comprehensive sexuality education can both delay sexual debut and increase the practise of safer sex when sex does happen.¹⁸ Providing positive information about condoms, abstinence and responsible relationships in an educational sense does not imply that everyone is or should be sexually active. In fact, evidence suggests that even “racy” advertisements can promote discussion of HIV and sexuality and have the unexpected side effect of reducing numbers of partners.¹⁹

Marriage itself is not protective in terms of HIV infection. There is strong evidence that young married women in Zambia are at higher risk of HIV than single women of the same age. For example, in Ndola, Zambia, 17% of the partners of single young women had HIV infection compared with 32% of the partners of married young women.²⁰ This is because new husbands are on average six years older than their wives and are also unlikely to have abstained before marriage. Newly married women have sex more frequently than single girls, and are less likely to use condoms because they want to prove their fertility.²¹

There are an estimated 130,000 children under the age of 15 living with HIV and many more young positive people over the age of 15 who may or may not know their HIV status.¹ This implies that HIV educators should always assume that some young people in their audience have HIV.

Programmes should not increase stigma towards groups of people or sexual behaviours

It is difficult to promote condoms for HIV prevention for high risk people only without stigmatising both the people and condoms. It is also not possible to claim that condoms do not prevent HIV and then say that high risk people should use them to prevent HIV. There is evidence that young people’s sexuality is a stigmatised issue in many societies and this discourages young people from protecting themselves if they are sexually active.¹⁷ There is also strong evidence that stigma and discrimination are among the key reasons why HIV prevention, care and treatment have such limited success.²²

High risk groups for HIV in PEPFAR terms are by implication “immoral” people who cannot abstain or be faithful and who have or may have HIV because of “unacceptable” sexual behaviour. People who aim to abstain until marriage and be faithful but fail to achieve this may not acknowledge to themselves that they have “failed” and be less likely to use condoms. In this climate, people may not view condoms as suitable for loving, moral people who want to protect themselves or each other or plan their family.

Many people are already reluctant to ask a “good person” whom they trust to use condoms and the issue of trust results in many couples stopping condom use after a few months. The SRH/HIV prevention community in Zambia has been working to make condoms morally neutral, useful for dual protection and an indication of trust for many years, with some success. The PEPFAR climate is reversing this achievement, making it again more difficult to access, talk about and use condoms. This is also reversing actions recommended in the UNAIDS position paper on condoms, to remove all social and economic barriers to condom use.⁴

The messages that condoms have low reliability for HIV prevention imply that people living with HIV should not be having sex at all, because they will kill people. If people believed they could only have sex six times using a condom with a person with HIV before they were infected, who would have the courage to go for an HIV test or marry a person with HIV? This will increase stigma and discrimination towards people with HIV and add to psychosocial distress and fear. It will fuel behaviour such as that of a community health committee member “outing” a man who had died of AIDS at his funeral and telling the community that they had better fear and avoid his widow. (Personal communication, Chipangali, 2005)

Finally, promoting condoms to prevent HIV as only suitable for high risk groups may jeopardise their use for contraception. Family planners may exacerbate this situation by emphasising condom failure rates for contraception. Many people negotiate condom use by relating it to child spacing, fertility control or even pleasure, thus avoiding accusations and suspicions of infidelity. Stigmatising condoms takes away a powerful negotiating tool, especially from women. As the Society for Women and AIDS in Africa–Ghana points out:

“The image of condoms needs to be reshaped to represent respect for health and future fertility and preserve vaginal health and planning births.” ²³

Information about condom reliability

The message that condoms are not reliable enough to be worth using comes from a lack of understanding of statistics and a misplaced desire to promote abstinence and fidelity as the only viable choices.

Studies overwhelmingly demonstrate that condoms are highly effective in preventing HIV transmission. An evaluation of existing published evidence shows that consistent and correct users of male condoms reduces the risk of HIV infection by at least 90%. All the evidence on condom promotion and distribution programmes indicates their efficacy at increasing condom use and decreasing HIV and STI prevalence. This makes condom promotion and distribution one of the most effective prevention programmes that exists.²⁴ Whilst it is true that we do not yet know enough about the complex role of condoms as a public health measure in high prevalence generalised epidemics, we know enough to say that they are an essential component of any HIV prevention programme.

The female condom provides women with another type of condom for the prevention of pregnancy and STI/HIV, which they can use themselves. This is a key method for the empowerment of women and has also been shown to be effective in reducing the risk of HIV transmission.²⁵

When making a decision about sexual activity people need to understand the risk if they or their partner have HIV, the risk of HIV transmission from one infected person to another, the reliability of condoms, their effectiveness in preventing pregnancy, STIs and HIV, and how this can be maximised through correct and consistent use. Voluntary counselling and testing helps people to adopt safer behaviour if either has HIV.

Discussion

Our experience in Zambia has been that it is important to ensure that everything possible is done to reduce negative messages and stigmatisation of condoms. Young people should be able to seek condoms easily from empathetic, non-judgmental providers who are able to counsel them on their situation and help them to make good decisions, which include abstinence, fidelity and condom use. Teaching people how to use condoms correctly and consistently and ensuring an uninterrupted supply requires resources and commitment. This increases for rural communities and other areas with poor infrastructure, but when they are in place, condom demand and use rises with positive results for sexual and reproductive health.

Male and female condoms are an essential STI and HIV risk reduction tool in individual, community and national prevention strategies. They are also an important contraceptive. Many children and young people already know something about condoms because they have been widely advertised in most countries. Young people need accurate, positive and comprehensive information about safer sex and condoms either because they are already sexually active or because they will be in the future. This is part of a process of educating young people with essential survival information, so that when they grow up they will use condoms if necessary and ensure that the rest of the community also has correct and positive information about condoms.

Everyone involved in HIV/AIDS programming, civil society, governments and international agencies, needs to reflect on their own work in relation to this new climate and create strategies to ensure that all prevention options are widely available, that correct information is given and that condoms are available for everyone who needs them. Faith-based organisations that feel unable to promote or provide condoms should refer people to programmes able and willing to do so. Everyone needs to engage with what is happening in this environment, whatever their funding and beliefs, because of the evidence that abstinence-only programmes risk increasing stigma and reducing condom use, with negative results for the health and lives of young people and the whole community, not only in Zambia but also in all the other countries where similar problems are occurring.

Note

The views expressed here do not necessarily represent the views of the International HIV/AIDS Alliance.

Acknowledgements

A version of this paper was presented at Condoms: An International Workshop, London, 21–23 June 2006.