US scientific chief calls for truce in abstinence vs condoms controversy

The senior medical scientist at the US government agency at the centre of the controversy over US HIV prevention policy has called for a truce in the debate that pits condoms against abstinence as solutions to the spread of HIV.

While declaring that he is a `condom lover` who has bemoaned the condom gap in Africa, James Shelton of USAID says: “I see major limitations of condoms and abstinence in the intractable high-prevalence generalised hyperepidemics still raging in certain southern African countries.”

While HIV prevention witnesses a relentless argument pitting condoms against abstinence, the behaviour that really needs addressing – partner reduction – is largely ignored, according to Shelton in a Comment in this week's issue of The Lancet.

James Shelton calls for an armistice in the polarised argument of condoms versus abstinence for HIV prevention and for a strong focus on partner limitation. Early evidence from Uganda is now bolstered by Kenya, where HIV incidence has been declining since the early-to-mid-1990s. Multiple partners among all men dropped substantially across the entire reproductive age range between 1993 and 2003. While these data are not proof, it’s plausible that such a sea-change in behaviour would decisively reverse the epidemic, argues Dr Shelton. He notes that South Africa has had no such reduction in HIV and no such decline in the number of partners as revealed in the survey of 2002 and 2005.

“In Kenya in 2003, only 1–2% of married women used condoms for contraception. Such low use in established relationships is troubling because concurrent regular sexual partnerships are critical in generalised epidemics, partly because the very high infectiousness of new infections allows for rapid transmission through continuing sexual networks.”

Dr Shelton concludes: "With a strong backdrop of partner limitation, condoms are a vital backstop for high-risk situations, including [HIV-]discordant couples. Abstinence efforts provide an opportunity to promote personal self-efficacy more broadly among young people, as well as fidelity and partner limitation once sexual activity commences…We need a harmonised HIV prevention strategy using all valid approaches, where partner limitation takes centre stage."