AIDS intervention programmes have often been characterised by an obsession with the theory, rather than the practical outworking of that theory.
Thus the two extremes in approach of activists wanting to change sexual behaviour are described as the 'moralisers' and the 'public health fundamentalists'. These are said to be mutually incompatible with a strong polarisation of their approaches and their messages.
The 'public health fundamentalists' want to give only a positive message without using any fear. Their message can be summed up as: 'Enjoy life, live as you want, have sex whenever you feel like it, you don't need to think about the consequences provided you use a condom.'
The 'moralisers' want to give a sense of sin and guilt to those with high risk sexual behaviour, leading to repentance and then to a change of behaviour. Their aim is to promote 'life-time mutual monogamy and sexual abstinence outside marriage'. However, both approaches may have limitations in practice which should be recognised.
Method effectiveness
Public health 'fundamentalists' have assumed that the method effectiveness of the condom in protection against HIV (which is very high and has been confirmed in many excellent research studies) is somehow the same as use effectiveness. Thus a typical Swedish poster proclaims: 'You won't catch the virus if you use a condom when you have sex.' This is a dangerous half-truth (or more accurately, a dangerous half-lie!).
Method effectiveness is not the same as use effectiveness as is shown in ten large studies in various countries analysed by the World Health Organisation (WHO). Method effectiveness is how effective condoms are when used to perfection and here they have a very high rating. Use effectiveness is how effective condoms are in the real world.
In practice condoms only reduce the danger of HIV spread to around 40% of the risk without a condom. (Analysis of a further nine large studies by WHO showed that condoms only reduce the risk of infection with other sexually-transmitted diseases (STDs) by one third compared to those not using condoms.) Both of these studies show a yawning gap between theory and practice in condom use. There seems to be a conspiracy of silence in many circles in facing up to these uncomfortable findings.
Disappointing results
Very enthusiastic condom campaigns in most developed countries have produced disappointingly low results in behaviour change. Thus a major condom campaign in Uppsala University, Sweden, had almost no effect in improving the use of condoms. One third of the male students in the university had had a new partner in the last year without a condom. One quarter had had an STD. Almost 50% had intercourse 'the first night' without using a condom. The average age at first intercourse was 17.6 years for the girls and the average number of partners of those female university students attending the Student Health Centre was six.
Three main reasons for these disappointing results are the inconsistent use in those who claim to be condom users, the incorrect use in those who actually are using a condom, and breaks in condoms even when used consistently and correctly. These three reasons cause failure in all countries, and lie behind the well-known failure rate of condoms when used alone as a form of contraception. There the pregnancy rate for women whose partners are said to consistently use condoms is between five to 15 pregnancies per 100 women years.
Special reasons for the high failure rate in Africa would be non-availability of condoms, use of out-of-date condoms or condoms damaged by exposure to heat, the common practice of re-use of condoms, and the co-factor of alcohol increasing each of the three causes of failure (as in Europe).
Many studies in various countries have shown up the reasons why even motivated people have failed to use condoms. These include condoms being perceived as unnatural, as interfering with intercourse, making intercourse unsatisfying, and condoms being messy and uncomfortable. There is also a major factor of embarrassment with a new partner.
Someone has said rather sweepingly that the only two groups who have high use effectiveness are motivated prostitutes and stable partners.
Many assume that the behaviour change promoted in condom campaigns is a sustainable change. This assumption is flawed, as shown even in groups with initially very high levels of motivation (e.g. homosexual men in the industrialised countries). Here, initially impressive success in condom use has been followed by a gradual waning of interest with a tendency to return to a previous lifestyle without use of condoms.
Of course this is not to belittle the value of condom promotion in a situation of 'clustering' (where people with high risk sexual behaviour and with very many partners gather in one geographical locality), and especially where condom promotion is carried out by peer educators, but it is only a first emergency step and unless it is accompanied by other steps to change behaviour, its effect will be short-lived.
No-risk lifestyles
The 'moralisers' have sometimes campaigned with the assumption that a no-risk lifestyle can be forced onto a whole population who may not necessarily share their beliefs. Confucius summed up the dilemma well: 'Rare are they who prefer virtue to the pleasures of sex.'
Behaviour change by legislation or by propaganda from a repressive bureaucracy or clergy has never been shown to be sustainable. This was particularly striking in previous experiences of trying to contain the spread of syphilis in Europe (Sweden is a particularly clear example of a country where such a campaign was tried and failed).
It seems a common phenomenon that religion is often turned into an instrument for controlling others, either putting them or keeping them 'in their place'. The history of such religious manipulation and coercion is long and tedious. It is little wonder that people who have only known religion on such false terms, experience release or escape from it as freedom. The trouble is that the freedom turns out to be short-lived.
There is no place in AIDS campaigns for unrealistic moralising or for a realism that is unscrupulous (i.e. devoid of morals).
Dramatic individual changes in behaviour as a result of a conversion experience are well known to be effective and sustainable. These individual conversions on a large enough scale can have an impact on a whole nation, as shown by the measurable changes in lifestyle brought about by the preaching of such men as Wesley and Whitefield in the late 18th century in Britain. The level of social misery, especially in the poorer communities, was exemplified by the level of alcohol abuse. London hospitality was caricatured by the saying: 'You can get drunk for a penny, dead drunk for two, and have straw to lie on for nothing.'
Awakened consciences
The 'awakening' which followed the preaching of Wesley and Whitefield caused major social transformations, not least of which was the arousal of the social conscience of the upper and middle classes, who had previously been as uncaring about the plight of the poor as their equivalents in France prior to the French Revolution. Virtually all the main social legislation that was introduced during this period can be directly attributed to the effect of these awakened consciences.
However, to assume that people without a personal commitment to faith will heed 'top-down' pronouncements from either clergy or politicians is naive. The effect of the alcohol prohibition in the United States was to create a massive underworld of big-time crime syndicates that made enormous profits but never reduced the levels of alcoholism.
The role of legislation in moral issues is to remove all hindrances to young people growing up in a society with a balanced and healthy moral climate.
All cultures at all times have had their restraining control mechanisms promoting orderly social behaviour. The idea of completely unrestrained sexual licence is a phenomenon of a society in chaos and always increases the level of social misery, especially for the young, the weaker and the marginalised. All human societies have their acceptable code of conduct, even those whose ideas of morality differ drastically from our own. There are no communities in the world which live without some ethical constraints, and a person who imagines that he/she is above ethics is often the first to complain bitterly if someone encroaches on their freedom. Morality is an essential part of community life among human beings.
Einstein's relativity
Einstein expressed this need for morality in daily living very eloquently: 'The most important human endeavour is the striving for morality in our actions. Our inner balance and even our very existence depend on it. Only morality in our actions can give beauty and dignity to life.' Sadly, in the light of new revelations about Einstein's private life, we would be wise to listen to what he said and not to copy how he lived. This exemplifies how easy is the theory and how difficult the practice.
Dr. Gunnar Holmgren, MRCP, DTM&H, is a consultant in International Health Care and HIV/AIDS. He was a missionary doctor at a Swedish Baptist Mission for many years in Zambia, and is now back in Sweden.
. . . to be continued next month
