Abstinence, not condoms, is the word in Mozambique


CHOKWE, Mozambique -- In the dimly lit church made of mud brick and corrugated metal, the young people gathered here believe it is a given that safe sex is anything but safe.

"From what I know, some condoms have got holes," said 23-year-old Zodwa Ubisse, rising from a wooden bench to address 20 of her peers. "I've tried taking some new ones, but water comes out, so they're not safe."

"So abstinence is the key, isn't it?" summed up Nelda Nhantumbo, the 25-year-old student-teacher, drawing nods and murmurs of assent.

That is the message going out to young people in schools, churches and social clubs across Mozambique, where about 500 people a day become infected with HIV and AIDS. The message is being delivered, in this case, by Baltimore-based World Relief, the humanitarian arm of the National Association of Evangelicals, and the United States is paying for the effort.

World Relief's Bible-based "Choose Life" campaign stresses abstinence until marriage, a cornerstone of President Bush's $15 billion, five-year global AIDS program, which began in 2004. Twenty percent of that money is earmarked for prevention efforts, and a third of all prevention funds, or $1 billion, must be devoted to abstinence-only programs, a shift from previous policy promoting condoms.

Critics among public health experts say the growing focus on abstinence is wrongheaded given the scanty evidence that such programs succeed. Some worry that teaching only abstinence will lead to decreased use of condoms, which the United Nations calls "the single most efficient, available technology" to prevent HIV infection among the sexually active.

"The danger, obviously, is that you are undermining the belief in one of the few tools we have that is cheap, affordable and efficacious," said Dr. Chris Beyrer, director of the Johns Hopkins Fogarty AIDS International Training and Research Program at the Bloomberg School of Public Health.

The Bush administration dismisses such criticism, pointing out that the United States is shipping a record number of condoms to Mozambique and other African nations. Last year, Mozambique received 17 million condoms, up from 4.5 million in 2001. Also, a $4 million U.S. grant helped the nonprofit Population Services International distribute 18.5 million condoms provided by the British government and sold at a steep discount to bars and stores nationwide.

U.S. officials say the United States is committed to a three-part strategy called ABC: abstinence, being faithful in marriage and "correct and consistent use of condoms" for high-risk behaviors such as prostitution and, in countries like Mozambique where the AIDS epidemic is "generalized," casual sex. Last year, U.S.-funded programs promoting abstinence and fidelity reached 995,000 Mozambicans; those promoting condoms reached 809,000.

American officials also assert that new studies show that abstinence does help drive down HIV rates in Africa. "The declines are real, and the behavior change is real," said Dr. Mark Dybul, deputy U.S. global AIDS coordinator in Washington. He cited recent findings in Kenya, Uganda and Zimbabwe - findings that some experts call inconclusive or misleading.

Infection epidemic

World Relief acknowledges it has no proof that its abstinence education is working in Mozambique beyond anecdotal evidence. "Only when we see the [rate of new HIV infections] dipping will we know that this education is effective," said Samuel Grottis, World Relief's southern Africa director.

The infection rate is still climbing. Recent data in Mozambique "show a dramatically worsening epidemic overall, with rising infection levels in all regions," according to a report the U.N. AIDS office, or UNAIDS, and the World Health Organization issued in December. From 2002 to 2004, the estimated number of adults infected with HIV rose to 16 percent of the adult population, up from 14 percent.

Mozambique's epidemic is younger than most, and the infection rate is well below those of nearby South Africa and Swaziland. A long civil war, which began in 1977, two years after Mozambique gained independence from Portugal, and which ended in 1992, limited mobility and therefore transmission of HIV in the impoverished country of 19 million.

But that is changing, a major reason life expectancy at birth has fallen to 38 years. The problem is especially acute in Chokwe, a district of about 250,000 people 120 miles north of Maputo, the capital. Men from Chokwe have long worked in South African gold mines, and many become infected from prostitutes and bring the disease home to wives and girlfriends.

Complicating the situation is entrenched gender inequality that can undermine any program advocating abstinence, fidelity and condoms. Girls may be pressured or forced to have sex. In 1997 the median age for Mozambican girls first having sex was 16 and for marriage was 17, according to the Center for Health and Gender Equity, an advocacy group in Takoma Park. Forty percent of teens were bearing children.

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