prominence of commercial sex in HIV transmission

The difference in programme emphasis between use of condoms and reduction in the
number of sexual partners appears more related to differences in local epidemiology—
namely differences in the prominence of commercial sex in HIV transmission—than to
differences in philosophy.
These two countries’ responses to the HIV epidemic were based on correct assessment
of the main factors driving their epidemics and an understanding of local sociocultural
characteristics. Thailand’s emphasis on condom use in sex work venues would not have
worked in Uganda as this factor was not driving the Ugandan epidemic. A Ugandanstyle
programme emphasizing partner reduction for the general population probably
would not have worked well in Thailand. In both cases, what did work was a determined,
multisectoral effort that enlisted broad public support and responded to local realities।
Condoms and the combination behavioural
change approach
The continuing debate on the place and role of condom promotion in HIV prevention
programmes particularly for young people has generated mixed messages. These tend
to confuse young people and constrain consensus as to what works for youth. This
controversy illustrates concern about the interactions between condom promotion,
on the one hand, and other behavioural change approaches (particularly those aimed
at sexual abstinence) on the other. At the root of this concern is a fear that condom
promotion may increase sexual activity and may encourage people to have more sexual
partners9.
Reproductive health programmes for young people, including sexual health education,
have been investigated extensively to determine whether condom education and
promotion have, in fact, resulted in young people switching from abstinence to
sexual activity with condoms. A review in 2002 identified 41 studies that examined
programmes with condom education components. These programmes were based in
schools or in the community, or were carried out through the mass media, workplaces
or health facilities10. Almost all resulted in improved knowledge and attitudes, and
many produced an increase in contraceptive use. Seven of the programmes showed a
significant impact in the direction of reduced sexual risk (in terms of delayed sexual
initiation or reduced number of sexual partners). It may be noted that most of these
studies did not specifically focus on condom promotion interventions.
This conclusion reinforces the need for a range of prevention options for young people,
covering the full spectrum of sexual behaviour. It is important to offer adolescents
choices for HIV prevention. This combination behavioural change approach has been
labelled as ABC—i.e., Abstinence, including delay of sexual initiation or debut, Being
safer by being faithful to one’s partner or reducing the number of sexual partners, and
correct and consistent Condom use (see box). Providing information and education on
a range of safer sexual behaviours is consistent with current empirical evidence of the
diversity of young people’s sexual behaviours.