I. SummaryHIV/AIDS is a preventable disease, yet approximately 5 million people were newly infected with HIV in 2003, the majority of them through sex.1 Many of these cases could have been avoided, but for state-imposed restrictions on proven and effective HIV prevention strategies, such as latex condoms. Condoms provide an essentially impermeable barrier to HIV pathogens. According to the Joint United Nations Programme on HIV/AIDS (UNAIDS), scientific data “overwhelmingly confirm that male latex condoms are highly effective in preventing sexual HIV transmission.”2 However, many governments around the world either fail to guarantee access to condoms or impose needless restrictions on access to condoms and related HIV/AIDS information. Such restrictions interfere with public health as well as set back internationally recognized human rights—the right to the highest attainable standard of health, the right to information, and the right to life. In the midst of this crisis, the world’s leading donor to HIV/AIDS programs, the United States, has ramped up its support for HIV prevention programs that promote sexual abstinence and marital fidelity. The United States Leadership against AIDS, Tuberculosis and Malaria Act of 2003 (commonly known as the President’s Emergency Plan for AIDS Relief or PEPFAR) devotes 33 percent of prevention spending to “abstinence until marriage” programs, concentrating these programs on fifteen heavily AIDS-affected countries in sub-Saharan Africa, the Caribbean and Asia.3 As implemented domestically in the United States, government-funded “abstinence only” programs censor science-based information about condoms and suggest that heterosexual marriage is the only reliable strategy for prevention of sexually transmitted HIV.4 Abstinence-only programs do not provide a proven effective alternative to programs that include accurate information about condom use, and may cause harm.5 Not only do these programs deprive people at risk of HIV of lifesaving information, but by teaching that heterosexual marriage is the only legitimate context for sex, they discriminate against lesbians and gay men, who cannot legally marry in most countries. It is not only the United States that restricts access to condoms and lifesaving information about HIV/AIDS. In many countries, political and/or religious leaders have made public statements associating condoms with sin or sexual promiscuity, implying that people who use condoms lack the moral fortitude to abstain from sex until marriage. In countries with significant Roman Catholic populations, governments frequently bow to pressure from religious leaders to censor information about condoms in school-based HIV/AIDS curricula or other HIV-prevention programs. The Holy See, which represents the Vatican diplomatically and exerts considerable influence over HIV/AIDS policy in many Roman Catholic countries, explicitly objects to condom use and at times has publicly distorted scientific information about the effectiveness of condoms against HIV. Since the announcement of PEPFAR in 2003, pressure by the U.S. to make abstinence a more central part of HIV prevention strategies in donor counties appears to have reduced condom availability and access to accurate HIV/AIDS information in some countries. Given these restrictions, it should come as no surprise that the vast majority of people at risk of HIV lack the basic tools to protect themselves from this fatal disease. In 2003, fewer than half of all people at risk of sexual transmission of HIV had access to condoms.6 Less than one quarter had access to basic HIV/AIDS education.7 The United Nations Population Fund (UNFPA) estimated in 2000 that over 7 billion additional condoms were needed in developing countries to achieve a significant reduction in HIV infection.8 International funding for procuring condoms declined throughout the 1990s, and U.S. condom donations remain well below levels seen in the early 1990s despite recent reported increases. At the same time, U.S. funding for international “abstinence until marriage” programs increased exponentially in 2003 with the enactment of PEPFAR. Condoms are not a complete solution to the spread of HIV, but they are a necessary tool to combat that spread. In the absence of equally effective alternatives or of evidence that abstinence-until-marriage programs work, there is no scientific basis for restricting access to and information about the only device available to prevent HIV transmission through sex. While abstinence and fidelity may work for some people in some cases, promoting these behaviors at the expense of condoms deprives people of complete information and services for HIV prevention. To avert this health and human rights crisis, governments and international donors should immediately lift any restrictions on access to condoms and take concrete steps to guarantee comprehensive and science-based HIV-prevention services to all those who need them. [1] Joint United Nations Programme on HIV/AIDS (UNAIDS), 2004 Report on the Global AIDS Epidemic: 4th Global Report (2004) p. 10; World Health Organization (WHO), The World Health Report 2004: Changing History (2004), p. 1. [2] UNAIDS, 2004 Report, p. 75. [3] United States Leadership against HIV/AIDS, Tuberculosis and Malaria Act of 2003, P.L. 108-25, 22 U.S.C. sections 7601 et seq. (2003), ss. 402(b)(3), 403(a); see also Office of the United States Global AIDS Coordinator, “The President’s Emergency Plan for AIDS Relief. U.S. Five Year Global HIV/AIDS Strategy,” February 2004. The fifteen countries are Botswana, Cote D’Ivoire, Ethiopia, Guyuana, Haiti, Kenya, Mozambique, Namibia, Nigeria, Rwanda, South Africa, Tanzania, Uganda, Vietnam, and Zambia. [4] See, e.g., Human Rights Watch, Ignorance Only: HIV/AIDS, Human Rights and Federally-Funded Abstinence-Only Programs in the United States, vol. 14, no. 5(G) (September 2002). [5] There is mounting evidence that abstinence-only programs show no long-term success in delaying sexual initiation or reducing sexual risk-taking behaviors among youth and that participants in abstinence-only programs are less likely to use contraceptives once they become sexually active. See, e.g., Edward Smith, et al., Evaluation of the Pennsylvania Abstinence Education and Related Services Initiative: 1998-2002, Pennsylvania Department of Health, January 2003, pp. 1 and 21 (noting concern that 2/3 of ninth graders in abstinence-only program were sexually active, and only about ½ of them used contraceptives, and that most programs had no effect on reducing sexual debut); Minnesota Department of Health, Minnesota Education Now and Babies Later Evaluation Report 1998-2002, 2003 (finding that abstinence-only programs had little long-term impact on sexual intention and behavior, and percentage of sexually active youths was higher in several counties with abstinence-only programs than state average); see also Peter Bearman and Hannah Brückner, "Promising the Future: Virginity Pledges as they Affect Transition to First Intercourse," American Journal of Sociology, vol. 106, no. 4 (2001), pp. 859-912 and Bearman and Brückner, “After the Promise: the STD Consequences of Adolescent Virginity Pledges,” 2004, http://www.yale.edu/socdept/CIQLE/cira.ppt (retrieved November 10, 2004) (finding that pledging abstinence until marriage ineffective in stemming acquisition of sexually transmitted diseases and that teens who break promise to remain sexually abstinent until marriage much less likely to use contraceptives once they become sexually active). The Institute of Medicine, a body of experts that acts under a Congressional charter as an advisor to the U.S. federal government, noted in 2001 that scientific studies have shown that comprehensive sex and HIV/AIDS education programs and condom availability programs can be effective in reducing high-risk sexual behaviors. The Institute further noted that there was no such evidence supporting abstinence-only programs, and stated that investing “millions of dollars of federal…funds…in abstinence-only programs with no evidence of effectiveness constitutes poor fiscal and health policy.” Committee on HIV Prevention Strategies in the United States, Institute of Medicine, No Time to Lose: Getting More from HIV Prevention (Washington, D.C.: National Academy Press, 2001), pp. xi-xii and pp. 118-20. A 2001 report analyzing studies of HIV prevention programs found that programs that include information about both abstinence and condoms can delay the onset of sex and increase condom use among sexually active teens. The same study found no evidence existed that abstinence-only programs had an effect on sexual behavior or contraceptive use among sexually active teens. Douglas Kirby, Emerging Answers: Research Findings on Programs to Reduce Teen Pregnancy (Washington, D.C.: National Campaign to Prevent Teen Pregnancy, 2001), pp. 5, 88-91. A 1998 study comparing a program that educated students about safer sex (including condom use) with an abstinence-only program found that both programs affected sexual behavior in the short term, but that the safer sex program was more effective at reducing unprotected sexual intercourse and frequency of intercourse in the long term. John B. Jemmott et al., “Abstinence and Safer Sex HIV Risk Reduction Interventions for African American Adolescents,” Journal of the American Medical Association, vol. 279, no. 19, May 20, 1998, pp. 1529-1536. [6] Global HIV Prevention Working Group, Access to HIV Prevention: Closing the Gap (May 2003), p. 2. [7] Ibid. [8] According to UNFPA, only 950 million of the estimated 8 billion condoms needed to achieve a “significant reduction” in HIV infection in developing countries were donated in 2000. United Nations Population Fund (UNFPA), “Global Estimates of Contraceptive Commodities and Condoms for STI/HIV Prevention, 2000-2015,” UNFPA, Technical Report. See also, N. Chaya and K. Amen with M. Fox, Condoms Count: Meeting the Need in the Era of HIV/AIDS (Washington, D.C.: Population Action International, 2002), p. 29.
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