BioEd Online

Former US president Bill Clinton became the most prominent leader yet to criticize US AIDS policy at the XVI International AIDS Conference in Toronto, Canada, yesterday.

Clinton said that US global AIDS spending is doing "more good than harm," but that the United States should not fund programmes that focus on abstinence as the only way to prevent HIV infection in young people.

"The evidence is that abstinence-only programmes are ultimately unsuccessful," Clinton said. "Abstinence-only is an error."

US law requires one-third of funding on its overseas AIDS prevention initiatives to be spent on abstinence education programmes. This funding is mainly distributed through the President's Emergency Plan for AIDS Relief, commonly called PEPFAR. Since 2004, PEPFAR has spent more than US$8 billion on HIV care, prevention and treatment programmes in 15 poor countries, according to the State Department.

The PEPFAR programme has drawn praise from many including Clinton for its generosity, which exceeds that of Clinton's own administration in this area. But many at the AIDS conference have spoken out against abstinence strategies, including Microsoft chairman Bill Gates, often singling out US prevention policy for criticism.

"In some respects PEPFAR is intelligent, in the money that is being appropriated for treatment and care," Stephen Lewis, UN Special Envoy for HIV/AIDS in Africa told reporters on 14 August. But, he added, "It is not intelligent in terms of prevention."

Some studies for example, one presented at the conference which dealt with children in Philadelphia show behaviour change in children given abstinence-only education. But the most comprehensive report on abstinence programmes, scheduled to be presented at the conference on 17 August, claims to find little evidence that the programmes have worked in developing countries, where the AIDS epidemic has hit hardest.

The review, conducted by researchers from the Johns Hopkins School of Public Health in Baltimore, Maryland, and from the World Health Organization in Geneva, Switzerland, compiles data from nine separate studies of abstinence programmes in poor countries. Some of the papers reported that such programmes led people to change their attitudes or beliefs. But the studies did not find evidence that people enrolled in the programmes actually changed their behaviour, according to the report's abstract.

Campaigns that have a role for abstinence have been credited with success in the past. The ABC strategy Abstinence, Be faithful and use Condoms is widely seen as having helped to lower HIV prevalence in Uganda in the 1990s (see ' Uganda's HIV epidemic wanes'), the first African country to achieve this feat. But on 13 August, Beatrice Were of ActionAid Uganda said that the ABC policy is now empowering groups that emphasize abstinence and fidelity over condom use, and that these groups are driving a new wave of stigma against people with HIV and AIDS in Uganda. "The 'C' part is now mainly silent," Were said, warning that because of this, "The success story is unraveling."

In light of such experience and evidence, the activists and scientists here are near-unanimous in arguing that President Bush's administration should abandon its focus on abstinence programmes. Republicans and Democrats in both the House and Senate have introduced measures that would loosen the PEPFAR funding restrictions. And Clinton called on Tuesday for Bush to rethink his approach even in the absence of Congressional action.

"The administration might be persuaded to interpret the [funding] guidelines in ways that promote abstinence in the context of a more comprehensive prevention policy," Clinton said. "That's what I'd like to see happen."

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