The Man2Man Alliance is opposed to mainstream HIV prevention strategies in the US and elsewhere which are known generically as "condom campaigns."

"Condom campaigns" take as a given that all men who have sex with men do so anally and promiscuously, and that the best one can do in preventing HIV infection among these men is to persuade them to use condoms "every time" they have sex.

Those who support "condom campaigns" are generally opposed to the other major form of HIV prevention, which is called "primary behavior change."

In programs which promote "primary behavior change," the most prominent of which is Uganda's ABC program, recently endorsed by the Bush administration's African AIDS Initiative, the focus is on changing sexual behavior by directing men and women away from high risk activities to those which carry little or no risk.

"Primary behavior change" strategies include encouraging a later or delayed age of onset of sexual activity -- usually referred to as "abstinence"; partner reduction -- usually referred to as "fidelity," "monogamy," or "be faithful"; and, the avoidance of anal sex.

In Uganda, where HIV prevalence has been reduced by 66%, the acronym used is ABCD, which stands for:

Abstain;
Be faithful / change Behavior;
use a Condom if you won't practice the first two; or
Die.

In the United States, frot activist and Alliance strategist Chuck Tarver has suggested that a useful version of ABCD for men who have sex with men (MSM) would read:

Avoid Anal sex;
Be faithful;
use a Condom if you can't or won't do the first two; or
Die.

A number of recently published studies support our contention that:

1. anal sex is the most important vector for HIV transmission, with far higher rates of heterosexual anal transmission than previously believed;

2. the failure rate of condoms is unacceptably high;

3. Primary Behavior Change is a better strategy both because it's been proven successful in radically reducing HIV prevalence and because it has the potential to reduce risk to zero.

Relevant Research

The data for heterosexual anal intercourse as a significant vector for HIV can be found in

Halperin, D. T. (1999). Heterosexual anal intercourse: prevalence, cultural factors, and HIV infection and other health risks, part I. AIDS Patient Care 13 (12): 717-730

The data for condom failure rates can be found in

Weller S, Davis, K. (2003) Condom effectiveness in reducing heterosexual HIV transmission. (Cochrane Review). In: The Cochrane Library

(see abstract below)

(Note that the article addresses vaginal sex and that the article defines failure as HIV infection, which occurs 20% of the time.

Anal sex is far rougher on a condom than vaginal sex, and it's reasonable therefore to assume that the failure rate -- that is, HIV infection rate -- is higher in anal sex.)

An overview of the Uganda experience can be found in

Green, E. C. (2003, March 1). A plan as simple as ABC. New York Times.

http://www.nytimes.com/2003/03/01/opinion/01GREE.html?th

And a statistical analysis of the failure of condom campaigns can be found in

Richens, J., Imrie, J., & Weiss, H. (2003). Sex and death: why does HIV continue to spread when so many people know about the risks? J. of R. Statist Soc A 2003;166, 207-215.

Summary

"Condom campaigns" are destructive because

1. they re-inforce the idea among MSM that "every time" men have sex with men, it will be anal; and

2. they disinhibit -- by promoting a false sense of safety, they make it more likely that people will have more partners, be less selective about their partners, and choose to do anal sex, the single most dangerous sexual act, with those partners.

That's the reason for the finding, which seems counter-intuitive, that men who use condoms have a *higher* risk of HIV infection than those who don't:

Condom use is associated with a constellation of unsafe behaviors which effectively negate the condom's limited utility.

For those reasons, in HIV and other STD prevention programs, the Man2Man Alliance endorses "Primary Behavior Change," and supports Chuck Tarver's formulation of ABC -- Avoid Anal sex, Be faithful, use a Condom only if you must.

And of course the Alliance recommends that men who avoid anal choose Frot -- which is highly pleasurable, mutually genital, phallus-to-phallus sex, and very low risk.

Bill Weintraub

July 25, 2003

Interested readers can find further discussion of these issues in terms of "risk reduction" (condom campaigns) and "risk avoidance" (primary behavior change) in the introductory section of our Media Watch page.

In addition, readers may wish to consult the entries under risk avoidance and risk reduction on our Definitions page.