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Frerichs, R.R. A middle road to successful HIV prevention? 

SEA-AIDS Network, February 5, 1999.

R.R. Frerichs Posting

Does a middle road exist to successful HIV prevention in developing countries? An interesting item appeared today on the western African country of Senegal, summarizing a recent news article in the Washington Post. It suggests that there might be such a middle road that combines a broad message of fidelity and abstinence (supported by local religious leaders), special focus on high risk groups (i.e., commercial sex workers), early recognition and treatment of sexually transmitted diseases, an active HIV testing program (i.e., every six months for CSWs and on demand for others), and availability and promotion of condoms (likely through social marketing).

Based on UNAIDS estimates of 1997, the prevalence of HIV infection among adults, aged 15-49 in Senegal was 1.77 percent. This level is lower but similar to the high prevalence countries of South-east Asia (i.e., Cambodia, 2.40%; Thailand, 2.23%; and Myanmar, 1.79%).

Perhaps other groups in Asia are experimenting with similar innovative efforts that combine multiple strategies, and would be willing to share their experiences in SEA-AIDS.

Source: Daily Kaiser Foundation HIV/AIDS Report, Feb. 3, 1999. 

"SENEGAL HIV-Prevention Program Worthy of Emulation"

Senegal has had marked success in controlling HIV infection rates, and other African nations and the U.S. should follow its methods, Village Voice columnist Mark Schoofs asserts in the Washington Post. Senegal's campaign includes an "enlightened approach to preventing prostitutes from spreading the disease, according to Schoofs. To operate legally, prostitutes must be tested every month for STDs and every six months for HIV.

Prostitutes who test positive for HIV do not have their licenses revoked, since the government recognizes this would only drive infected prostitutes underground. Instead, Schoofs says, they are "counseled about why practicing safe sex is in their own best interest. With a weakened immune system, picking up an STD from one of their johns could be fatal."

Success Story

The campaign was started more than a decade ago by gynecologist and STD expert Dr. Ibrahima Ndoye, who enlisted the help of "unlikely allies -- religious leaders." Ndoye said, "We said that they could preach fidelity and abstinence, but permit us -- NGOs and the government -- to promote condoms." The compromise appears to have worked. In 1988, only 800,000 condoms were distributed in Senegal, but "by 1996, that figure had soared to 7 million." In addition, the number of STDs, including HIV, has fallen among Senegalese prostitutes over the past three years. "We considered AIDS an epidemic since the beginning. We didn't do denial," Ndoye said. An estimated 60,000 people in Senegal have AIDS and 1.77% are HIV-positive, far less than other sub- Saharan countries. Next ... the World!

Schoofs writes that Senegal's "unsung success needs to be heralded" because "it proves that foresight, pragmatism and can, even in the midst of deep poverty, hold one of the world's leading infectious killers at bay." Referring to education and behavioral prevention, Peter Piot, director of UNAIDS, said, "We don't need to come up with some super-technological secret weapon. The answers are already in Africa." Schoofs calls on the U.S. to embrace the realism of Senegal, and concludes, "While the molecular biologists toil toward a cure and a vaccine, we need to heed the wisdom of countries that are succeeding with the humbler, human resources that are available right now" (Schoofs, Washington Post, 1/31).

The original Washington Post article gives additional detail on several components of the Senegal program, including the unusual alliance between public health, non-governmental organizations, and religious leaders (see below).

Source: Schoofs, M. "In Senegal, Common Sense Spells Success." The Washington Post, January 31, 1999, p. B02

...And right from the start, Ndoye enlisted the help of unlikely allies -- religious leaders. Senegal is heavily Muslim, and in two national meetings, one for imams and the other for Christian priests and pastors, "We said that they can preach fidelity and abstinence," Ndoye recalls, "but permit us NGOs [nongovernmental organizations] and the government to promote condoms. We came to this agreement, this modus vivendi. No organization should be a barrier to the others."

It works. The Catholic organization Sida Service gives out condoms only to married couples in which one or both partners are infected. But on posters and in counseling sessions, the group does tell its clients to use condoms if they can't be faithful. And in Senegal's bustling market, Paco, a young cloth merchant, described to me the AIDS education he receives in his mosque. "Condom is vulgar, so the imam uses another word," he explains. "He tells us to wear a 'sock.' "