CHANTING THE MANTRA OF HARM REDUCTION

'Abstinence Does Not Work: People Lie,' Scientist Says

TORONTO - About midway through the International AIDS Conference, Dr.
Mark Wainberg, the bookish-looking AIDS scientist from Montreal and
the meeting's co-chair, found himself in the thick of a chanting
demonstration of prostitutes.

As the sex workers and their supporters, including a statuesque
Indian transvestite, shouted out for legalization, Dr. Wainberg
shouted along. As they punched the air in defiance, the respected
microbiologist punched, too.

At this massive and extraordinary conference, supporting such causes
is almost compulsory. As is speaking out for the rights of injection
drug addicts, lamenting the plight of the overlooked transsexual and
tolerating promiscuity, so long as that multiple-partner sex involves condoms.

Abstinence is a dirty word and human rights take precedence over quarantine.

To some outsiders it might seem like political correctness run amok.
But as the largest-ever AIDS conference ended yesterday, researchers
and agency leaders said the science is irrefutable that judgmental
approaches to the groups most at risk of getting HIV do not work;
trying non-coercively to change that behaviour or make it less likely
to spread HIV -- something called harm reduction -- is the best hope.

"Yes, a number of people can get emotional about the issues ... but
the fact is that it ought to be scientific agendas that drive what we
do," Dr. Wainberg said in an interview.

"And it's as simple as this: Harm reduction works -- that is
established medicine -- abstinence [programs] does not work and
people lie about their sexuality and their sexual behaviour all the time...."

"Anyone who would articulate that being faithful is the solution to
this problem is clearly putting their heads in the sand," Dr. Wainberg said.

Only by reaching out to "marginalized," and in some cases criminal,
groups such as drug addicts and prostitutes, can public health hope
to communicate ways to make their behaviour safer, scientists
stressed at the forum.

That largely meant, though, that the role of personal responsibility
in avoiding infection, at a time when some men in North America, for
instance, are increasingly neglecting safe-sex methods, was largely overlooked.

Still, some aspects of the liberal approach were challenged at the
meeting, which drew 17,000 delegates and 2,300 media workers from
around the world. A few public-health leaders called for more
aggressive HIV screening systems that put the onus on people in
endemic areas to opt out of "routine" testing, rather than waiting
for them to volunteer. Human rights activists are opposed, though.

And in a closing news conference, the acting head of the World Health
Organization said the conference did not deal enough with personal
behaviour and condom use.

"We have one magic bullet that works," said Dr. Anders Nordstrom,
holding aloft a condom, after colleagues suggested there is no one
method that can always prevent HIV infection through sex.

"The WHO believes in a rights-based approach but as the epidemic has
changed ... keeping on doing the standard approaches that we always
have used is reactionary," said Dr. Kevin DeKock, the UN agency's
head of infectious disease. "We need to evolve. Evolve or die."

Scientists also voiced guarded hope about a range of experimental
drug technologies -- and old-fashioned male circumcision -- that
could eventually prevent many HIV infections biologically or chemically.

AIDS luminaries such as Canadian Stephen Lewis pleaded emotionally
for the West to spend billions of dollars more on fighting the
disease, and harshly condemned South Africa for promoting unproven
folk cures and withholding well-tested drugs in the face of the
world's worst epidemic.

AIDS funding, at a record $8-billion now, needs to climb to
$22-billion by 2008 to begin to address the shortfall, Dr. Nordstrom said.

Dr. Wainberg called it the most science-based International AIDS
Conference yet. Work on new anti-retroviral drugs that can better
beat back the virus, anti-microbicides that women apply before sex
with the aim of preventing infection and vaccines that could be
available within 10 years were among the promising scientific
developments discussed at the conference.

Underlying many discussions were two pillars of HIV prevention that
have proven hard to take for some governments: promoting safe sex
over abstinence, and harm reduction -- tactics to make needle-sharing
drug addicts and the like less likely to pass around the virus.

The U.S. government's $3-billion a year in international AIDS funding
is tied in part to recipients promoting abstinence and being
faithful, a policy that many aid groups and researchers say is
creating damaging stigma around condom use. Evidence at the
conference of the effectiveness of abstinence-education was mixed at best.

A review of studies on abstinence-only prevention in Africa by the
Johns Hopkins School of Public Health found that some of the programs
changed beliefs on the topic, but none actually changed behaviour.

As for harm reduction, researchers at the B.C. Centre of Excellence
for HIV and AIDS discussed studies that found Vancouver's
controversial safe injection site -- where addicts can shoot up under
medical supervision -- has cut overdose deaths, reduced crime and
pushed more users toward detoxification treatment.

Another mainstay of the HIV battle has been testing that is
voluntary, avoiding any kind of pressure that might force people
underground. But Dr. DeKock of the WHO says that means that millions
visit health care facilities in Africa and other endemic areas and
are never asked to be tested. That makes no sense when an estimated
90% of HIV-positive patients do not even know they are infected, and
when early diagnosis, if it is followed by drug treatment, can add
years to a person's life, he said.

The agency believes people should always be asked to be tested, but
still be allowed to decline. A project in Malawi to do just that
resulted in 22% more people getting screened, according to research
presented at the conference. Yet human rights groups such as the
Canadian HIV/AIDS Legal Network complained the policy could be
damaging to people who are not ready to hear about a positive test,
or unsure how to disclose it to others.

"To couch this debate as one of human rights is neither completely
helpful nor completely understanding of the whole situation," Dr.
DeKock said. "What we're trying to do is ensure maximum access to
life-saving testing and care."