Changing sexual behavior is a more effective way to prevent the spread of HIV in Africa than relying on HIV-prevention plans based primarily on promoting condoms, a witness told the Senate Health, Education and Pensions committee hearing Tuesday.

Encouraging men to be faithful in their marriages and delaying the age of first intercourse are the major ways to stop the spread of the virus that has infected as many as one in four people in some African countries, Norman Hearst, a professor from the University of California, San Francisco School of Medicine told the panel. The committee held the hearing on reauthorizing the President’s Emergency Plan for AIDS Relief, or PEPFAR, a 2003 law (PL 108-25) aimed at fighting HIV/AIDS that expires at the end of fiscal 2008.

“It’s easier to change sexual behavior than getting the people to use an imported sexual device all of the time,” Hearst said, referring to condoms.

While changing behaviors could drastically reduce HIV transmission, discrediting the role that condoms play in a comprehensive international prevention strategy is dangerous, said Global AIDS Alliance Communications Director David Bryden.

“Condoms are not the answer to all the problems those countries face. But it’s inaccurate to say that condoms are doing more harm than good,” Bryden said in an interview. “It’s critical that we reduce the stigma about condom use at the same time we promote faithfulness and delayed onset of sexual activity.”

Contrary to the views of many experts, Hearst said promoting an “American idea” that increased condom use equals fewer HIV transmissions is false.

He acknowledged that correct and consistent condom use is 85 percent to 90 percent effective in preventing the spread of HIV in concentrated epidemics, such as in the gay community in San Francisco or among Thai sex workers. But Hearst added that condom use is not effective in preventing the spread of disease in a generalized HIV epidemic, like that in Africa, particularly because of the prevalence of married men having longer-term sexual relationships inside marriage and therefore not likely to use a condom.

“No generalized HIV epidemic has ever been rolled back by a prevention strategy based primarily on condoms,” he said. “Instead, the few successes in turning around generalized HIV epidemics, such as in Uganda, were achieved not through condoms, but by getting people to change their sexual behavior.” HIV-prevention plans in African countries based primarily on promoting condom use are doing “tremendous damage” in Africa, Hearst said after the hearing.

Currently, PEPFAR promotes an “ABC” principle in its 15 focus countries, which stands for “abstinence,” “be faithful,” and “use condoms.” But for the program to turn its focus from an emergency management plan to a long-term disease prevention program, it needs give individual countries the financial freedom to customize their own interventions and to focus to new methods of HIV prevention, such as male circumcision, testified Helen Smits, vice chairwoman of the evaluation committee that published an Institute of Medicine report analyzing PEPFAR’s progress. Recent studies have found circumcision provides protection for men against HIV/AIDS.

In addition, current law requires that one-third of the PEPFAR’s funds allocated for preventing HIV/AIDS must focus on abstinence-only education. A bill (S 1966) sponsored by Richard G. Lugar, R-Ind., would specify that at least 50 percent of the funding for any HIV sexual transmission prevention program must go toward abstinence and fidelity education. Lugar’s bill would pledge $30 billion to reauthorize the program through fiscal 2013 — an amount also called for by President Bush.

Experts have said $30 billion may not be enough to fight the epidemic in the next five years.

Democratic presidential candidate and Senate Foreign Relations Committee Chairman Joseph R. Biden Jr. of Delaware, called on Bush and Congress to “pledge $50 billion over the next five years for global HIV/AIDS, tuberculosis and malaria programs.”

Fellow Democratic presidential contenders Illinois Sen. Barack Obama, New York Sen. Hillary Rodham Clinton and John Edwards, a former North Carolina senator, also have pledged, if elected, to provide $50 billion by 2013 to fight HIV/AIDS.

Mark Dybul, U.S. Global AIDS coordinator, voiced support for Lugar’s measure and said he disagrees with allocating specific funding for abstinence-only education because its not evidence-based.

Smits said, “We support eliminating all earmarks. We’d like you to work with the agencies to set goals for agencies you are particularly concerned with.”

But Hearst said earmarks are necessary to make sure enough funding gets allocated for prevention, and added that the creators of individual plans are often Western consultants anyway.

The witnesses also stressed the importance that PEPFAR address improving access to drugs that are easier to use, improving diagnostic testing for infants, increasing the lab capacity in at-risk countries and improving the nutritional status of HIV positive people.

PEPFAR has supported the testing and counseling of nearly 30 million people, provided services to prevent mother-to-child transmissions of HIV to women during more than 10 million pregnancies, and provided preventive anti-retroviral medications for more than 800,000 HIV-positive women during their pregnancies.

Corrects to say Lugar bill would specify at least 50 percent of the funding for any HIV sexual transmission prevention program must go to abstinence and fidelity education; also that PEPFAR has supported testing and counseling of nearly 30 million people, provided services to prevent mother-to-child transmissions of HIV to women during more than 10 million pregnancies, and provided preventive anti-retroviral medications for more than 800,000 HIV-positive women during their pregnancies.

First posted Dec. 11, 2007 6:12 p.m.