Sarah Boseley

Demonstrators delayed Mr Tobias’s presentation, chanting “Bush lies, people die.” He declined to go to the podium until the placards in front of him stating “He lies” were lowered. But he did not duck the controversial issues. He cited the Ugandan president, Yoweri Museveni, in support of the US “ABC” policy  abstinence, be faithful and condoms  “where appropriate.”

Mr Tobias said: “When we say we are listening, and we say those on the ground know best, then we must surely listen and learn from the man who has led one of the most successful and pivotal battles against this disease. Yoweri Museveni has, largely by sheer leadership and will, fought back this disease in his country with an ABC prevention focus.

“We must learn from his leadership in the fight against Aids. Abstinence works  being faithful works  condoms work. Each has its place.”

The UN agencies have all expressed their doubts about abstinence and fidelity, pointing out that women in southern Africa often do not have the power to say no and that married women are more likely to be infected with HIV, via their unfaithful husbands, than unmarried women.

“There is an urgent need to rethink the ABC approach,” said Thoraya Obaid, executive director of the UN’s Population Fund, at the launch of a report which outlined the dire plight of women in southern Africa, who make up 57% of those now infected and unable to protect themselves.

But Mr Tobias said there was confusion about the US position and there was no right answer to preventing the spread of Aids. “Those who want to simplify the solution to just one method, any one method, do not understand the complexity of the problem,” he said.

The US president’s emergency plan for Aids relief (Pepfar) would work with local people in affected areas, he said, giving money directly to groups in the communities who would know best what worked for them.

Mr Tobias, who has expressed doubts about the quality of the generic Aids drugs made in India, said if the drugs were submitted for approval by the US drug regulators, they would be eligible for US purchase “so long as international patent agreements and local government policies allow their purchase.”

The US has been criticised for failing to put more money into the Global Fund for HIV/Aids, Tuberculosis and Malaria, which funds programmes put forward by developing world governments. The fund was “a young venture and still maturing”, Mr Tobias said, but “a very promising vehicle and a critically important part of the work that all of us are doing.”

While the United States is not named, there is widespread anxiety over the effect of its pro-abstinence agenda in countries such as Uganda, where statements by Janet Museveni, the president’s wife, and alleged problems with supply have led to a serious shortage of condoms.

The U.S. has pledged $15 billion over five years to fight the disease, most of which is channeled through the President’s Emergency Plan for AIDS Relief. PEPFAR grants come with conditions, however — two-thirds of the money has to go to pro-abstinence programs, and it is not available to any organizations with clinics that offer abortion services or even counseling. The U.S. is also opposed to the provision of needles and syringes to drug users on the grounds that it could be construed as encouraging their habit.

But the statement from 22 European Union member states, released at a meeting under the U.K. presidency in London Wednesday, calls on developing world governments to use every prevention tool, from condoms to clean needles to sexual health clinics, in a bid to slow down the spread of HIV. UNAIDS’ latest figures show 40 million people are now infected, and the rate is rising as fast as ever.

“We, the European Union, firmly believe that, to be successful, HIV prevention must utilize all approaches known to be effective, not implementing one or a few selective actions in isolation,” the statement says.

The international development secretary, Hilary Benn, told the Guardian that the evidence had shown what worked, from tackling stigma to supplying condoms and clean needles. “It is very important that those messages are heard loud and clear by everybody,” he said.

Asked whether the U.K. disagreed with the U.S. emphasis on abstinence, he said: “Abstinence works if people can abstain, but I don’t think people should die because they have sex. We need to make sure people have all the means [of prevention] at their disposal — condoms and clean needles. It includes education and access to sexual and reproductive health services. We are very clear about that.”

In August the U.N. secretary general’s special envoy for HIV/AIDS in Africa, Stephen Lewis, accused the United States of “doing damage to Africa” by cutting funds for condoms in Uganda while promoting abstinence. “There is no doubt the condom crisis in Uganda is being driven by” U.S. policies, said Lewis. “To impose a dogma-driven policy that is fundamentally flawed is doing damage to Africa.”

Only 35 million condoms were distributed in Uganda between October 2004, when the government said there was a problem with the quality of the stock, and August of this year, compared with 120 million in previous years.

Uganda has historically been cited as one of the HIV/AIDS success stories, and experts generally agree it was partly the availability of condoms that brought the infection rate down. But Museveni has said condom distribution pushes young people into sex and recently equated condom use with theft and murder in an interview with the BBC World Service. The shift in government thinking is being linked within Uganda to PEPFAR.

AIDS activists in the U.K. are pleased by the E.U. stance. “Activists have been warning for years that the U.S. prevention policy is reckless and could cost lives,” said Fiona Pettit of the U.K. Consortium on AIDS and International Development. “The relentless promotion of abstinence only is already having an impact in countries like Uganda. Abstinence only is an unrealistic policy in many communities and a one-size-fits-all approach simply won’t work.”

“In reality, people have sex … much as conservative evangelists in the U.S. might prefer that they didn’t,” said Andrew George, the Liberal Democrats’ spokesman on international development.

This article has been provided by the Guardian through a special arrangement with Salon. ) Guardian Newspapers Limited 2005. Visit the Guardian’s Web site at http://www.guardian.co.uk.

“These abstinence-only programs leave Uganda’s children at risk of HIV,” said Jonathan Cohen, one of the report’s authors. “Abstinence messages should complement other HIV-prevention strategies, not undermine them.”

Human Rights Watch says condoms have been widely available in recent years in Uganda and have helped keep HIV prevalence down to around 6 percent, after the big fall from an estimated 15 percent in 1992. The infection rate dropped when President Yoweri Museveni’s government promoted openness about AIDS and awareness of the dangers of HIV infection. But recently the president and his wife have spoken out against the use of condoms, which are considered by most AIDS experts to be the most effective protection against the virus.

Human Rights Watch says Uganda is falling in with the Christian right in the United States, which backs sexual abstinence before marriage and believes that promoting condoms leads to promiscuity. Uganda, says the report, is redirecting its AIDS strategy away from scientifically sound policies. “Although endorsed by some powerful religious and political leaders in Uganda, this policy and programmatic shift [are] nonetheless orchestrated and funded by the U.S. government.”

A spokesman for Museveni denied that the U.S. was influencing policy. “The president and the first lady are being misunderstood. They have been consistent in advocating for a multipronged approach,” he said. “He says that those who are sexually active should be faithful to their partners; that others should abstain, and those who cannot abstain should use condoms.”

But while the United Nations and most organizations fighting AIDS back the “ABC” mantra — abstinence, be faithful and condoms — Uganda’s AIDS commission last November issued a draft “Abstinence and Be Faithful” policy document, which argues that promoting condoms and abstinence at the same time would be confusing for young people.

Government-sponsored youth rallies have also cast doubt on condom use, says the report. At one rally it was said that using a condom to protect against disease was like “using a parachute which opens only 75 percent of the time.” In October the government withdrew all free condoms, saying they had failed quality-control tests, and imposed new tests on all imports.