• Topic: Advocacy
• Article on Advocacy

KEY POINTS Every day 16,000 people are infected with HIV and almost a million people become infected with other STIs. Reducing the spread of STIs would save many lives and relieve strain on health care systems.
1	Family planning programs help people avoid STIs. They offer communication, education, and counseling that encourage adoption of safer sexual behavior, including delayed sexual initiation,monogamy, and condom use.
2	Programs that encourage safer sexual behavior can be good public health investments. Governments and health care providers could shift resources to meeting other needs for health care, education, and development.

The extent of the HIV/AIDS epidemic underscores the urgent need for action. Worldwide, nearly 1 adult in every 100 between the ages of 15 and 50 is infected with HIV (258). As estimated at the end of 1998, at least 33 million people had HIV/AIDS and another 14 million had died as a result of HIV/AIDS. Every day another 16,000 people become infected with HIV—about 5.8 million each year (258). The number of HIV infections is expected to reach 40 million cases sometime in 2000 (231).

Not only HIV/AIDS but also other STIs are becoming increasingly common (126). Around the world, about 333 million new cases of STIs occur each year (161). Each year over 230,000 people die from STIs other than AIDS (160). Gonorrhea and syphilis are the most widely known STIs, but more than 40 others also pose health risks. People are more susceptible to infection with HIV if they have another STI, particularly an STI that causes genital ulcers, such as chancroid, genital warts, herpes simplex, and syphilis (170, 249).

How programs can help. At the ICPD in Cairo countries agreed that health care providers have important roles to play in reducing STIs. Because HIV/AIDS and other STIs spread principally through unsafe sexual behavior, reducing infections requires changing behavior.

While surveys show that many people have changed their sexual behavior because of the AIDS epidemic, many obstacles remain. Many people who know about AIDS and also know about condoms nevertheless do not know that using condoms can prevent AIDS. Social and cultural norms may encourage men's sexual risk-taking and discourage both women and men from talking about or using condoms (35, 67, 74).

To help fight the AIDS epidemic, family planning programs can encourage young people to delay sexual initiation, advise couples to remain monogamous, and promote condoms more among unmarried men (74). At the same time, condoms are also a method that an estimated 44 million married couples rely on for family planning. Today, family planning communication and social marketing campaigns often promote the dual role of condoms in preventing pregnancy and avoiding STIs (79, 89).

Programs also are starting to promote the female condom, a new contraceptive method that protects against HIV/AIDS and most other STIs. Many women favor the female condom because it is convenient, can be used with oil-based lubricants, and women have more involvement in initiating use (10, 215).

The importance of condoms. When used correctly, condoms prevent HIV infection. Laboratory tests show that no STI organism, including HIV, can pass through an intact synthetic condom. In fact, a condom protects against any STI that is passed through bodily fluids (170).

All 10 studies conducted through 1995 that evaluated condom effectiveness among heterosexual couples showed that consistent condom use protected against HIV. The most convincing evidence comes from studies of couples in which one partner is infected with HIV and the other is not. Such studies have found low risks of HIV transmission among consistent condom users. In three recent studies infection rates were less than 1% per year among consistent condom users (51, 52, 199). A multicountry European study of 256 couples, in which one partner had HIV and the other did not, found that after 20 months not even one infection occurred among couples who used condoms consistently (51).

Bridging the condom gap. By informing and counseling sexually active people about safer sexual behavior, family planning programs help to bridge the gap between condom use and the need for condoms. Worldwide, about 6 to 9 billion condoms are used each year, but almost three times as many—an estimated 24 billion—are needed to protect against STIs (74).

An estimated 70% of the total need for condoms is among unmarried people. Many married people also need condoms. In addition to married couples who use condoms for family planning, other married men and women need them to prevent HIV/AIDS and other STIs because they have sexual relations outside marriage (see Figure, below).

To meet the need for condoms, governments, the commercial sector, international agencies, and nongovernmental organizations must cooperate. Together, they can ensure that condoms are accessible to all people who want them. They can lower costs of condoms through social marketing and other subsidies, promote them widely, and change public policies that limit public access to condoms or to information about them (74).

24 Billion Condoms Needed Worldwide

Population Reports estimates that 24 billion condoms are needed annually, including among married couples and unmarried men, to avoid unintended pregnancies and STIs.

Focusing on preventing STI transmission typically is cost-effective. When programs encourage safer sexual behavior, they save on treatment and so conserve resources for other purposes (74). Based on analysis of data from 34 countries, the World Bank observed that, on average, treating one AIDS patient for one year costs about the same as educating 10 primary school students for a year (258).

The costs of STIs. Along with other STIs, HIV/AIDS is severely straining health systems in many developing countries. As the epidemic spreads, demand for medical care is soaring, and clinics and hospitals are devoting more and more money, equipment, medical staff time, and other resources to AIDS patients. STIs strain personal budgets. People with STIs often pay private providers as much as one-third of their monthly earnings for drugs (128).

As well as causing widespread suffering, coping with the HIV/AIDS epidemic hampers development efforts. Individuals, households, and economies lose many productive working days and much income each year due to AIDS. In some African countries rising rates of AIDS-related mortality have dampened the productivity of the labor force, as skilled workers die, while the costs of providing health care and death benefits are becoming enormous (258). Since the start of the AIDS epidemic, some 8.2 million children have lost their mothers to AIDS. Their deaths have caused suffering and increased public spending for the care of many orphaned young children (234).

With adequate leadership commitment and financial support, family planning programs can do more to prevent the spread of HIV/AIDS and other STIs. As studies have found, program efforts can and do change people's sexual behavior (193, 200, 233). In some countries the prevalence of STIs has decreased as health care programs have focused more on prevention (193). Family planning programs have helped slow the spread of HIV/AIDS by encouraging safer sexual behavior, particularly condom use.

Fill in national data from Table			Focusing on preventing AIDS typically is cost- effective as a public health investment.
Measuring HIV Prevalence
HIV Prevalence (percent of adults with HIV/AIDS)
Country Data	Regional Estimates for 1997	%
	Sub-Saharan Africa North Africa and Near East South and Southeast Asia East Asia and Pacific Latin America Caribbean Eastern Europe and Central Asia Western Europe North America Australia and New Zealand	7.41 0.13 0.06 0.05 0.52 1.82 0.09 0.23 0.55 0.11