AIDS Condom Campaign--an Uphill Battle in Africa : Health: Anarchy in Zaire threatens to destroy what prejudice and ignorance couldn’t--a U.S. group’s plan to slow the spread of a fatal disease.

For a window into the implacable difficulties of fighting AIDS in Africa’s hinterland, consider the fate of one of the most successful education and prevention programs ever: a plan to get Zairean men accustomed to the idea of using condoms.

Using a technique known as “social marketing,” in which public health ideas are sold to mass markets just like soap or beer, an American nonprofit group financed by the U.S. Agency for International Development increased countrywide sales of its brand of condoms from 1 million in 1988 to 3.6 million a month at the beginning of this year.

“Zaire was our flagship program,” said Peter Clancy, a West African representative of the group, Population Services International.

Then came October and an army mutiny that pushed Zaire into near total chaos. The U.S. assistance agency stopped funding all programs in Zaire and evacuated expatriate workers. Population Services had a stock of 20 million condoms still in Zaire, and although it believes the stock is intact--in the hands of its local staff and probably still on sale--there is no way to be sure.

For now, the group has no way to replenish the supply or to get its goods out of the capital, Kinshasa, to rural areas, where sales were strong. Worse, the widening anarchy in Zaire threatens to destroy the delicate social fabric that health workers were weaving in an attempt to change the behavior that was helping spread AIDS.

“We’re trying to salvage what we had and keep things going,” said Steve Chapman, a Population Services special projects officer in Washington.

The success of and threat to the condom program in Zaire were outlined this week at the Sixth International Conference on AIDS in Africa. It has drawn more than 2,000 medical and social workers and African officials here to consider the medical, social, political and economic implications of the disease on the continent that is almost certain to be the hardest-hit on the globe.

Already 6 million Africans--or one of every 40 adults--have been infected with the human immunodeficiency virus that causes AIDS and another 750,000 children have been born infected. By the year 2000, the World Health Organization estimates, there will be 14 million infected adults and 4 million infected children in Africa. “In other words,” Michael H. Merson, head of WHO’s Global Program on AIDS, said Monday, “I am afraid the worst is yet to come.”

For all that, many AIDS workers were heartened by the heavy attendance at the weeklong session here and by the fact that almost every African nation now has an official anti-AIDS program, even if most of them consciously underestimate their caseloads and some still treat the subject as something of a taboo.

Condom-distribution programs met with tremendous interest at the conference for several reasons. One is the epidemiology of AIDS in Africa: unlike in the West, where the greatest numbers of those infected are homosexuals and intravenous drug users, in Africa, the disease is spread mostly by heterosexual sex, a high percentage of which involves prostitutes; 80% of those with the disease are infected in that fashion. Another 10% contract it from transfusions of contaminated blood; the final 10% are infants infected by their mothers.

Short of persuading Africans to abstain from sex or to avoid multiple partners--a herculean task given the high proportion of African men who work as migrant laborers, truck drivers and in other fields requiring long absences from home--the only way to stem heterosexual AIDS infection is to promote condom use.

Researchers at the Dakar conference argued that condoms provide another benefit of great value in Africa: They inhibit the spread of venereal diseases, which are chronic and pandemic. This preventive aspect may be doubly important because many experts here believe that these other diseases, which cause lesions and discharges, may account for the unique high rate of heterosexual AIDS transmission in Africa.

But condoms present a host of problems in Africa--from the difficulty of shipping them to remote locales and distributing them to the challenge of educating men and women in their use and safe disposal. Another important obstacle is the widespread impression that African men have an ingrained aversion to using condoms. A host of surveys has reinforced this.

“Our last study showed that only 6% of Nigerian men have used condoms even once in their lives,” said Dr. Babatunde Osotimehin, provost of the college of medicine at the University of Ibadan, Nigeria. Only 7.8% of those surveyed thought condoms could prevent AIDS, he said.

But others say that conclusion does not mean that condom programs cannot be effective. “Anyone can line up a group of African men who will say they won’t use them, but you’ll always find a few who will,” said Malcolm Potts, of Family Planning International, another nonprofit public health group active in Africa. “And those few will be enough to keep us busy. The number of people prepared to use them probably exceed our resources to provide them.”

One more problem is the lack of empirical data showing a correlation between condom sales or use and a decline in the spread of AIDS. This would be almost impossible to show in any case, since AIDS transmission rates are still rising across the continent. “No one’s validated a good way to check,” said David Sokal, an epidemiologist who has worked for the U.S. Agency for International Development.

In any case, because the AIDS incubation period is almost 10 years in Africa and the first condom program is scarcely more than 3 years old, “it’s too early to tell if it’s working.”

The important thing, say many researchers, is that Population Services’ experience in Zaire suggests that habits can be changed and that opinions about the habits of African men may even be somewhat mythical.

When the program began in 1988, condom use in Zaire was scarcely higher than that suggested by the Nigerian study. But Population Services salesmen fanned out across the dense, remote Zairean bush armed with supplies of “Prudence” condoms. The condoms are manufactured by an American company, Ansell; Population Services says they are identical to the condoms the company sells commercially in the United States.

The salesmen met with prostitute groups, trying to convince them that condoms would benefit them. In true promotional style, they even cajoled some hotels to include packs of condoms in the price of their rooms. A “Prudence” jingle became familiar among the boites or night clubs of Zaire’s tenderloin districts.

The salesmen stressed, and a diagram included with the packages reinforced, that condoms were to be used only once. They then were to be carefully discarded so they were not picked up by children. Any number of myths had to be exploded, including one misimpression among women that condoms could get lodged in the uterus and could be removed from there only by surgery.

Price was an important consideration, says Clancy and others associated with the program. (Population Services runs similar programs in 10 other African countries). An axiom in African public health is that a couple should spend no more than 1% of its annual income on family planning (about 100 condoms). Population Services has tried to keep the price of “Prudence” at a penny per condom; they are sold in packs of three. But given Zaire’s sudden hyper-inflation this year, that meant the condoms’ price went from 50 zaires per three-pack in 1988 to 15,000 zaires now.

One step the group avoided was making the condoms available for free. Leaving in a profit motive allows them to be marketed through shops and bars, a key to establishing a distribution network. If they were free, the condoms would have been distributed through Zaire’s public-health system, which, like every other public institution in the country, is almost out of business.

A year after the program began, “Prudence” sales quadrupled to 4 million. In 1990, Population Services says, sales reached 8 million; in the first part of 1991, some 20 million were sold.

But Zaire’s collapse this fall was a deadly blow to the program.

Population Services got a special dispensation to continue using property the U.S. assistance agency had financed, including a truck and warehouse.

But until conditions settle down, managers for the group will be able to get into Zaire perhaps once every six weeks to check on the local staff.

“Part of this is a leap of faith,” Chapman said.