Male Ebola survivors in Liberia are being warned by local health authorities to abstain from sex for at least three months after being discharged from treatment centres, over fears the virus can still be passed on, even once the person has been given a clean bill of health.
"When you survive from Ebola, you need to wait until after three months before you have sex," a public service announcement tells radio listeners in Monrovia. "If you don't wait, you will infect your wife and she will get Ebola."
The Ministry of Health and Social Welfare is spreading similar abstinence messages nationwide via TV spots, billboards and word of mouth.
"I am glad the health workers have taken to the airways to educate people about this," said Musu Tuan, a mother of four from Monrovia. "I think this is a serious situation and it could make the virus stay longer in the country."
There are now more than 1,200 Ebola survivors in Liberia, according to the Ministry of Health.
The World Health Organization (WHO) says that while no cases of the sexual transmission of the disease have ever been documented, studies done in the Democratic Republic of Congo and Uganda have shown that the Ebola virus can live in the semen of recovering men for at least 82 days after their first onset of symptoms.
"We really don't know if they can transmit the virus as such," said Pieter Desloovere, a communications officer for WHO in Liberia. "There is certainly no scientific evidence as of yet and we cannot say that male patients, who are being discharged, are infecting their wives. But we do know the virus can survive in the semen for a maximum of three months, and so our advice for men coming out of treatment centres is to abstain from sex for three months."
If abstinence is not possible, then WHO says men should use condoms. WHO also recommends that men "maintain good personal hygiene after masturbation". They do not recommend isolating men for an additional 90 days, once their blood tests negative for the virus.
WHO experts say they still don't know why the Ebola virus can live in semen longer than it can in one's blood or saliva, or why it lives in only some men's semen. There have been just four studies looking at the presence of the Ebola virus in the semen of male survivors since 1977. Of the 43 patients looked at, just three had the live virus in their semen.
Better safe than sorry
A survivor from Monrovia, who requested anonymity, told IRIN that he is taking his doctor's advice not to have sex for three months seriously.
"Though I know it is a difficult rule, I have been abiding by it to save the lives of my family," he said. "In fact, since I came back home, my wife and myself do not sleep in the same room. We do not bathe together, nor do I watch her undress herself. I do all these things not to be tempted to have sex with her," he said.
His wife, who also declined to be named, said: "I know this is a hard decision, but life comes first, then sex. So I am patient for now," she said. "After observing the three months, sex will come later."
Thirty-five-year-old Sarah Jackson told IRIN she is also heeding the Ministry's advice.
"I am really scared of this news," she said. "For me, though I am not married, since the outbreak, I have stopped having sex [because] I am scared of contracting the disease. I may not know the status of my other partners, so the right thing to do is to be on the safe side. For me, no sex for now."
An uphill battle
But not all Liberians are happy about being told to abstain from sex.
Joseph Saah, a district health officer at the Ministry of Health and Social Welfare, said it has been difficult to convince some men to stop having sex after they have recovered.
"I tell the Ebola survivors. `If you really love your wife, you will abstain from sex for three months'," he said. "I make them understand that nothing will happen to them if they abstain from sex for three months. But we see now that most of them are getting irresponsible. and with this, if we are not careful, we will have another serious outbreak."
Saah told IRIN the Ministry is also urging the wives and girlfriends of men who are survivors not to agree to have sex with their partners during the three-month period after their recovery and that they should report any attempts by a survivor to have sex with them.
John Socree, a local businessman in Margibi County, said he is urging all Liberians to heed the Ministry's advice.
"If it will help stop the spread of the virus in Liberia, our Ebola survivors need to adhere to the advice," he told IRIN. "It is in the greatest interest of the people and the nation."
Abstinence not the answer
Despite the "potential" for the virus to spread via sexual intercourse, Médecins Sans Frontières (MSF) recommends safe sexual practices, over enforced abstinence, for the three months following recovery.
"Discharged cured patients have won the battle against the virus, so the continued reduced presence of virus in the semen. does not mean that a survivor is contagious or still incubating after discharge," said Laetitia Martin, a spokesperson for MSF in Liberia. "If the patient and their partner prefer to abstain during this time, that is their choice. But as long as condoms are correctly and systematically used there is no need for this."
Malay Mulbah, 46, from New Kru Town on Bushrod Island, said using protection is the more realistic option.
"For me it is difficult to abstain from sex, so the best thing I am doing now is to protect myself from the virus," she told IRIN. "I normally travel with my condoms everywhere I go."
Using condoms, however, is just one safety measure. MSF says the focus should remain on the main modes of Ebola transmission, including unsafe funeral practices, caring for or coming into contact with an infected person and coming into contact with materials that have been soiled by a sick person's bodily fluids.
"This recommendation [to use condoms]. should by no means become a priority message, as to this day we have no documented cases of sexually transmitted Ebola," Martin said. "If sexual intercourse with Ebola survivors was a major transmission route for the virus, it would make itself known to us, epidemiologically-speaking. So far it hasn't."