A quiet breakthrough in AIDS policy

According to UN statistics, around the world, about 40 million people live with HIV/AIDS. During 2004, about 4.9 million became infected and 3.1 million died, including half a million children. (1)

Although the steepest increases in the past two years have taken place in East Asia and Eastern Europe and Central Asia, sub-Saharan Africa remains the worst-affected region. Just under two-thirds of all HIV-infected people live there, and more than three-quarters of all infected women.

Amongst all the tragic stories told on World Aids Day, few were more touching than Botswana's. This tiny African nation surrounded by South Africa is relatively wealthy because of its diamonds and tourism. Yet an incredible 37 per cent of all adults in Botswana are HIV positive - compared to less than one per cent in the US and Western Europe. Its president, Festus Mogae told the BBC bleakly that his message was abstain from unsafe sex, or die.

A recent United Nations report on world security and UN reform says that international efforts to combat the spread of HIV/AIDS have been "shockingly late and shamefully ill-resourced". (2) It set a goal of increasing global spending from US$2.8 billion in 2002 to over $10 billion per year. A large chunk of that will be coming from the United States after President George W. Bush pledged $15 billion over five years to fight the disease last year. With the UN claiming that HIV/AIDS is a threat to international security on a par with nuclear terrorism, it could be money well spent.

The problem is: how?

The US government is backing abstinence and marital fidelity as key elements in fighting AIDS in Africa. Although its critics say that this is an ideologically blinkered solution, the Bush Administration says that the data supports it. In any case, it is not putting all its eggs in one ideological basket. Like Bush's policy on stem cell research, his approach to AIDS is a pragmatic compromise which also supports the use of condoms. In fact, although it is not widely known, the US exported 550 million condoms to developing nations in 2004. (3) How effective this is remains to be seen: African countries like Botswana with high availability of condoms also have some of the highest rates of HIV prevalence in the world.

The model for the US approach was first used in Uganda. It does not place condoms at center stage but it is still the world's most successful. In 1991, the infection rate in Uganda was 21 per cent. Now, after years of a simple, low-cost program called ABC, it has dropped to about 6 per cent.

ABC stands for Abstain, Be faithful, or use Condoms if A and B are not practiced. Ugandan President Yoweri Museveni preaches the ABC of AIDS with the fervour of an evangelist. "I am not in favour of condoms in primary and even secondary schools... Let condoms be a last resort," he said recently at an international AIDS conference in his capital, Kampala. "I have grown-up children and my policy was to frighten them out of undisciplined sex. I started talking to them from the age of 13, telling them to concentrate on their studies, that the time would come for sex and that peer groups at school gave them wrong advice from bad families. Indeed, I succeeded in this."(4)

The Catholic Church, which is influential in many African countries, takes an even narrower view of the solution to the AIDS epidemic. It abridges the ABC to AB. The World Aids Day message from the head of the Church in Madagascar, Cardinal Gaetan Razafindatrandraare, was stark. "Condoms do not work. They do not stop the virus getting through," he said in a speech which the government had invited him to make. "In fact, they are encouraging young people to behave in a promiscuous manner." (5)

None of this is advice which many AIDS activists warm to. "ABC is a middle-class, middle-aged response to an epidemic, all overlaid with a kind of morality that doesn't hold any more," comments Mary Crewe, director of the Centre for the Study of Aids at the University of Pretoria. (6) "Governments should be promoting condom use, not treating condoms like contraband," said Jonathan Cohen, of Human Rights Watch. "The clear result of restricting access to condoms will be more lives lost to AIDS." (7)

In the light of this polarising debate, then, the best news arising from this year's World Aids Day may have been an article in the world's leading medical journal, The Lancet. (8) In it, 140 public figures, activists, public health workers, scientists and academics from 36 countries agreed on three basic principles. The signatories included such disparate figures as Uganda's President Museveni, South Africa's Nobel laureate Archbishop Desmond Tutu, AIDS groups, abortion-rights groups, and church groups. Finding common ground was a remarkable achievement.

The first principle is that approaches must be adapted to local cultures and respect human rights. Second, that the ABC approach is legitimate. Third, that it is legitimate for community-based groups, including religious organisations, to tell people to change their sexual behaviour - not just to offer them "non-judgemental" medical solutions.

The most intriguing feature of this consensus is that it casts strategies based on abstinence and fidelity (known as "zero-grazing" in Uganda) in a surprisingly positive light, even though it insists on promoting condom use for sexually active people and providing "accurate and complete" information about condoms.

Thus, when targeting young people, for those who have not started sexual activity the first priority should be to encourage abstinence or delay of sexual onset, hence emphasising risk avoidance as the best way to prevent HIV and other sexually transmitted infections as well as unwanted pregnancy. After sexual debut, returning to abstinence or being mutually faithful with an uninfected partner are the most effective ways of avoiding infection... [P]arents should be supported in communicating their values and expectations about sexual behaviour... When targeting sexually active adults, the first priority should be to promote mutual fidelity with an uninfected partner as the best way to assure avoidance of HIV infection.

One of the academic signatories, Dr Jokin de Irala, a lecturer in public health at the University of Navarre in Spain, welcomed the statement, with some reservations, for he believes that even high-risk groups are capable of A and B. In his view, it put an end to a paternalism which dismisses abstinence or fidelity as unrealistic for young people. "This is a landmark in the history of AIDS prevention to recognise officially that the work of many organisations which teach the value of waiting and fidelity is of prime importance in the fight against this epidemic." (9)

Abstinence or waiting until marriage are often derided as unrealistic goals for young people. However, one of the experts who drafted the consensus, Dr Edward C. Green, a senior research scientist at the Harvard Centre for Population and Development Studies, and a member of President Bush's advisory council on HIV and AIDS, pointed out to MercatorNet in an email interview that Uganda's success is due more to an emphasis on fidelity than abstinence, especially in a society where people marry at a quite an early age.

"The word abstinence has often been misused," he says. "Most people aged 15 to 49 (the age group in which we track HIV infection rates and behavioral trends) are not abstaining. This is not realistic. Uganda's dominant message was 'Stick to one partner!' or 'Zero-Graze' or 'Love Faithfully!' The major behavioral change in Uganda was not 'abstinence'; it was fidelity or monogamy."

To Dr Green's great disappointment, the media almost completely overlooked the story. "I was surprised that a landmark statement signed by 140 scientists plus the President of Uganda, got so little notice," he said ruefully. "Maybe journalists who have been sceptical of ABC took it as a rebuke? Or they thought it was so common sense as to not require commentary? Or this is old news since ABC is now official US policy? But even if the last is true, the new policy is hardly being implemented as of yet. It is very slow to get started. Old habits are hard to break and there is incredible resistance to what for Africans is indeed just plain common sense."

In a recent book, Rethinking AIDS Prevention, (10) and elsewhere, Dr Green argues that there is a fundamental difference between fighting AIDS in the West and in Africa. In the West, a risk-reduction model has been followed on the premise that tightly-knit high-risk groups such as homosexuals and drug addicts cannot change their behaviour and that the best way of coping with the disease is by promoting condoms. Outside of high-risk groups in the general population this model is inappropriate - but it was imposed on Africans anyway.

"What Americans and Europeans forgot when designing these approaches is that African cultures are still largely bound by tradition and religion, and that they have not undergone the general sexual revolution, and certainly not the gay-lesbian revolution, of the West. This should have been Anthropology 101," Dr Green wrote last year.(11) Westerners should realise that Africans do not share their horror of "moralising about behaviour".

In fact, President Museveni has been an unashamed moraliser. "We made it our highest priority to convince our people to return to their traditional values of chastity and faithfulness or, failing that, to use condoms," he told American pharmaceutical executives last year. "The alternative was decimation." (12)

Or, as Dr Green put it to MercatorNet, "How did we ever think we could solve AIDS with just condoms, drugs and testing? That would be like solving the global lung cancer problem with just better filters on cigarettes, and lower-tar cigarettes."


(1)UNAIDS, "Aids Epidemic Update 2004"

(2)"A More Secure World: our shared responsibility", Report of the High-level Panel on Threats, Challenges and Change, 2 December 2004

(3)"Politics and Policy | Bush Seeks 'Immediate Release' of $500M to 15 PEPFAR Countries", kaisernetwork.org, 24 June 2004

(4)"Museveni Opposes Condoms in Schools", AllAfrica.com, 30 November 2004

(5) "Parades Mark World AIDS Day, Africans Told 'Abstain'", Reuters, 1 December 2004

(6) "Abstinence row overshadows Aids Day", Daily Dispatch (South Africa), 30 November 2004

(7) World AIDS Day: Condom Restrictions Cost Lives, Human Rights Watch

(8) "The time has come for common ground on preventing sexual transmission of HIV", The Lancet, 27 November 2004 (free article, but registration required)

(9)" Un consenso internacional para prevenir la transmisión sexual del VIH", Aceprensa, 154/04, 1 December 2004

(10)Green, E.C., Rethinking AIDS Prevention. Westport, Ct.: Praeger Press, Greenwood Publishers (2003).

(11) "Culture Clash and AIDS Prevention.", The Responsive Community. Vol. 13(4); 4-9 2003.

(12)Joseph Loconte, "The White House Initiative to Combat AIDS: Learning from Uganda", Heritage Foundation, Executive Summary #1692, 30 September 2003.


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