Broken Promises

Harvard University researcher Edward Green rose to prominence in the AIDS controversy with his 2003 book, Rethinking AIDS Prevention. His new book, Broken Promises: How the AIDS Establishment
has Betrayed the Developing World
, chronicles the continuing battle over how to
prevent the spread of HIV/AIDS in sub-Saharan Africa. Green, a key
player in the struggle, documents how two radically
different strategies have competed for funding and support.

The first is ABC: Abstinence (or delay of
sexual debut); Be faithful (only one sexual partner); Condoms for those who
engage in high risk behavior in spite of warnings and for couples where one is
already infected. This is a risk elimination strategy

The second is the condom code. The
supporters of condoms as the primary prevention method insist that any program
be “sex positive”. In other words, there is no need for anyone to change their
sexual behavior as long as they use a condom every time. This is a risk
reduction strategy since new infections would not be eliminated, only reduced, given
the known failure rate of condoms and the fact that even the most motivated
sexually active persons rarely achieve 100 per cent usage.

Green and others studied the results of
condom programs: 

simply compared the prevalence of HIV among people in three groups: those who
never used condoms, sometimes did, and always did. And we found no association between
HIV status and consistent condom use… those who reported using a condom with
every sex act were just as likely to have HIV as those who had never used one
at all…we also found that inconsistent users had the same or greater HIV
prevalence as non-users… And sporadic use is the norm in Africa and in
countries everywhere. (pp 223-4)

As an anthropologist with years of experience
in field work, Green was trained to listen to the local people. He familiarized
himself with their traditions and customs. He takes great pains in the book to
point out that he is not a social conservative or a religious zealot, but a
professional who respects the people he studies. Before becoming involved in
the battle over AIDS prevention, he worked for population control groups and on
a condom marketing study. He approached the problem of AIDS in sub-Saharan
Africa with an open mind, seeking to discover which strategies worked (that is,
decreased new infections) and which strategies failed.

In 1993 he visited Uganda as part of a team
studying sexually transmitted diseases, including HIV, among prostitutes. While
there, he saw the success of an indigenous HIV prevention program -- the
original ABC. Early in the epidemic President Museveni of Uganda recognized the
danger posed by HIV and spearheaded a comprehensive program which stressed
fidelity and delay of sexual debut. Museveni engaged the entire society in the
effort to prevent new infections. He included faith based organizations and
traditional healers in the effort. Fear was used to spur behavior change. The
program had been successful and new infections had decreased.

Unfortunately, western experts arrived on
the scene with their sex-positive strategy. A and B were pushed into the
background and all the money and marketing went to C. However, in spite of well
funded marketing campaigns, in Uganda, as well as in other African countries
where this strategy was implemented, new infections increased rather than
decreased. The experts reacted to this failure by insisting that they needed
more funding, and so more funding was provided.

The evidence for the failure of condom
marketing and distribution programs and the success of fidelity/delay was clear,
yet many of western experts and those funding prevention programs continued to
insist that condoms were the only solution and all Africa needed was more
condoms. Not only was the money spent on these programs wasted, but money to
deal with Africa’s other health care needs dried up.

Through his first book, Rethinking AIDS Prevention, Green had been able to convince some key leaders that behavior
change was more effective than condom promotion. Others were convinced by their
own research that prevention should focus on fidelity/delay, with condoms used
only as a back-up. The Bush administration was supportive, but those pushing
sex-positive condom marketing pushed back. In Broken Promises, Green reports on how the supporters of positive behavior
change would win one battle, only to lose the next.

Green was facing an entrenched AIDS establishment
run by gay AIDS activists, population controllers, and suppliers of condoms,
all committed to the sexual revolution and determined to impose that revolution
on Africa. Green was appalled by the racism he found among those involved in
condom promotion. They commented privately that AIDS spread in Africa because
African men are incapable of controlling their sexual urges and therefore the
only answer is condoms. This in spite of research which showed that Africans
when faced with the facts about HIV transmission are able to substantially
change their behavior and these changes reduced new infections in several

In 2004 in Washington DC, Green gave a 40
minute slide presentation to a conference of specialists in the field of AIDS.
He spoke on how Uganda’s program emphasizing abstinence, be faithful, and
condoms as a last resort had brought down HIV prevalence. He received muted
applause. Then a female college student came to the microphone and exclaimed,
“I think people should be able to have as much sex as they want, with as many
people as they want.” She received a thunderous, standing ovation.

In spite of mounting evidence of the
failure of condom programs, the AIDS establishment ridiculed as anti-scientific
anyone who did not support their strategy. When Pope Benedict XVI was asked
about AIDS in Africa, he said that “… if Africans do not help by responsible
behavior, the problem cannot be overcome by the distribution of prophylactics.
On the contrary, they increase it.” For this he was roundly condemned, but
according to Green, “He had summarized the best current research on AIDS
prevention in Africa.”

Green says that the rejection of programs
with records of success was driven by a rigid set of assumptions:

First, sexual freedom -- the belief that
“each person has the inalienable right to choose his or her sexual behavior and
express it freely, without inhibiting, judgments or censure from society… this
value has trumped essentially all other concerns, even health and life.”

Second, harm reduction. -- the assumption
that you can’t change behavior but only reduce the consequences of it, an
assumption the Uganda program proved wrong.

Third, cultural relativism -- the
assumption that no one has the right to criticize cultural practices such as
prostitution or gay promiscuity or sex between adults and adolescents. For
example, it is well known that in some African countries older men entice girls
into sex with gifts in what is known as “the sugar daddy phenomenon”. Rather
than condemning this sexual abuse of minors, says Green, an advertisement for
Botswana, funded by American taxpayers, “showed a fourteen–year-old girl who
smilingly tells us she had added flavor (and by implication, gifts and an
allowance) to her life by entering into a sexual relationship with a man twice
or more her age – and she could do it by using Lovers Plus condoms ‘every time’.”
Fortunately, in that case public outrage forced the US contractor to pull the

These three assumptions led to “AIDS
exceptionalism” -- the decision to exempt HIV/AIDS from standard public health
practices such as contact tracing, partner notification, routine testing, and
encouraging behavior change. This was justified by claiming that it was done out
of “respect for those already ill”. In other words, family and sexual partners
of the infected would become infected because the sex positive AIDS
establishment didn’t want to make those already infected feel guilty about
their behavior.

HIV has infected some forty-six million
people in Africa and eighteen million have died. Green believes this could have
been brought under control two decades ago, had ABC been employed, but because
it was not “we are now experiencing the greatest avoidable epidemic in

Dale O’Leary is a US writer with a
special interest in psychosexual issues and is the author of two books: “One
Man, One Woman" and“The Gender Agenda”.
She blogs at What Does The Research really Say?


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