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Let Africans Decide How to Fight AIDS

Dr Edward C. Green and Wilfred Mlay

Senior Research Scientist in the School of Public Health, Center for Population and Development Studies, Harvard University

Let Africans Decide How to Fight AIDS

As the United States prepares to implement President Bush's five-year, $15 billion Emergency Plan for AIDS Relief, special interests on both sides of the social-political spectrum are attempting to export some of the worst of America's prejudices to Africa. At issue is funding for prevention and, in particular, the widely debated approach to AIDS prevention known as ABC: Abstain, Be faithful or (for those especially at risk) use a Condom.

Under the legislation, 20 percent of the funding -- or $3 billion over five years -- would be used for prevention. How that money will be spent is the controversial and important issue -- and for many a matter of life or death.

Some U.S. conservatives favor an "abstinence-only" approach, while many on the other side dismiss abstinence in favor of condoms. Lost in the debate is the decline in extramarital and casual sex -- which has proven effective in reducing HIV infection rates in Uganda, Zambia and elsewhere.

In truth, good public health policy requires A, B and C to reverse the AIDS epidemic. But partisans ignore the facts.

Condoms are effective in slowing the spread of AIDS among those particularly at risk: people with HIV-infected partners, women trapped in the commercial sex industry, their customers and those customers' wives. While condoms arguably may have stabilized HIV transmission rates in the United States -- where AIDS is largely confined to those engaged in high-risk behavior -- they have proven inadequate in countries where most HIV is found in the general population.

Those who consider condoms a panacea for Africa's AIDS epidemic ignore their track record and naively apply a U.S. solution to an African problem. In fact, the African countries with the highest levels of condom availability -- Zimbabwe, Botswana, South Africa and Kenya -- also have some of the highest HIV rates in the world.

Uganda is a case in point. Between 1991 and 2001, Uganda lowered its infection rate from 21 percent to 6 percent. Unlike most heads of state, Uganda's president, Yoweri Museveni, intervened early and forcefully. Impoverished and war-weary, Uganda adopted the least expensive intervention available: public education stressing abstinence before marriage and faithfulness after.

"Zero grazing" -- staying faithful to one partner -- was the message Museveni and other government officials repeated over and over. Between 1986 and 1992, the Ugandan ABC model was mostly focused on A and B, reserving condoms primarily for those already infected and high-risk groups. Comparing condoms to penicillin, Museveni said, "Just as we were offered the 'magic bullet' in the early 1940s, we are now being offered the condom for 'safe sex.' We are being told that only a thin piece of rubber stands between us and the death of our continent. I feel that condoms have a role to play as a means of protection, [but] they cannot become the main means of stemming the tide of AIDS."

Museveni enlisted Uganda's religious community, which reinforced the A and B message. While many religious leaders opposed the use of condoms, they remained relatively silent on the issue to avoid undermining public health efforts. The approach worked. The number of young people engaged in premarital sex plummeted between 1989 and 1995. By 1995, according to a survey financed by the United States, 95 percent of Ugandans were reporting either one sexual partner or none. Most Ugandans in the ages surveyed, 15 to 49, are married and therefore sexually active, so "zero grazing" was the predominant response to the threat of AIDS.

Moreover, in countries where infection rates exceed 30 percent and funerals for family and friends are held several times a week, abstinence and faithfulness are attractive alternatives to death. This central fact is often lost in the U.S. debate over abstinence vs. condoms.

The Ugandan turnaround was well underway by the time foreign AIDS experts began to arrive in the early '90s, bringing with them Western public health approaches -- and values. They began to retool Uganda's AIDS prevention efforts away from abstinence and fidelity -- goals that many Westerners felt were unrealistic. As condom use increased, the percentage of young singles having sex rose from 27 percent to 37 percent between 1995 and 2000. Health officials worry that infection rates may increase as well.

Africa is finding its own solutions. In particular, its faith community -- which in many countries already provides most of the care and comfort for the sick and dying as well as the orphans and vulnerable children -- has a significant role to play in contextualizing and implementing Bush's plan.

The United States should be applauded for its generous investment in the fight against AIDS. But this historic opportunity -- not to mention billions of dollars and the lives of countless men, women and children -- will be wasted if ideology trumps proven public health policy. American partisans must not be allowed to make decisions from thousands of miles away -- and from a culture even more distant -- on ways African couples protect themselves from this most intimate of diseases.

Edward Green, a medical anthropologist with 25 years of experience in Africa, is a senior researcher at the Harvard School of Public Health. He latest book is "Rethinking AIDS Prevention." Wilfred Mlay is World Vision's vice president for Africa and a former professor and academic dean at the University of Dar-es-Salaam in Tanzania.