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Dialogue on AIDS Prevention
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Evidence is mounting that the global model of HIV/ AIDS prevention, designed by Western ex-perts, has been largely ineffective in Africa. The model is based on risk-reduction or “remedies” interventions (condoms, treating Sexually Transmissible Infections with drugs), rather than on risk avoidance (mutual monogamy, abstinence or delay of age of first sex). This dichotomy is imperfect because reduction in number of sexual partners would have to be classified as risk reduction, not avoidance. The remedies-based global model does not promote partner reduction, nor even address multi-partner sex.

September 2003 - Dr Edward C. Green and Paul Farmer

John Richens proposed the term primary behavior change (PBC) to denote fundamental changes in sexual behavior, including partner reduction, that do not rely on devices or drugs. He, I and a very few others have suggested treating AIDS as a behavioral issue that calls for behavioral solutions, although not to the exclusion of risk reduction remedies. The dominant paradigm model treats AIDS as a medical problem requiring medical solutions. PBC deals with the problem itself, getting at what is needed for primary prevention, while the medical model deals with symptoms.

Risk-Reduction Model

The dominant prevention paradigm was developed for high-risk groups in US cities like San Fran-cisco. Part of the risk reduction model was to not address sexual behavior. It was argued that this would amount to making value judgments, which is unscientific and would only drive away those who needed to be reached. AIDS experts settled for risk or harm reduction approaches, which assume that behavior is difficult or impossible to change, therefore efforts ought to be made to mitigate the consequences of risky behavior. Thus condoms and clean needles (if legal) were pro-vided to reduce risk of sexually transmitted and blood-to-blood HIV infection respectively. There was and is no discouragement of any form of sexual behavior, or injecting drug use. AIDS experts applauded themselves for their open-mindedness and realism.

This approach might have been suitable for San Francisco or Bangkok. But when exported to Africa and other parts of the world, and despite claims to the contrary, there was little attempt to adapt the model to other cultural settings or epidemic patterns. In the US, Europe and most of Asia, HIV infections are concentrated in a few fairly well-defined high risk groups. In (sub-Saharan) Africa, most infections are found in the general population. Actually, many are opposed to this distinction, arguing, “Let’s not single out particular risk groups. That will stigmatize them-blame the victims-and make the general public feel that they are not at risk. So our message should be, “We are all at risk of AIDS.” This has a nice, egalitarian ring; we are all in this thing together. Nevertheless, differences in epidemiological patterns and cultural settings are real, calling for-among other things-different approaches to prevention.

AIDS Prevention in Africa

How has the Western risk-reduction model fared in Africa? Most efforts have focused on condoms. There is no evidence to date that mass promotion of condoms has paid off in decline of HIV infec-tion rates at the population level. The UNAIDS multi-center study, published in a special edition of AIDS in 2001, found that condom user levels made no significant difference in determining HIV prevalence levels. And a 2003 UNAIDS review of condom effectiveness, by Hearst and Chen
concludes, “There are no definite examples yet of generalized epidemics that have been turned back by prevention programs based primarily on condom promotion.”

Some argue that not enough condoms are being used in Africa to have made a difference yet, that condoms would have an impact if only we exported them in the billions instead of the mere tens of millions. Maybe, but what we do know from recent USAID data is that, after 15+ years of intense condom social marketing in Africa, the result today is an average of only 4.6 condoms available (not necessarily used) per male per year in Africa. That figure was actually a bit higher in the mid-1990s; it has declined somewhat even since then in spite of the explosion of AIDS in southern Africa. The problem seems to be low demand.

Uganda’s Approach

In addition to condoms, the other relatively expensive AIDS prevention programs currently funded by major donors are mass treatment of STIs, voluntary counseling and testing and prevention of mother-to-child transmission through Nevirapine. Like condom marketing, remedies rather than behavior change. These programs, along with condom social marketing, had not yet started in Uganda when infection rates began to decline in the late 1980s. Yet Uganda has experienced the greatest decline of HIV infection of any country. Its home-grown prevention program was based largely on behavioral change. Reacting to Western advice, President Museveni said in 1990, “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, especially in couples who are HIV-positive, but they cannot become the main means of stemming the tide of AIDS.”

Uganda’s largely home-grown approach to AIDS led to a delayed age of first sex, less casual sex, and relatively high condom user rates among the few who still engage in casual sex. Uganda also pioneered approaches in reducing stigma, bringing discussion of sexual behavior out into the open, involving HIV-infected people in public education, persuading individuals and couples to be tested and counseled, and improving the status of women. The genius of Uganda’s ABC program (Ab-stain, Be faithful, or use Condoms) is that it focuses on what individuals themselves can do to change (or maintain) behavior, and thereby avoid or reduce risk of infection. But it also tackled the difficult social and institutional problems that only committed governments can impact in the near-to intermediate-term. These programs were led by the government (especially the ministry of health) but also involved many NGOs and community-based local organizations.

Providing More Options

It has been difficult for Western donor agencies and consulting firms involved in AIDS prevention to accept evidence that suggests what they have been doing may not have been very effective in Africa; meanwhile something they have not supported has worked better. Some have dismissed the ABC approach as simplistic or narrow. Yet the ABC approach adds primary behavior change (the A and B of ABC) to existing programs that, for the most part, do not go beyond “C,” beyond
condom (and drug) remedies. Adding primary behavior change provides people with more behav-ioral options for preventing HIV infection than are currently available, and these are sustainable options that do not depend on relatively high-cost Western imports.

Edward (Ted) Green, is a senior researcher at the Harvard School of Public health. He has applied anthropology for 30 years in Africa and Latin America/Caribbean. His new book, Rethinking AIDS Prevention, is due in November. See p 54 for his recent AIDS policy work.

AIDS: A Biosocial Problem with Social Solutions
Paul Farmer
Partners in Health
Harvard Medical School

Edward Green’s important piece raises two major questions about AIDS prevention paradigms. Why are they ineffective? And what can be done to make them less so?

Green begins his overview of the problem by noting, “Evidence is mounting that the global model of AIDS prevention, designed by Western experts, has been largely ineffective in Africa.” It would be hard to argue with him on this score as thousands of new infections accrue each week. With millions of new infections occurring each year, AIDS prevention is by and large a failure, especially on the world’s most heavily burdened continent, which is also, not coincidentally, the globe’s poor-est. Quibbling over terminology (the specialty of the seminar-room warrior) is not all that impor-tant, but permit me to object to the term “Western.” I could do so by saying that “Western” pre-vention paradigms are to some extent ineffective in Haiti, too—and that country is, as Alfred Metraux and others have noted, about as Western a nation as one could imagine: Haiti is a creation of European expansionism. Africa, too, is a vast and heterogeneous continent where many “tradi-tional healers” (as I learned from Green’s previous work on this topic, which is extensive) are as likely to use ampicillin as they are the wisdom of elders.

However, this is not the only way in which the term “Western” is misleading. “Western,” in devel-opment- speak, means wealthy countries, whether the US or Japan. The “global north” is a bit more accurate but the truly apposite term is “the haves.” Those who have—and we have now taken to calling ourselves, somewhat self-righteously, “the donor nations”—are those who are currently deciding the fates of hundreds of millions. So it’s crucial that we understand why HIV prevention hasn’t been more effective and Green is to be lauded for sticking with this topic for many years. Green is also to be applauded for taking on some of the sanctimonious sloganeering rife in AIDS prevention work. He summarizes such softheaded thinking: “Let’s not single out particular risk groups. That will stigmatize them—blame the victims—and make the general public feel that they are not at risk. So our message should be, ‘We are all at risk of AIDS.’ This has a nice, egalitarian ring; we are all in this thing together. Nevertheless, differences in epidemiological patterns and cultural settings are real, calling for—among other things—different approaches to prevention.”

All good, but Green should push this further. Why is HIV concentrated so heavily in the poorest parts of the world? Why do social inequalities, including gender inequality and racism, seem to fuel the AIDS pandemic whether in Africa or in the cities of the US? Why do economic policies foisted on poor countries tend to heighten HIV risk? Part of the answer to each question: because risk for HIV goes hand in hand with not having. The have-nots constitute the global risk group, if there is such a thing. Thus a behavioral model of HIV prevention such as that advanced by Green needs to be embedded in a much broader social analysis especially if one is as concerned with the prevention of new infections as with contributing to the scholarly literature.

Green also takes on other prevention pieties, including those regarding condoms. Condom promo-tion and social marketing are not “the” solution to the problem. But are there other solutions out there? I hope he’s right in lifting up Uganda as a model for other African nations. “The genius of Uganda’s ABC program (Abstain, Be faithful, or use Condoms),” Green argues, “is that it focuses on what individuals themselves can do to change (or maintain) behavior, and thereby avoid or reduce risk of infection.” But what Green refers to as Uganda’s “home-grown approach” doesn’t strike me as all that indigenous to Uganda. Quibbling over the origins of customs or behaviors is tiresome within anthropology, and hardly the primary issue. The real issue is to ask what really happened in Uganda and what is happening now. What worries me is that Uganda-as-an-AIDS-success story has already taken on a paradigmatic quality. There are skeptics out there—I am one— who think that what has happened in Uganda is complex and has as much to do with war, dying off, migration, and many other events and processes (including, in Kampala and beyond, increased access to better HIV care) not readily classed under the rubric “ABC campaign.”

All this will one day be hashed out in the pages of journals, but time is short. We know that a proper accounting of what has happened in Uganda needs to be profoundly biosocial. In addition to behav-iorist approaches, we will need to understand political economy, troop movements, trade, struc-tural adjustment policies from above and abroad and of course the cultural arcana so beloved by our own tribe.

To return to the second burning question, what’s to be done, Ted Green argues that AIDS is a “behavioral problem with behavioral solutions.” Perhaps. But AIDS is also, surely, a social prob-lem with social solutions. Some of these can certainly be classed as behavioral (there’s nothing wrong with the ABC campaign in my book), others as properly clinical (improved HIV care will lessen death, increase uptake of voluntary counseling and testing and also destigmatize AIDS and lessen provider burn-out). And isn’t a vaccine an important part of the solution? It’s hard to class vaccines as “behavioral.” What about repealing laws that penalize women who lose a partner to AIDS? Gender discrimination against poor girls? Prohibitively high school fees?

The list goes on, and it does not seem to be a very “behavioral” list—unless of course we talk about the behavior of the truly powerful. I would ask Green to make his analysis and his prescriptions more social. Hard to sum up concisely what needs to underpin behavioral models but it could go something like this: current AIDS prevention tools work least well precisely where individual agency is most constrained, usually by poverty and gender inequality. Because what the have-nots lack is agency. The only way to rehabilitate behavioral models honestly, in my view, is to scrutinize the behavior of the powerful: those who set economic policies for countries like Uganda or Haiti or Mozambique. Those who write laws. Those who decide who will have access to care and who will not. And a lot of these folks, whose agency is decidedly unconstrained, are not to be found on the continent of Africa.

Finally, I’d ask Green to consider the thorny issue of treatment for advanced HIV disease as part of the prevention agenda, especially for Africa. We can formulate a rather long list of the ways in which improving HIV care can enhance prevention and have done so. Mostly, these lists have been ignored by “prevention people” since prevention and care have been divorced, absurdly enough, by the “Western” experts who run much of the world. We need anthropologists like Ted Green to help the experts, with their varying agendas, resocialize the worst epidemic the world has ever known.

Paul Farmer, MD, PhD, is a medical anthropologist whose work draws primarily on active clinical practice and focuses on diseases disproportionately afflicting the poor. He is the author of AIDS and Accusation, Infections and Inequalities and Pathologies of Power.

“AIDS Debate in Anthropology News: a Final Synopsis. Anthropology News Vol. 45 (1), Jan.
Edward C., Green
Harvard School of Public Health

I thank Anthropology News for the opportunity to make final comments after four anthropolo-gists, Paul Farmer, Doug Feldman, Elizabeth Onjoro and Barbara Pillsbury, wrote essays respond-ing to my September contribution, “New Challenges to the AIDS Prevention Paradigm.”

Behavioral, Social, Biomedical

I think Paul Farmer and I are in agreement on the major points and issues. There are a few areas where we could split hairs, such as use of “Western,” although I am happy to concede that one. (Plus I have learned to never split hairs with anyone who uses words like apposite). He comments that “what has happened in Uganda is complex and has as much to do with war, dying off, migra-tion, and many other events and processes.” I agree that these factors may be relevant to some degree. But I find nothing unique about Uganda’s recent history, end of war, social structure, de-gree of social cohesions, migration, and so on. I am not saying that these factors are unrelated to prevalence decline, only that we can find other African countries with similar conditions and yet without prevalence decline, certainly without the same degree of decline. From my reading of evidence, I continue to believe that reduction in number of partners (not to be confused with “ab-stinence”) is the primary factor behind prevalence decline in Uganda. Those who do epidemiologi-cal modeling of African AIDS epidemics, such as Betran Auvert, NJ Robinson and RS Bernstein, all suggest that reduction in number of partners can have great impact on averting HIV infections, in fact greater than either condom use or treatment of STDs. Indeed, we now have the UNAIDS multi-site study (published as a special issue of AIDS) that found no evidence of levels of condom use making a significant difference. Please understand: I am not saying this, rather leading AIDS experts in a four-country study did so. I myself believe that condom use can make a difference, but we need to go beyond our current standard package of interventions to include (ie, add, not substi-tute) those that can result in reduced levels of casual sex and rise in age of first intercourse.

I agree with Farmer that AIDS “is also, surely, a social problem with social solutions,” and also one with biomedical solutions. I wrote about “treating AIDS as a behavioral issue that calls for behav-ioral solutions, although not to the exclusion of risk reduction remedies.” I meant to imply that “behavioral” should not be exclusive of any other type of solution as well.


As he has been doing for months on the AIDS and Anthropology Research Group (AARG) listserv, Feldman reduces my approach to AIDS prevention by branding it as politically conservative (I am not a conservative) and distorts my stated views. He does this rather than persuasively deal with the evidence and issues I raise. For example, his comment “Green believes that the Ugandan ABC religious-based approach of promoting ‘Abstinence, Be faithful, or use a Condom’ is unique to Uganda” is not true. The ABC approach is found in many countries. Uganda has been more bal-anced in implementing ABC interventions than perhaps any other country, especially in its early response to AIDS. But other countries like Jamaica and Senegal have achieved considerable bal-ance as well, along with stabilization or decline of HIV prevalence. And Uganda’s program was not “religious-based,” although religious groups were included in prevention.

I wonder who the conservative really is since Feldman: 1) vigorously support the status quo in AIDS prevention; 2) argues a prevention position that necessarily involves the transfer of com-modities from the “have” to the “have not” countries (to use Farmer’s language), an enterprise that generates ample corporate profits for companies and organizations in the “have” countries, and turns Africans and others into dependent consumers. Whereas I argue that in addition to (not instead of) risk reduction measures, why can’t Africans and others simply be presented with the option of simple behavioral change without indefinite dependence upon commodities supplied by the “have” countries? And then let them decide. After all, one approach is not going to suit every-one.

I admit that in the debate I have been conducting on the AARG listserv, I have dwelt quite a lot on the imperfections of condoms. But that is only because when I have argued for inclusion of sexual behavior, some have countered with, why even deal with sexual behavior when we already have the technology to prevent HIV transmission, namely condoms? This is when I bring up recent meta-analysis evidence showing how effective this technology has actually proven to be, which is less than most think. In the present politically charged atmosphere, it seems impossible to bring up evidence of this sort without being accused by someone of having an agenda that goes beyond AIDS.

I agree with Pillsbury that AIDS requires political solutions, and that Uganda is exemplary in this regard. I made the point in my essay that the Ugandan government made just such a commitment, although maybe I was too oblique in this when saying Uganda “…also tackled the difficult social and institutional problems that only committed governments can impact …” Whatever else we can say about President Museveini, he should be applauded for recognizing that there are no techno-logical quick fixes or magic bullets for a problem that is (as the contributors and I agree) at once biological, social, behavioral, political…lets just use “cultural” in the broad, anthropological sense to encompass these latter. Pillsbury provides a good description of some of Museveni’s activism at a time when almost all other African leaders were silent. She also summarizes some of the good things Brazil is now doing in treatment, which I agree is laudable. In my limited space, my essay dealt with prevention. And yes, I agree with potential synergies between prevention and treatment.

Cultural Difference

Elizabeth Onjoro raises one of the central issues that help explain why the standard package of prevention interventions of the major donors have not been more effective to date: it’s that there is a single, standard package in the first place. In spite of the great cultural, epidemiological, and virological differences found in the global AIDS pandemic, the truth is that the resource-rich do-nors offer the same programs in very much the same way in every country. Our anthropological instincts and experience should tell us that this couldn’t be right. I have designed and evaluated AIDS prevention programs in all major regions of the world and I can say that condom social marketing programs, for example, look very much the same everywhere, in spite of expensive marketing research that is supposed to place individuals of differing socioeconomic status in their sociocultural context.

Onjoro contrasts “a mainly condom strategy” of Botswana and Kenya with a “more culturally sensitive approach” of Senegal. In fact, I am glad she brought up Senegal. Senegal has a reputation among insiders as being a country that has had the courage to stand up to the foreign donors and not let them set the entire agenda for AIDS prevention. Perhaps as a result, Senegal has developed a balanced ABCD program, with D denoting drugs for treatment of the treatable STDs found in sex workers (as a result, STD infection rates among sex workers have fallen markedly). Senegal’s A and B programs have led to behavioral change in a population that already exhibited relatively low risk behaviors when AIDS first appeared, and condom user rates are relatively high among those en-gaging in casual sex. As in Uganda, there was high-level political commitment to deal openly and realistically with AIDS beginning in 1987 (Uganda’ response began in late 1986). HIV prevalence in Senegal is under 1%.

Whether initiatives come from donor organizations or recipient governments, there needs to be far more tailoring of programs to particular populations and epidemics than we have at present. Yet whatever we do in prevention, we need to deal with sexual behavior itself. If we do not, content to put all our faith and resources into devices and drugs, it is like trying to reduce rates of lung cancer without dealing with cigarette smoking.

Dr Edward C. Green is a Senior Research Scientist in the School of Public Health, Center for Population and Development Studies, Harvard University