Dr Edward C. Green

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

ABC or A through Z?

Readers of Global AIDSLink have long known about the ABC approach to AIDS prevention: Abstain, Be faithful, or use a Condom. Readers also know that Uganda did not invent this; they only implemented the ABC approach in an especially effective way. In the past few months, Uganda's ABC approach has become the model for AIDS prevention for the Bush administration, at least for the countries where the President's HIV/AIDS Initiative will be targeted. The House and Senate AIDS bills make specific reference to Uganda's ABC model, and I am one of the experts who testified about this model in both houses of Congress. In my opinion, the main thing Uganda did right was to implement a balanced program of the ABCs, and to actually include all three elements.

Still, there is a great deal of controversy surrounding HIV prevalence decline in Uganda. Few other countries have addressed sexual behavior directly, preferring instead to follow the prevailing risk reduction model of condom promotion and STI treatment. Another sensitive issue is that HIV incidence peaked and began to decline in Uganda before the programs most of us associate with AIDS prevention (condom social marketing, VCT, treatment of STIs) had even begun. For these and other reasons, critics have tried everything from denying there ever was a prevalence decline in Uganda, to dismissing the ABC approach as simplistic or inadequate. I will deal with this latter criticism.

Those who complain that ABC is simplistic or reductionistic suggest that we ought to be doing everything to prevent AIDS: A, B, C, D (for Drugs, or De-stigmatizing AIDS), E (for Equal opportunity)...all the way to Z (for Zero misbehavior?). I have noticed that some of the proponents of "A through Z" or "let's do everything" have trouble accepting the first two letters of ABC, so maybe the real idea is to bury or dilute these in every letter of the alphabet.

It is useful to distinguish between the direct and indirect factors that determine sexually transmitted HIV infection. While the former have to do with sexual intercourse itself, the indirect factors include things like political leadership, reducing AIDS-associated stigma and improving the status of women. I hear people say that the real reason prevalence declined in Uganda is because of President

Museveni's bold leadership, or because sex became a topic that could be discussed in public. But we might find political leadership or open discussion elsewhere, and still not necessarily find any impact on HIV infection rates. The sexual transmission of HIV can be directly prevented in three ways: by avoiding the exposure to risk through sexual abstinence; by reducing the risk of exposure through partner faithfulness and reduction in partners; or by blocking the efficiency of transmission risk through a barrier like a condom. In other words, by practicing A, B or C.

The genius of Uganda's ABC program is that it focuses on what individuals themselves can do to change (or maintain) behavior, and thereby avoid or reduce risk of infection. And it provides three types of behavioral options in a clear, unambiguous and, yes, simple manner. The ABC message has gone out to the public via every imaginable channel, and has been appropriately tailored to different groups based on age, gender and risk categories.

But ABC is far from all that Uganda has done. In fact, the country pioneered approaches towards 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, improving the status of women, involving religious organizations, enlisting traditional healers, and much more. Ask yourself, how many countries in Africa -- or anywhere else -- have tried to raise the status of women as both a political and AIDS prevention strategy?

If any country could be said to have promoted "A through Z" to prevent AIDS, it's Uganda. But Uganda's message for the public was the simple one of ABC, focusing on factors that, for the most part, are under an individual's control. And unlike most other countries of the world, there was true balance between ABC: it was not just condom supply and promotion, with an occasional nod in the direction of abstinence and mutual fidelity.

The only thing simplistic or reductionistic about Uganda's ABC approach is how some Westerners have interpreted it.

Dr Edward C. Green

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

Is ABC 'That Simple?

The ABC approach is frequently criticized as being overly simplistic (e.g., "The ABCs of HIV: It's Not That Simple" by Kevin Osborne). What critics fail to acknowledge, or even admit to themselves usually, is that what is currently funded as AIDS prevention by the major donors is simpler still: "Condoms, condoms and more condoms" (this in fact is the title of a new paper written by Professor Doug Feldman, a dedicated and vociferous critic of ABC). What donors currently fund under AIDS prevention are the risk reduction approaches of condoms, with some treatment of STDs and VCT added. What they do not fund are parallel programs of risk avoidance, also called primary behavior change, i.e., abstinence, delay of debut, and mutual faithfulness to one partner.

Risk reduction alone is far simpler than risk avoidance plus risk reduction.

The truth is, for all our enthusiasm about stigma reduction, empowerment of women, poverty reduction, political activism and the like, when it comes down to it, what the donors fund in AIDS prevention is pretty much reduced to condoms. The preventive target of most VCT programs is to get more people to use condoms, whatever their HIV status. The only program impact indicator currently proposed for UNGASS (United Nations General Assembly Special Session on AIDS) for behavior change is condom use during last intercourse, period. And this is for youth!

Even if ABC were simpler than the prevention program donors currently fund, simplicity does not necessarily mean ineffective. After centuries of trying everything imaginable to deal with alcoholism, the program of Alcoholics Anonymous was accidentally invented by a couple of amateurs in 1939. It's based on simply not drinking. It has been more successful than all the other programs around the world for centuries have been. If the AA program had been a proposal that had to be approved by an academic or government committee of some sort, no doubt it would have been rejected as being overly simplistic. Cure alcoholism by stop drinking alcohol? Is this some sort of joke?

AA likes to poke fund of the experts by saying that AA "is a simple program for complicated people."

Of course there is more to AA than not drinking. But nothing else works if one doesn't stop drinking. Just as prevention of sexually transmitted HIV doesn't work unless there is change at the level of the proximate determinants of HIV infection (avoiding the exposure to risk reducing the risk of exposure, or blocking the efficiency of transmission risk).

At the end of his essay, Kevin Osborne suggests, "We should put our global energies behind ensuring that sex - coercively or by will - is safe and that condoms are readily available. If we can win this strategic battle, we will make one of the most important contributions possible in fighting this epidemic: an environment free of judgment and prejudice. In this way, we can make choice a concept that has meaning."

This is one of the purest and most naïve expressions of Western, urban, post-sexual revolution values I have come across in months. These values are sure to clash with those of rural Africans. More importantly, in societies where rape, seduction of minors and coerced sex is common, the promotion of free sexual expression by outside experts might well exacerbate these problems.

Does Osborne mean we are not to "judge" coercive sex, even rape? Does he mean if a man chooses to force an underage girl into sex, its fine so long as the man remembers to use a condom? Even if we cared nothing about human rights, dignity of women, legal ramifications or morals, we would still expect the abused girl to have only an 80% reduced risk of HIV infection, compared to if a condom was not used, if the latest Cochrane meta-analysis of condom effectiveness is any guide. An "anything goes" hedonistic philosophy assisted by latex is not enough to combat AIDS, especially in developing countries where women have little power.

Dr Edward C. Green and Paul Farmer

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

Dialogue on AIDS Prevention

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.

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
http://www.aaanet.org/press/an/infocus/index.htm

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.
2004. http://members.aaanet.org/an/0401/dia-comm.cfm
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.

Politics

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

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

The WHO Forum on Traditional Medicine in Health Systems, Zimbabwe, Harare, February 14-18, 2000.

Journal of Alternative and Complementary Medicine. 2000, Vol.6(5) Oct. 2000, pp.379-382.

Preparation for the WHO African Forum

Most readers of this journal know that the World Health Assembly of the World Health Organization passed a resolution in 1977 promoting the development of training and research related to traditional medicine. The following year in Alma Ata, WHO and UNICEF issued additional resolutions supporting the use of indigenous health practitioners in government-sponsored health programs.

In preparation for the African Forum on the Role of Traditional Medicine in Health Systems (Harare, February 16-18, 2000), WHO's Regional Office for Africa had earlier (1998) submitted a questionnaire to its 46 member states. A completed questionnaire was received from 30 of the countries. Although 35 percent of countries did not respond and it was not possible to verify validity of answers submitted, the findings nevertheless shed light on the Africa-wide situation regarding traditional medicine and practitioners.

Findings suggest that a national management or coordination body for Traditional Medicine activities exists in 17 of the 30 countries (57%). Twenty-two countries (73%) indicated that associations of traditional medicine practitioners (TMPs) have been established. Ten countries (33%) indicated that a directory of TMPs exists. Four countries (13%) indicated that a training program for TMPs exists, and 17 countries had such programs for traditional birth attendants (TBAs) (WHO 1999).

There were many other findings from this survey that will probably be published in more detail by the WHO. The survey findings were sent to the delegates invited to the Forum prior to the meeting, to set the stage for assessments of how far traditional medicine has come since 1977, and for discussions about where to go from here. Much organizational work was done before and during the Forum by Dr. O.M.J. Kasilo, Acting Regional Advisor for Africa, WHO Traditional Medicine Programme. She also provided a great deal of leadership during the conference.

The WHO African Forum Itself

Delegates invited to the Forum represented most of the countries of Africa. A majority were connected with ministries of health or other government agencies, or with university departments of pharmacology or chemistry. A number of traditional healers were also present, mostly representing national traditional healers' associations.

In an opening plenary speech, Dr. Ebrahim Samba, Regional Director, Regional WHO for Africa, told the delegates that there is keen interest on the part of WHO in the mass production of phytomedicines for the treatment of malaria, AIDS, and other diseases identified as priority diseases by member states. It is a strategic objective of the WHO to develop a framework for the integration of traditional medicine into national health systems. The idea is to encourage local industry to invest in the local production of indigenous medicines, and make them commercially viable. Governments should create policies related to conservation, safety and toxicity, and phytomedicine regulation in order to assist local production industry. If outside funding is necessary, both the African Development Bank (ADB) and the WHO are possible sources. The ADB now invests more money in Africa than the World Bank, and it too has become very interested in traditional medicine.

There has been relatively little mass-production, promotion and distribution of phytomedicines in Africa. However, countries such as Nigeria and Mali seem quite advanced in this regard. For example, Nigeria has developed phytomedicines for ulcers, anemia, contraception, malaria and HIV, and it now holds patents for some of these medicines in several countries. Nigeria is about to have two phytomedicines registered with the MOH there: one for HIV and one for sickle cell anemia. Dr. Charles Wambebe, Director General of the National Institute for Pharmaceutical Research and Development (NIPRD) in Abuja, Nigeria, gave a fascinating presentation about the development of two phytomedicines. Both were developed from herbal medicines obtained from local traditional healers. The NIPRD followed a procedure in which the traditional healers and their patients sign consent forms, allowing study of the phtomedicine and the effects on patients. In phase 1 placebo-assisted clinical trails, patients were given the experimental phytomedicines for both sickle cell anemia and for HIV. After three months, patients in the experimental group were found to be improving. The clinical trials are continuing. The NIPRD is also targeting malaria, and is starting a pilot clinical trial of a new antimalarial phytomedicine in July 2000.

The HIV/AIDS phytomedicine is called Dopravil. From preliminary anecdotal and experimental evidence, this new compound looks promising. But since research results will no doubt be published, I will confine my comments to the NIPRD's plan for recognizing the intellectual property rights of traditional healers by means of a scheme for sharing any future royalties from a phytomedicine that becomes a profitable drug (or patentable comound). For most of the history of drug development in which initial drug discovery leads came from indigenous healers, both the healers and their communities received no benefit.

Dr. Wambebe was very eager to talk about this often-ignored issue. He gave me a copy of a Consultancy Agreement between the NIPRD and traditional healers who serve as consultants and provide phytomedicines they are already using. When a healer signs this contract, she becomes eligible for three types of benefits: an on-going consultant fee during the clinical trial phases; a share of future royalties "amounting to at least 10 percent" of net profit, or a one-time payment in lieu of on-going royalties. Nigerian researchers found that healers are more likely to cooperate if they are able to gain something from the relationship here and now, and not have to wait until some future date when there may or may not be royalties.

Development of an African Phytomedicine Industry

Some delegates made the point that the high Western standards of testing new drugs, costing in the neighborhood of at least four hundred million dollars and taking 20 years, can never be used in Africa. Dr. Gerard Bodeker (from GIFTS of Health, Oxford, UK) and others argued for a quicker research strategy based on affordable, appropriate technology (Bodeker calls it Rapid Response Research) that can allow the development of crude extracts through a process of research that results in either a synthetic drug, or at least a complex phytomedicine that can be approved, mass-produced, widely distributed in-country and exported to the world market. Another idea discussed was to develop something like the German Commission E monographs which establish toxicity, dosage and use, and which document that a herbal medicine has already been widely used for many years. The hope was that Africa can develop and export indigenous phytomedicines, just the USA and Europe export herbal tablets such as St. John's Wort and Echinecea to the rest of the world.

The cultivation, mass-production, local distribution and export of African phytomedicines could help reduce dependency on expensive Western pharmaceuticals (saving money for other purposes), help take care of the health needs of Africans, and develop much-needed local industries. But this is far from easy to accomplish. As became clear from presentations and discussions, local production of phytomedicines requires a complex partnership between groups such as the WHO, the ADB, ministries of health and agriculture of member countries, local businesses, agricultural interests, local regulatory officials, environmentalists, traditional healer associations, etc. A complicating factor is that there is major asymmetry in levels of education, power and resources among these partners. Moreover, a regulatory framework is needed to guide advertising, sales, manufacture, and distribution of phytomedicines. There is also a need for testing plant medicines for heavy medals, pesticides and microbial contamination. Development of an African phytomedicine industry furthermore requires an environment of political support and popular acceptance, not easy to achieve.

Private Sector African Medicine

There had been several comments throughout the Forum about how nothing is possible without funds from donors or governments. On the last day of the conference, professor M. Gundidza from the University of Zimbabwe (dept. of Pharmacy) stood up and made a powerful point about resources available in the private sector. He started by asking for a show of hands to see how many people present actually consulted traditional healers. At first virtually no hands were raised. He urged us further, saying that we needed to be honest and put our hands up if we ever consulted traditional healers. A few hands finally went up, perhaps no more than 10 percent of the audience. The professor said this proved the point he wanted to make: We come together at conferences like this to extol traditional medicine, and yet deep down, we regard it as second-class. He has asked his colleagues why they don't use traditional medicine or go to healers and their favorite answer is "that traditional healers have no training."

To remedy this, this professor teaches naturopathic medicine at the University of Zimbabwe. He asked two of his recent graduates to stand up and take a bow, which they did. He then mentioned that a couple of other graduates had wanted to be at the Forum but their clinics were so full of patients waiting for treatment that they simply couldn't get away. He said (and I paraphrase from my notes):

"This is homegrown African enterprise! Why wait for the World Health Organization to help us? The WHO has no money! Come and see our clinic. Our students come from O- and A-level high school graduates whom I then train at various levels: certificate, graduate, post-graduate. They learn complementary and alternative medicine. They learn physiology, anatomy, hygiene, and more. You say you feel that traditional healers aren't properly trained. Well, that's why we are here! To train Africans more comprehensively and systematically."

This made the point dramatically that there is plenty of money to be made in and through the private sector in traditional medicine. Millions of people, rich and poor, in Africa and elsewhere, are ready to pay for treatment with herbal and other natural medicines. Not that this example necessarily solves the problems of mass production, conservation, forming complex partnerships, etc. But Dr Samba made a strong, eloquent speech at the end of the conference about the need for private sector initiative. Such initiative will need to be demonstrated to attract donor support from the likes of the WHO or the African Development Bank.

Reference:

WHO (Regional Office for Africa), African Forum on the Role of traditional Medicine in Health Systems. Harare, 16-18 February 200. Traditional Medicine in the African Region: an Initial Situation Analysis (1998-1999).

Dr Edward C. Green

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

Alternative and Complementary Medicine at the 1998 World AIDS Conference

Journal of Alternative and Complementary Medicine, Vol.4(3) 1998, pp 349-351.

While the general tone of the 12th World AIDS Conference held in Geneva was somber, due to increasing failure rates of combinations of antiretroviral drugs, the mood was very different for those interested in, or using, alternative and complementary therapies.

A number of scientific papers were presented demonstrating the value of herbal and other "unorthodox" treatments for HIV-related syndromes, and for HIV itself. For example, controlled studies of Chinese and Thai phytomedicines both showed inhibition of HIV, increased immune function, enhanced CD4 cell counts, and increased survival rates of those tested as HIV-positive (abstracts are available for all such papers).

It was hard not to encounter long-term survivors of HIV/AIDS at the conference; one needed to look no further than a special symposium convened for them. Long-term survivors are those living with the HIV virus for 10 or more years. What impressed me most about the conference was the number of these survivors that have been relying on indigenous (or "traditional") medicines and therapies (if they were from developing countries), or on alternative and complementary medicines and therapies if they were from so-called developed countries.

There seemed to be fewer PWAs (persons with AIDS) from poor, developing countries, no doubt because of the prohibitive expense of flying to Europe and paying the hefty conference registration fee. But there were some, and there were also many healthy PWAs from developed countries who have been living with HIV for 10-18 years. We can use PWAs' own definition of healthy: feeling generally well and energetic, and having no symptoms of AIDS. Some men and women had relatively high CD4 levels and low viral loads. Others had less desirable test values, but most seemed not to let themselves become very concerned with such test results. Some were aware that Kary Mullis, Nobel-prize winning biochemist and inventor of the PCR test used to measure "viral load" of HIV, has repeatedly criticized the use of his invention as an accurate measure of the amount of HIV circulating in the body.

At least a dozen survivors I chanced to meet have chosen not to take conventional antiretroviral drugs of any sort, singly or in "combo cocktails." Instead, they rely on a range of other therapies, including herbs, nutrition, yoga, acupuncture, exercise regimens, homeopathy, massage, and movement therapy, among others. A number (but not all) had stopped smoking and drinking alcohol and had opted for generally healthy lifestyles. Many were of the opinion that their greatest strength was simply not believing that an HIV diagnosis means a death sentence. They had positive attitudes and faith in the future.

Since I was in Geneva to participate in a symposium on alternative and complementary medicine, and I met some of these healthy long-term survivors in connection with this symposium, there was no doubt a bias in favor of my encountering PWAs who favor indigenous or alternative therapies. But I met about half of those I spoke with through chance encounters. Many of the total felt that their numbers were not reflected in official medical statistics since they do not participate in clinical trials and many do not even consult conventional doctors. They virtually all felt that the unconventional therapies they were following, through self-treatment and consulting alternative practitioners, were not adequately reflected by the single two-and-a-half hour Community Symposium (which means not on the "scientific track") that was allotted by the conference organizers. Its title was Alternative and Traditional Healing Practices, and it was co-chaired by Kaiya Montaocean and Xevi Garcia Flores. Others not living with HIV but conducting research in a variety of areas considered unconventional agreed with this assessment, as did many other delegates who have themselves found value in unconventional therapies.

As a result of the foregoing and the "Alternative" symposium itself, the following Declaration was developed and officially presented to:

The Global Network of People Living with HIV/AIDS (GNP+)
The International AIDS Society (IAS)
The International Council of AIDS Service Organizations (ICASO)
The International Community of Women Living with HIV/AIDS (ICW)
The Joint United Nations Programme on HIV/AIDS (UNAIDS)
The Government of the Republique et Canton de Geneve

Declaration on Traditional, Alternative and Complementary Medicine

Recognizing that in developing countries (the "south"):

• Some 90% of people rely on indigenous, natural medicine either through self-treatment or treatment by traditional medical practitioners;
  
• Natural medicines have been found to be effective in the treatment of some of the opportunistic infections associated with HIV,
  
• Pharmaceutical drugs, especially antiretrovirals are beyond the reach of most of the world's poor;
  
• A number of pilot projects and ongoing health programs have shown that traditional medical practitioners can collaborate with biomedical personnel to help prevent the spread of HIV and STIs (by promoting partner reduction, safer sex, condoms, sterilization of razor blades, etc)
  
• Traditional healers are in a unique position to provide individualized and home-based care and counseling and holistic treatment for HIV+ and AIDS patients;

Recognizing that in industrialized countries (the "north"):

• Often 50% or more of populations (e.g., in the USA, Germany, Australia) use some form of "alternative or complementary medicine" such as medicinal herbs, nutritional therapy, homeopathy, acupuncture, chiropractic, massage, dance or movement therapy,
  
• Individuals with HIV and AIDS often rely on such alternative medicines to relieve suffering associated with either the disease or the symptoms of antiretroviral treatment,
  
• Some living with HIV/AIDS, including long-term survivors, rely exclusively on alternative therapies, either because of drug resistance, drug failure, or personal choice;

And recognizing that traditional, alternative and complementary medicine receive small fraction of 1% of global health funds with less than half of that targeted to HIV/AIDS, in spite of the fact that a majority of people living with HIV use traditional or “alternative,” complementary medicines,

1. We resolve the role of natural medicines and traditional medical practitioners, as well as alternative and complementary medicines, be acknowledged in AIDS prevention and treatment, and therefore this health sector should be allocated an equitable share of AIDS research, treatment and prevention resources.
   
2. We resolve that venues and tracks be set aside at regional and international AIDS conferences for the exchange of ideas and experiences related to traditional and alternative therapies, and that regional and global networks be supported.

The natural, Alternative, Traditional and Complementary Medicines (NATC) Caucus of the International AIDS Society (IAS) will be responsible for follow-up on the response to this Declaration, and for promoting these resolutions.

The Declaration was accepted for publication in the official conference report.

Incidentally, there was so much interest in the Symposium on Alternative and Traditional Healing Practices that participants requested, and were granted, a conference room the following day for a continuation of discussions begun earlier. Some 40 people showed up and stayed for another 3 hours, during which plans were discussed for more and larger alternative medicine symposia to be held in Durban, South Africa, the World AIDS Conference site for the year 2000.

Daniel Callahan is Director, International Program, The Hastings Center, and a Senior Fellow at the Harvard Medical School.

There is hardly a developed country where health care reform has not become a kind of chronic disease of modern medicine: as soon as some reforms are implemented, a call comes for yet another round. Costs continue to climb, but nothing seems to contain their growth for very long.

Why? Politics surely plays a role. But a more fundamental reason is the nature of modern medicine itself. Most developed countries have a growing number and proportion of elderly. Since health care costs for those over 65 are approximately four times higher than for those under 65, aging societies place massive claims on medical resources.

This is compounded by the constant introduction of new (and usually more expensive) technologies, together with increased demand for high-quality health care. We want more, expect more, and complain more loudly if we don't get it. When we do get it, we quickly raise the bar, wanting still more.

The net result has been an average general system-wide cost increase of 10%-15% annually in the United States for the past several years--and with no end in sight. European countries are under severe cost pressures as well, undermining their cherished ideal of equitable access.

Unfortunately, greater use of co-payments and deductibles, privatization of health-care infrastructure, and waiting lists for elective surgery and other non-emergency care are unlikely to work much better in the future than they have in the past. What is needed is a radical change in how we think about medicine and health care, not simply better ways to reorganize existing systems. We need a "sustainable medicine" that is affordable to national health care systems and provides equitable access in the long term.

The notion of "sustainability" comes from environmentalism, which seeks to protect the earth and its atmosphere in order to sustain indefinitely human life of a good quality. As with environmentalism, sustainable medicine requires reformulating the idea of progress that drives technology costs and fuels public demand. The Western idea of progress, translated to medicine, sets no limits on the improvement of health, defined as the reduction of mortality and the relief of all medical miseries. However much health improves, it will never be sufficient--so further progress is always required.

But unlimited progress cannot be paid for with finite funds. Long-term affordability and equitable access requires a finite vision of medicine and health care, one that does not try to overcome aging, death, and disease, but tries to help everyone avoid a premature death and to live decent, even if not perfect, lives.

This implies shifting medical resources sharply towards health promotion and disease prevention. Billions of dollars have been spent on mapping the human genome. Comparable sums must be spent on understanding and changing health behaviors that are most likely to bring about disease. Why is obesity increasing almost everywhere? Why do so many people continue smoking? Why is it so difficult to persuade contemporary people to exercise?

Sustainable medicine also requires comparing health care expenditure with spending on other socially important goods. In a balanced society, health care may not always be the top priority. At the same time, we often overlook the health benefits of spending money in ways that have nothing to do with the direct delivery of medical care: education and health, for example, are strongly correlated: the higher the former the better the latter.

In any case, sustainable medicine acknowledges that rationing is and always will be a part of any health care system. No system can give everyone everything they need. Our aspirations will always exceed our resources, particularly since medical progress itself raises public expectations. But, to be fair, rationing requires the knowledge and general consent of all who are subject to it.

One place to start is to evaluate the economic impact of new technologies, preferably before they are released to the public. Evidence-based medicine--a popular technique for controlling costs--is ordinarily aimed only at the efficacy of diagnostic or therapeutic procedures. But if drug companies must test new products for their safety and efficacy, why not also for their economic impact on health care? New technologies should not be dropped into health care systems uninvited. Only if a technology does not significantly raise costs, or does so only exceptionally, should governments be willing to pay for it.

Most fundamentally, a finite model of medicine must accept human aging and death as part of the human life cycle, not some kind of preventable condition. Medicine must shift its focus from length of life to quality of life. A medicine that keeps people alive too long is not a decent and humane medicine. We can live to be 85, but we are likely to do so with chronic conditions that leave us sick and in pain.

This is not an argument against progress: I, for one, am glad that people don't die of small pox at 40 anymore. But aging and death will still win out in the end. Medical progress is like exploring outer space: no matter how far we go, we can go further. With space travel, the economic limitations of unlimited exploration soon became obvious: no more moon walks. Medicine needs an analogous insight.

Slower technological progress may seem a high price to pay for sustainable health care. But our current systems carry an even higher price, threatening justice and social stability. At the same time, only about 40% of the rise in health status over the past century is attributable to medical progress, with the rest reflecting improved social and economic conditions. This trend is likely to continue, so that even if technological progress slows, people are almost certain to live longer lives in the future--and in better health--than they do now. That outcome should be acceptable to everyone.

Copyright © Project Syndicate

Dr Edward C. Green

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

Poverty Does Not Mean that Effective AIDS Prevention Is Impossible

One often reads and hears nowadays that poverty underlies AIDS, or at least that poverty drives the epidemic. The same is often said of marginalizion. In a recent article, Richard Parker comments, “In all societies, regardless of their degree of development or prosperity, the HIV/AIDS epidemic continues to rage, but it now affects almost exclusively the most marginalized sectors of society.” That presumably means that those primarily infected with HIV may not always be poor, but they are likely to be marginlized, that is, members of groups on the margins of society, such as IDUs, men who have sex with men, commercial sex workers, or racial minorities. This may be true for the United States and Brazil (where Parker has done much AIDS work), but it this is not an accurate statement for Africa.

Let us consider the first proposition. One explanation for why poverty causes or underlies AIDS is that poor women turn to sex work, putting themselves and their partners at risk, risk that would no exist if such women had not had to resort to sex work. Another argument is heard less often, namely that poverty leads to poor nutrition, which makes may make people shed more viruses and be more infective if they are already HIV-positive (Stillwagon 2002). Or that poor nutrition and weakened immune systems (more related to concurrent infections than to poor nutrition) makes people more susceptible to HIV infection in the first place (Root-Bernstein 1993). Those who accept that poverty underlies AIDS proposition uncritically can be led to proposing AIDS prevention solutions such as “forgive Africa’s debt” and “overthrow the World Bank.”

We see at once that there must be more to the story, at least in Africa, because the wealthiest African countries (South Africa, Botswana, Swaziland, and until very recently, Zimbabwe) in fact have the highest HIV infection rates on the continent (25-40%), not the lowest as we might expect. Meanwhile, some of the poorest countries (Somalia, Guinea, Liberia, Mali, Eritrea) have among the lowest rates (under 3%). Certainly the two African countries that stand out as successful in reversing the direction of HIV infection rates, Uganda an Senegal, cannot be called wealthy. Uganda’s GNP per capita income is about $240, while Senegal is under $240 (Sittitrai 2001).

In fact, there is growing evidence that affluence rather than poverty can drive local HIV epidemics. Several studies in Africa (e.g. Over and Piot, 1993; Smith et al 1999; Vandemoortele and Delamonica 2000) have shown that there is an association between increased education and income, increased HIV risk behaviors, and increased HIV infection. And, not so incidentally, with increased use of condoms. In pondering the notion of an “education vaccine” against AIDS, Vandemoortele and Delamonica (2001:1) note:

An inverse association between the disease burden and the level of education exists for most infectious diseases. The incidence of malaria and cholera, for instance, are known to be negatively associated with the level of education. But because of its main propagation channel, HIV/AIDS first affects those with more opportunities, including more educated, mobile and better-off people.

“Better-off” of course means those with higher incomes. The authors note that it is often observed that men who wear a tie do not get cholera. Yet these are often the men in Africa who are most likely to become HIV infected. One even hears of the "three Cs" risk factors for AIDS - cash, car and cell phone (Altenroxel 2003). But why? It appears that higher incomes allow men to pay for commercial or transactional sex or, as is more often the case in Africa, simply to have many sexual partners. A taxi driver in Guinea Bissau might have preempted this whole poverty/AIDS debate in 1987, when he explained to a visiting New Yorker journalist that in Africa, “The more money you have, the more women you can get.” And he made clear was not talking about commercial sex in the usual, Western sense (Shoumatoff 1988:155).

Vandemoortele and Delamonica (2001:2) note that a direct relationship between education and HIV infection rates (i.e.. higher levels of education are associated with higher HIV infection rates) tends to be found in countries with high HIV prevalence, whereas there tends to be an inverse relationship in low-prevalence countries. Hence the difference we see between Sub-Saharan Africa and, say, Brazil. Others have suggested that the direct relationship between education and HIV infection might only characterizes countries in the early stages of an HIV epidemic, that as an epidemic becomes mature, we no longer see it. Yet studies of populations with mature epidemics often show continuation of the direct relationship. For example, in one study, American and Ugandan researchers examined the association between education (usually linked to income) and HIV prevalence in rural Rakai district, Uganda, based on a cross-sectional analysis of a randomly selected, population-based cohort. The Rakai HIV epidemic must be one of the most mature in the world. They found:

Higher levels of education were associated with a higher HIV seroprevalence in bivariate analyses (OR 2.7 for primary and 4.1 for secondary education, relative to no education). The strength of the association was diminished but remained statistically significant after multivariate adjustment for soicodemographic and behavioural variables (adjusted OR of HIV infection 1.6 (95% CI: 1.2-2.1) for primary education and 1.5 (95% CI: 1.0-2.2) for secondary education (Smith et al 1999:452)

The authors conclude that higher educational attainment is associated with higher incomes which in turn “facilitate behavious that place individuals at greater risk,” such as more travel and having multiple sex partners (Smith et al 1999:457).

Another random sample, population-based study of socioeconomic status (defined by possessions, acreage, housing quality and education) and HIV infection was also conducted in Rakai. The researchers found that “Higher economic status and certain occupations were consistently associated with more partners (lifetime or within last year) and higher levels of concurrent partnerships for both sexes.” (Ssengonzi et al 1996)

A study of socioeconomic status and HIV prevalence among pregnant women in Dar es Salaam, likewise found that “…women of higher socioeconomic status in Dar es Salaam were at greater risk of HIV infection “ (Msamanga et al 1996). Other studies show that lower education and other SES (socioeconomic status) indicators are associated with greater risk behaviors, such as not using condoms, but this may not translate into higher HIV infection rates, at least in Africa. Elsewhere, such as Brazil (Veloso et al 1998), there tends to be a relationship between lower SES and higher HIV infection rates.

Carael, Cleland and Deheneffe (1995) reviewed sample surveys conducted in 1989-1993 of male and female respondents aged 15-49 years reporting sex with a nonregular partner in the preceding year. Significant positive associations between educational level and risk behavior were found among women as well as men in about half the studies.

And in the most recent national sentinel surveillance study in Zambia, HIV prevalence still clearly increases with level of education and ranges from 13 percent in women with less than primary education to 26 percent among those with college/university education (Table 1, following) (SIDA/CDC 2003:26).

Table 1. Trends in HIV Prevalence for Women attending Antenatal Care by Type of Site and Level of Education Completed

This topic was discussed at a regional conference held in Nairobi to discuss young women and HIV/AIDS in Eastern and Southern Africa. From a conference summary posted on

This e-mail address is being protected from spam bots, you need JavaScript enabled to view it (12/19/02):

The role of education was discussed at length by F. Malola from Malawi. In a presentation that proved to be controversial to some, he outlined how education has contributed to the spread of HIV - not only through providing a venue for men and women to meet but also that with education one is able to secure employment thus money "to woo girls into sexual relations." Much debate was spurred, in and out of session halls, if it was just location (e.g. schools, university) that was the risk factor or the impact of being educated itself.

Some who argue very publicly that poverty drives AIDS epidemics might concede that in Africa, wealth may be even more of a risk factor than poverty for men, but not for women. We have just seen some data that show that SES may be associated with higher HIV infection among women as well. But what about the increased risk of women driven to prostitution or transactional sex by poverty? Even this may be more complicated than it appears. Chin and colleagues (Chin, Bennett, Mills 1998) showed that level of FSW (female sex worker) customer turnover (the average of number of clients per week) is a major factor explaining HIV infection levels, at least in Asia. One of the reasons that HIV infection levels remain below 1% among sex workers in the Philippines is that they have an average of 2-3 clients per week, compared to more than this per day in some countries. When I was evaluating the impact of AIDS prevention programs in the Philippines in 2001, infection rates among FSWs were still below 1%, in spite of significant economic decline in the previous 2 years. It appeared from interviews my colleagues and I conduced and from available data that while more Filipina women had turned to commercial sex, the number of male clients was the same, or even lower, due to the weak economy and perhaps to the effects of AIDS preventive education. This meant that the number of clients per women was even lower than it had been before. This would prevent infection rates among CSWs from rising. Incidence, if someone took the trouble to measure this, might even decline, assuming other contributing factors remained roughly the same.

On the other hand, poverty may be one of the “causes” of the “sugar daddy” phenomenon in Africa, Jamaica, and elsewhere. This refers to older men offering gifts of cash or kind to young unmarried women in exchange for sexual favors. This has become sufficiently widespread that it often provokes little or no negative social sanction (Gupta and Mahy 2001). In fact, a good deal of female sexual behavior in Africa can best be understood as strategies for economic survival and adaptation to patterns of male dominance in low-income countries (Cohen and Trussell 1996:120; Guyer 1994; Green 1994: 99-100). As Barnett and Blakie (1992) have summarized it, African women gain access to economic resources through a range of sexual relationships with men, including monogamous and polygamous marriage, long-term relationships lacking de jure recognition, stable non-resident relationships involving visits on a regular basis, casual liaisons, and the type of commercial prostitution familiar in industrialized countries.

The economic transaction may not be the main or express aspect of the relationship for the participants, but given women's underlying unequal access to economic resources, sexual favours and reproductive potential are powerful resources--sometimes the only resources--on their side of the transaction (Barnett and Blakie 1992:77-8).

Thus, we see widespread a pattern of transactional sex that is not the same as commercial sex in Asia or elsewhere. This is said to be a pattern driving the epidemic in Cameroon, which has one of the highest levels of infection in the West African region (Calvez 1999).

None of this is to argue that there is no relationship between poverty and HIV infection levels, or becoming HIV infected. But it is not the simple, unidirectional casual relationship that is usually presented. We have already seen that greater income can, through various mediating factors, underlie higher HIV infection rates. Poverty can lead or even force women into sex work, but poverty can also greatly limit the number of customers, and the proportion of men who are clients of sex workers. There seems to be a relationship between drug abuse and poverty, so it might be said that poverty, along with other social factors, can contribute to the high numbers of injecting drug users who are then at high risk of acquiring an HIV infection (Chin 2002). Thus, the evidence suggests that any relationship between poverty and AIDS is complex and multi-directional.

Another part of the issue is that poverty is a difficult factor to influence. Part of the value of the National Research Council table of epidemiologic factors relevant in generalized HIV transmission areas (Cohen and Trussel 1996, Fig. 1, next page) is that it reminds us that some desirable changes may not be achievable in the short or medium term, to use the language of the table. For example, poverty, unemployment and gender inequality are the aspects of AIDS that occupy the attention of many or most American anthropologists concerned with international AIDS (cf. Schoepf 2001). Yet it could be argued that little will result from denouncing poverty, at least not as much as putting into place effective, workable prevention programs. In fact, poverty and inequality are an easy set of factors to invoke, since one can argue on the side of the angels yet little can be done to change these factors during anyone’s lifetime. For example, it has long been recognized that poverty and gender inequality underlie high fertility and associated problems, and that poverty and unemployment provide the conditions for child diarrheal disease. Yet during the decades this has been known, poverty and unemployment have become worse, not better, in Africa.

It is fine to denounce the evils of poverty, and better still to work actively to change the broader social and institutional systems that need changing. But let this not keep us from finding better ways in the short and medium term to prevent HIV transmission, even if delay of sexual debut does not have quite the same visceral appeal as “end poverty, racism, gender inequality and homophobia NOW!” Certainly when I was a sophomore, I never would have attended a rally centered on the theme of delay of sexual debut.

The Rev. Eugene Rivers, an African-American social justice and AIDS activist from Boston, met with religious leaders and others in June 2002 in Abuja, Nigeria to discuss that country’s response to AIDS. There was discussion and debate about the “true root causes" of AIDS, i.e., poverty, the status of women, crushing external debts, lack of education, and the like. According to a US Embassy cable describing the event, “Rivers agreed that all these issues must be addressed, but he said there was no time to wait for root causes to be solved. This focus was a distraction or an excuse for no action. The immediate prospect of death for so many millions required immediate, direct action.”

This reflects my position. I don’t support the simplistic belief that AIDS is caused or driven by poverty, but this in no way means I am against overcoming poverty, nor that poverty does not exacerbate HIV epidemics in some ways. We should all be against social and economic ills, but let this not be confused with a sound AIDS prevention strategy.

Note: This paper is condensed from: Green, E.C. for STWR, Rethinking AIDS Prevention. Westport, Ct.: Praeger Press, Greenwood Publishers (2003).

http://www.greenwood.com/books/BookDetail.asp?dept_id=1&sku=T316&imprintID=

Biography:
Dr. Edward C. Green is a world renowned expert on AIDS in Africa. He is a medical anthropologist, and Senior Research Scientist in the School of Public Health, Center for Population and Development Studies, Harvard University. His work in developing countries has spanned Africa, Latin America, the Caribbean, and Asia, and he has worked as an adviser to the ministries of health in both Swaziland (1981-83) and Mozambique (1994-95). He is also the author several books, including "Rethinking AIDS Prevention" (2003); "AIDS and STDs in Africa," and "Indigenous Theories of Contagious Disease"; as well as more than 200 journal articles, book chapters, presented papers, and commissioned reports. Dr. Green is currently lead researcher on the role of behavioral change in HIV/AIDS epidemics in Africa and southeast Asia, under a US government-funded research project. He has recently testified in both houses of congress on AIDS issues, and is a member of the Presidential Advisory Council for HIV/AIDS

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