October 27, 2003
By Joseph Loconte
Randall Tobias, President Bush's pick to oversee his $15 billion
AIDS initiative for Africa and the Caribbean, sailed through his
recent confirmation vote in the U.S. Senate--only to find himself
at the center of a controversial bid to reshape America's AIDS
President Bush invokes the experience of Uganda--the most
successful country at confronting the disease-- as the paradigm for
key portions of his AIDS initiative. Uganda has "shown the world
what is possible" in preventing the spread of HIV, Bush said when
Ugandan president Yoweri Museveni visited the White House. Indeed,
a decade's worth of research confirms a result that has startled
the AIDS establishment: From 1991 to 2000, Uganda reduced its
national HIV infection rate from about 21 percent to 6 percent
among pregnant women. In Kampala, the rate dropped from 30 percent
to 10 percent.
How did a poor, war-torn nation with a tiny health care budget take
the lead in HIV/AIDS prevention? The answer goes to the heart of
the political fight likely to ensnare Tobias and the
When the epidemic emerged as a problem in Uganda, President
Museveni, who came to power in 1986, launched an all-fronts
campaign to discourage behavior that spreads the AIDS virus.
Government officials enlisted religious leaders to join them in
delivering a consistent AIDS message: Abstain from sex or be
faithful to your partner. Failing that, use a condom--or die. They
called the campaign "ABC"--Abstain, Be faithful, or, as a last
resort, use a Condom. Within a few years, Uganda had developed what
researchers call a "social vaccine" against HIV: cultural norms
about sexual responsibility, preached in clinics and public
schools, as well as churches and mosques.
Proud of his country's achievement, Museveni rejects the Western
priority on condom distribution--as if "only a thin piece of rubber
stands between us and the death of our continent." Rather, he says,
"we made it our highest priority to convince our people to return
to their traditional values of chastity and faithfulness or,
failing that, to use condoms." Ugandans have a colorful term for
their goal of fidelity to a single partner: "zero grazing."
Research confirming the effectiveness of Uganda's behavior-based
model comes from an unlikely quarter: the very health organizations
that champion "safe sex" and condom distribution. The list includes
the U.S. Agency for International Development, the Joint United
Nations Program on HIV/AIDS (UNAIDS), the World Health
Organization, and the Harvard School of Public Health. Most
researchers now agree that 9 out of 10 Ugandan adults changed their
behavior to avoid the disease.
Abstinence and marital fidelity were the most important changes,
according to a recent study by Daniel Low-Beer and Rand L.
Stoneburner in the African Journal of AIDS Research. Even
teenagers, in large numbers, delayed having sex. Condom use among
high-risk groups, such as those involved in commercial sex,
apparently played a much smaller role. "Many of us in the AIDS and
public health communities didn't believe that abstinence and
faithfulness were realistic goals," says Edward Green, a medical
anthropologist at Harvard with 30 years' experience in Africa and
Latin America. "It now seems we were wrong. The Ugandan model has
the most to teach the rest of the world."
The question still outstanding is whether the rest of the world is
willing to listen.
The president's Emergency Plan for AIDS Relief, approved by
Congress earlier this year, challenges wealthy countries to focus
on 14 nations, most of them in Africa, where 29 million people are
dying of AIDS or infected with the HIV virus. Most of the U.S.
money (55 percent) goes toward treatment. There's also money for a
previously ignored group, AIDS orphans, of whom some 11 million
live in Africa.
The White House plan, however, sets aside at least 20 percent of
the funds for prevention, one-third of it earmarked for
abstinence-based programs--at a time when most health organizations
and donor agencies are flooding countries with condoms,
needle-exchanges, HIV test kits, and safe-sex media campaigns. The
Global HIV Prevention Working Group, convened by the Bill and
Melinda Gates Foundation and the Henry J. Kaiser Family Foundation,
omits any reference to the ABC program in its 2002 report
describing Uganda. Amazingly, it credits the government's success
to "extensive condom promotion."
This commitment to "safe sex" seems impervious to hard evidence. A
UNAIDS study published in 2001, for example, found that condoms
made no significant difference in HIV prevalence. A UNAIDS review
released earlier this year saw "no definite examples" of
generalized epidemics turned back by prevention programs relying
primarily on condoms. Condom use remains relatively low in Uganda,
while nations with the highest levels of condom
availability--Zimbabwe, Botswana, South Africa--have the world's
highest HIV prevalence rates.
But however clear the evidence, and however sound the
administration's rhetoric so far, it is uncertain whether Bush's
team can actually alter U.S. AIDS policy on the ground. Federal
lawmakers are now debating language affecting the distribution of
AIDS funds. The modest earmark for abstinence-based programs is one
of the critics' targets; another is a provision encouraging the
involvement of faith-based organizations, including a "conscience
clause" protecting their right to administer AIDS money in accord
with their religious beliefs. Catholic clinics, for example, do not
distribute condoms. Jim Kolbe, the Republican congressman from
Arizona, has introduced language striking protections for
faith-based groups and casting doubt on the funding for
Such fierce opposition should come as no surprise: Grant managers
have a history of balking at religious programs that promote
responsible sexual behavior. But it is particularly self-defeating
in Africa, where weak public- health systems are supplemented by
large numbers of church-based clinics and workers affiliated with
medical charities. "Many of the faith-based organizations have been
on the ground for years," says JoAnne Lyon, executive director of
World Hope International, an evangelical group working with 250
churches in Zambia to help AIDS orphans. "We bring a network of
relationships...and a belief that people and structures can be
Bush's critics aren't buying it. They demand that every penny of
U.S. assistance continue to flow through health care providers who
hold the opposite view: that high-risk behavior is difficult or
impossible to change. These providers already receive most
international AIDS money. They invest it in "risk reduction"
programs, which by any fair assessment tend to legitimize
promiscuity, prostitution, and illegal drug use.
Plainly, Bush's AIDS chief will face stiff resistance to the
disbursement of money to new players. At his confirmation hearing,
Tobias said he endorsed Uganda's emphasis on abstinence and marital
fidelity. Democrat Russ Feingold interrupted him--unable to
tolerate this deviation from public-health orthodoxy--and insisted
that condoms had played a crucial role. "I don't accept that
characterization," Feingold said. "The lessons of Uganda must not
be changed from what actually happened."
Tobias should not be intimidated. The president's approach has
formidable backers. "Faith-based organizations remain a great
untapped potential in the global fight against AIDS," says
Harvard's Edward Green, author of "Rethinking AIDS Prevention:
Learning from Successes in Developing Countries" (2003). "They
ought to be given more support in doing what they do best, namely,
supporting fidelity and abstinence."
Joseph Loconte is
the William E. Simon Fellow in Religion and a Free Society at the
Appeared in The Weekly Standard
The president's Emergency Plan for AIDS Relief, approved by Congress earlier this year, challenges wealthy countries to focus on 14 nations, most of them in Africa, where 29 million people are dying of AIDS or infected with the HIV virus.
William E. Simon Fellow in Religion and a Free Society
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