September 29, 2003 | Backgrounder on Africa
Earlier this year, the Bush Administration persuaded Congress to authorize $15 billion over the next five years to fight the AIDS pandemic in Africa and the Caribbean. The U.S. Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003 is a bold legislative effort.1 About 42 million people worldwide are dying of AIDS or are infected with the HIV virus that causes the disease. Of these individuals, 29 million live in Africa. In addition, Africa is home to a staggering 11 million orphans who have lost their parents to AIDS.
In the legislation, Congress devotes 55 percent of the $15 billion to treating individuals with HIV/AIDS, 15 percent to palliative care, and 10 percent to organizations helping orphans and vulnerable children. The remaining 20 percent is for prevention programs: mother-to-child transmission programs, clean syringes for medical injections, condom distribution, and abstinence and monogamy programs. Although effective treatment programs are essential to combating the AIDS virus, prevention is more critical.
The Bush Administration is basing its AIDS initiative on the success of Uganda, which has experienced the greatest decline in HIV prevalence of any country in the world.2 Studies show that from 1991 to 2001, HIV infection rates in Uganda declined from about 15 percent to 5 percent. Among pregnant women in Kampala, the capital of Uganda, HIV prevalence dropped from a high of approximately 30 percent to 10 percent over the same period.3 How did Uganda do it?
The best evidence suggests that the crucial factor was a national campaign to discourage risky sexual behaviors that contribute to the spread of the disease. Beginning in the mid-1980s, the Ugandan government, working closely with community and faith-based organizations, delivered a consistent AIDS prevention message: Abstain from sex until marriage, Be faithful to your partner, or use Condoms if abstinence and fidelity are not practiced.
The link between Uganda's "ABC" approach and the dramatic reduction in the country's HIV/AIDS rate is now widely acknowledged. Based on research data collected over the past decade, several lessons can be drawn from the success of Uganda's strategy:
The White House correctly insists on basing U.S. AIDS policy on these lessons and the best available research about effective prevention and treatment programs. "The Ugandan model has the most to teach the rest of the world," says Edward Green, a senior research scientist at Harvard and author of Rethinking AIDS Prevention. "This policy should guide the development of programs in Africa and the Caribbean funded under the President's initiative."4 Jeff Spieler, chief of the research division in the U.S. Agency for International Development (USAID) population office, states, "It just happens to be where the evidence is pointing."5
Congress should follow the evidence as well. Although it has approved the President's initiative, Congress is still debating whether to follow Uganda's ABC approach. Lawmakers should be guided by good data, not ideology, in the upcoming appropriations and confirmation debates.
The President's AIDS initiative faces profound challenges. First, most of the African continent lacks the health care infrastructure required to treat HIV/AIDS and other deadly diseases effectively. Second, many African governments are either unprepared to face their AIDS crisis seriously or too corrupt and unaccountable to mount effective treatment campaigns. Finally, international AIDS organizations and activists continue to ignore the success of Uganda while promoting flawed approaches to disease prevention. A recent Washington Post story about Uganda, for example, quoted health care workers enthusiastic about condoms but omitted any testimony from government health officials about their emphasis on sexual abstinence and partner reduction.6
Similar omissions of fact continue to appear in some research studies and popular press accounts about Uganda's success. It is evident that ideology, not good science, threatens to derail the White House initiative and thwart efforts to redirect resources toward effective AIDS prevention. New York Times columnist Nicholas Kristof, citing prevention approaches that emphasize abstinence, calls it "baffling" to see governments and the NGOs "buying into junk science in ways that will lead to many more deaths."7
What is truly baffling--and inexcusable--is how anyone concerned about preventing AIDS can ignore the straightforward conclusions of virtually every reputable survey and qualitative study of the Uganda experience. Data supporting the effectiveness of the ABC approach have come from USAID, the Joint United Nations Program on HIV/AIDS (UNAIDS), the World Health Organization (WHO), the Harvard Center for Population and Developmental Studies, the Ugandan government, and numerous independent studies published in medical journals.
Despite different approaches, the reports all agree on at least one central fact: Abstinence and reduction in the number of sexual partners, not condoms, were the most important behavioral changes linked to HIV prevalence decline in Uganda.
The results in Uganda are both startling and unambiguous: Uganda's Demographic and Health Survey of 2000-2001 found that 93 percent of Ugandans changed their sexual behaviors to avoid AIDS.8 The U.S. Census Bureau/UNAIDS estimates that Ugandan HIV prevalence peaked at about 15 percent in 1991 and fell to 5 percent as of 2001.9 As a 2002 USAID report states, "This dramatic decline in prevalence is unique worldwide, and has been the subject of...intense scientific scrutiny."10
Considering its limited financial resources, Uganda's success is even more impressive. America spends about 40 times more per capita on AIDS than Uganda spends on all its health care issues.11 Yet, in the United States, the incidence of HIV/AIDS is again rising, prompting health officials to warn of "a resurgent epidemic."12 The U.S. increase in HIV infection rates comes despite aggressive marketing of condoms and expensive anti-retroviral drugs--the treatment paradigm mostly ignored by Uganda.
How exactly did Uganda achieve its results? President Yoweri Museveni came to office in 1986 and quickly launched a frank and sobering education campaign about the deadliness of the disease and the hazards of irresponsible sex. It offered three clear options for avoiding death from AIDS: The emphasis for the majority population was on monogamy. The emphasis for youth was on abstinence. Condoms were offered as a last resort, mostly for high-risk groups.
The message was delivered from middle-school classrooms to churches to community seminars and in radio, print, and television broadcasts. The government established highly effective partnerships with the religious community, working cooperatively to design and implement the ABC program. The effect was to create what researchers call a "social vaccine" against HIV: a set of cultural values that encouraged more responsible sexual attitudes and behaviors.13
The most significant changes in Uganda involved high-risk sexual behaviors. One data set shows dramatic declines in the number of people engaging in sex with multiple partners. Only 21 percent of Ugandan males reported having more than one partner in 1995, down from a high of 41 percent in 1989. Among females, only 9 percent reported multiple partners.14
Ugandans embraced what they call "zero grazing," meaning being faithful to one partner, typically in a marriage relationship. Faithfulness "was the main message for the majority of Uganda's population," says Dr. Green, a medical anthropologist with 30 years of experience in developing countries. He adds that it was a message remarkably well received: "Fidelity to one partner...seems to have been the main response to the epidemic."15
Contrary to the assumptions of public health officials, Uganda's emphasis on abstinence and fidelity resonated strongly with young people. Consider the changes in premarital sex, which for young people can shape their sexual behaviors--and health risks--well into adulthood. From 1989 to 1995, researchers reported a drop in the premarital sex rate among young men from 60 percent to 23 percent. Among females, the number dropped from 53 percent to 16 percent.16 A UNAIDS report found that among 15-year-old boys and girls, those reporting that they had never had sex rose from about 20 percent to 50 percent over the same period.17
Some researchers admitted that the findings took them by surprise: Many assumed that teenagers, driven by "raging hormones," would be immune to abstinence messages.18 The Ugandan government not only rejected this assumption, but made youth the primary target audience of its national program.
Numerous studies lend support to the effectiveness of the ABC model in changing sexual behaviors. A USAID evaluation found that Uganda experienced changes in all three primary prevention behaviors: abstinence and delay in sexual debut among youth, marital faithfulness and partner reduction, and the use of condoms.19 A UNAIDS report--though exaggerating the data on condom usage--nevertheless found "substantial differences in sexual behavior in almost every aspect that was investigated," including delayed sexual debut and fewer sexual relations with non-regular partners.20
Another USAID study, conducted by epidemiologist Dr. Rand Stoneburner, formerly with the Centers for Disease Control and Prevention, concluded that Uganda's success "appears to have taken root from the behavior changes motivated by this communication-based, community-level response to the epidemic."21 The study expressly noted that "something of a large magnitude took place" in terms of messages and changes in sexual behavior among ordinary Ugandans.22
How large a magnitude? Two final numbers suggest its significance. A 1995 survey found that 89 percent of Ugandan men had changed their sexual behavior to avoid AIDS.23 The same was true for Ugandan women: At least 98 percent were reporting either abstinence or no sex partner outside their regular partners.24 Jim Shelton, senior medical scientist in the USAID Office of Population, observes:
What happened in Uganda is that a lot of forces at one time were promoting more responsible sexual behavior, so you get to a social norm, a tipping point kind of thing. At some point all these messages, plus seeing more people dying, get people to change their sexual behavior.25
Many people are dying of AIDS in other African countries, of course, and at even higher rates. Yet most of these other countries do not offer a clear, unambiguous ABC prevention message. (Senegal does, and it is Africa's other notable success story in AIDS.)26
The Ugandan approach was directed at two major population groups: children (and unmarried youth) and the rest of the population (mostly married). The message for the former group was to postpone sexual activity until they were older, preferably until they were married. For the remaining majority, the main message was "zero-grazing." (In Uganda, it was common for married men to seek out other sexual partners.)27 The strategy appears to have worked: Research data suggest a causal link between changes in sexual behavior and the drop in HIV prevalence.
Dr. Elizabeth Madraa, an AIDS program manager in Uganda's Ministry of Health, reported in a UNAIDS study that "the increased targeting of youth groups has contributed to the decline of HIV incidence among the age groups of 13-19 and 19-24 years."28 In the African Journal of AIDS Research, researchers Daniel Low-Beer and Rand L. Stoneburner identified a decrease in casual sex as the most significant variable. "The most important factor in this decline is a decrease in non-regular partners by 65 percent (1989-1995), and a contraction in sexual networks," they wrote. "This has been shown in successive analyses of Ugandan epidemiological and behavior data over time."29 Stoneburner presented similar findings at a USAID technical meeting last year: The drop in HIV incidence "suggests a preceding process of behavioral change to avoid risk infection," he concluded. "In the case of Uganda, this behavioral change primarily took the form of partner reduction."30
The data are consistent with the findings of several studies involving epidemiological modeling of HIV transmission. They indicate that the single factor most likely to reduce HIV prevalence levels is a decrease in the number of sexual partners.31 "Reduction in the number of sexual partners was probably the single most important behavioral change that resulted in prevalence decline," concludes Dr. Green. "Abstinence was probably the second most important change."32
Some claim that declining HIV prevalence is a mirage: So many people succumbed to the disease, it is argued, that the number of AIDS deaths simply dwarfed the number of new infections. Deaths from AIDS can lower prevalence, but mostly in older age groups. It does not account for prevalence decline among 15-19-year-olds, who simply are not old enough to have become sick and died of the disease. The only reasonable explanation for the drop in HIV rates among this population group--in a culture with low rates of condom use--is a change in sexual behavior.
Although calling the link between the government's ABC program and HIV reduction "not yet completely understood," a USAID report nevertheless admitted that changes in the age of sexual debut, casual and commercial sex trends, and partner reduction "all appear to have played key roles in the continuing declines."33 The trend was observed across geographic and demographic populations: "Uganda's falling HIV prevalence is likely not due merely to measurement bias or a `natural die-off syndrome,' but rather mainly to a number of behavioral changes that have been identified in several surveys and qualitative studies."34
Most U.S. and foreign health organizations--including the USAID, Centers for Disease Control, UNAIDS, and World Bank--focus on condom education and distribution to combat AIDS. They assume that the real problem is a "condom shortfall."35
This was neither the assumption nor the strategy of the Uganda campaign. "We are being told that only a thin piece of rubber stands between us and the death of our continent," says Uganda President Yoweri Museveni. "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."36
Under Uganda's ABC approach, condoms were considered the last option, aimed primarily at high-risk groups such as commercial sex workers unlikely to change their sexual behaviors. The general population, however, mostly rejected the condom option. Dr. Vinand Nantulya, an infectious disease advisor to President Museveni and senior health advisor at the Global Fund for AIDS, Tuberculosis and Malaria, summarized, "Ugandans really never took to condoms."37
Although there is some evidence that condom use has increased among those who are sexually active,38 several studies conducted during the previous decade strongly suggest that condoms played only a marginal role in lowering Uganda's HIV/AIDS rate:
Condoms may be somewhat effective when targeted at high-risk groups such as commercial sex workers and their clients. However, there is no credible evidence that condom promotion is ultimately the best way to protect these groups from AIDS.
First, the overall effectiveness of condoms in preventing HIV/AIDS transmission remains hotly debated. A meta-analysis published in the Cochrane Review suggests that, even when condoms are used consistently, their effectiveness is only about 80 percent.43 A draft report for UNAIDS puts the failure rate of condoms at about 10 percent (meaning that something goes wrong in about 10 percent of all cases when condoms are used). The report's lead author, Norman Hearst, a professor at the University of California at San Francisco, says that policymakers should be talking about "safer sex," not safe sex, when speaking of condoms.44
Second, regular use of condoms may delay--but not prevent--HIV infection. This approach, known as "risk reduction," is ultimately fatalistic; it holds out little hope that people can abandon destructive behaviors. It also rests on a deeply flawed assumption: that people engaged in dangerous and self-destructive lifestyles--making highly irrational choices--will somehow act rationally once they are given a condom. The high-risk behaviors of those in the sex industry almost guarantee that they eventually will contract HIV or other life-threatening diseases. A truly humane approach would link the targeted distribution of condoms with programs that rescue sex workers from the streets by providing education, job training, family assistance, and exposure to supportive faith communities.45
Insisting on condoms as the primary strategy to reduce AIDS not only overlooks the lessons of Uganda and the failure rate of condoms, but also ignores how the disease is usually transmitted. When the AIDS virus is contracted widely throughout a society--as it is in much of Africa--condoms appear to be the least effective means to control it. A UNAIDS report makes the point clearly: "There are no definite examples yet of generalized epidemics that have been turned back by prevention programs based primarily on condom promotion."46
Harvard's Dr. Green, a supporter of condom distribution programs before 1993, now agrees: "It must be acknowledged that program emphasis on condom provision and promotion alone does not seem to have paid off."47
This helps explain why countries with the highest levels of condom availability--Zimbabwe, Botswana, South Africa, and Kenya--still have the world's highest HIV prevalence rates.48 It is essential that the principles of the ABC program be applied in the right order: abstinence, fidelity, and then condoms as a last resort. "Kids are willing and able to abstain from sex," says Dr. Anne Peterson, USAID director of global health. "Condoms play a role. They are better than nothing, but the core of Uganda's success story is big A, big B and little C."49
Participation in Uganda's AIDS campaign by faith-based organizations (FBOs) across Christian, Muslim, and Jewish traditions appears to have been a crucial part of the effort's success. Faith-based organizations were involved from the beginning of the national response and were considered adept at promoting abstinence and faithfulness.
Churches, mosques, and other houses of worship provide an important social infrastructure, especially in rural areas, and congregations generally trust and respect their religious leaders and do not perceive them as politically motivated.50 One UNAIDS report concluded that "it is crucial to work at the community level to personalize social norms such as mutual fidelity and the moral responsibility not to endanger others."51
National religious groups, such as the Islamic Medical Association of Uganda (IMAU) and the Anglican Church Human Services Prevention Program, mounted serious education campaigns.52 The IMAU, for example, worked in rural Muslim communities, training local religious and community leaders. Leaders from about 850 mosques trained 6,800 volunteers to assist in its education campaign. The Protestant Church of Uganda organized a workshop for bishops and other religious leaders and launched AIDS education projects in numerous dioceses. The Catholic Church and its affiliated hospitals designed AIDS home-care programs and programs for AIDS widows and orphans while promoting marital fidelity and abstinence.
As early as 1993, more than 1,500 NGOs were addressing HIV/AIDS in Uganda. Local church-based organizations have led the prevention and treatment efforts among NGOs operating in the country. "Religious groups form an essential part, if not the bulk, of such organizations," says Dr. Jeremy Liebowitz of the Health, Economics, and HIV/AIDS Research Division of the University of Natal.53
Although government and religious groups did not always share the same priorities or approaches, they appear to have worked side by side wherever possible. The three chairmen of the Uganda AIDS Commission have included an Anglican and a Catholic bishop.
A hot-button issue for some religious groups was condom distribution, but it was handled through consultation--not government fiat. The IMAU, for example, held workshops for imams on the topic. By the end of the process, they reached a compromise consistent with their religious beliefs, which became part of their education program.54 Says Liebowitz: "Religious leaders and government officials seem to have pursued their approach on parallel tracks rather than as opponents."55
Church-state cooperation was evident from the start of the crisis, when religious leaders from various faith traditions formed the Inter-Religious Council of Uganda (IRCU) to design a unified response. The IRCU coordinates a comprehensive, national, church-based approach that includes:
Religious bodies are sometimes accused of stigmatizing people with AIDS. In Uganda, the reality was exactly the reverse: The religious community's sober approach to the AIDS threat helped to greatly reduce the stigma attached to the disease while challenging people to adopt safer sexual behaviors.
When the Reverend Gideon Byamugisha, a nationally known religious leader, learned that he was HIV positive, he went public. His message was not one of condemnation, but an appeal to act responsibly. Religious communities have led efforts to care for those suffering with HIV/AIDS, offering counseling, palliative care, and home visitation. They have reached out to vulnerable children orphaned because of the disease.
Reinforcing the government's educational efforts, faith communities have helped promote a change in sexual mores: a culture in which abstinence and marital fidelity are held out as realistic and responsible lifestyle decisions. "The Christian church spearheaded AIDS care services in Uganda," observes Dr. Elizabeth Madraa, program manager of the STD/AIDS Control Program of Uganda's Ministry of Health. "The success of Ugandan prevention efforts would not have occurred without intensive participation and involvement of community leaders."56
By leading through example and teaching the values of abstinence and fidelity, religious groups helped instigate positive changes in cultural attitudes toward women. Critics have dismissed morality-based prevention programs, in part because they assume that African women lack the social status to make independent decisions about their sexual behavior.
But the messages of sexual responsibility carried by governmental and non-governmental organizations, including religious groups, have strongly supported Ugandan women. Indeed, the empowerment of women has been a deliberate government policy since 1986. A recent multi-country survey found that Ugandan women ranked first among all African nations in their ability to refuse unwanted sex or insist upon condom use.57
The U.S. Congress has specifically noted that faith-based organizations "are making an important contribution to HIV prevention and AIDS treatment programs around the world." The U.S. Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act includes language that protects the religious conscience of these organizations as they partner with government to help people in need. As the legislation stipulates:
[FBOs] shall not be required, as a condition of receiving the assistance, to endorse or utilize a multisectoral approach to com-bating HIV/AIDS, or to endorse, utilize, or participate in a prevention method or treatment program to which the org-anization has a religious or moral ob-jection.
Such religious liberty protections are non-negotiable: The Catholic Church, for example, cares for one in every four AIDS patients worldwide, yet rejects strategies based on condom distribution for religious reasons. Faith-based organizations such as World Relief, the Islamic Medical Association of Uganda, and American Jewish World Service are all important players in the overall response to the global AIDS crisis.
These and other FBOs, often working in difficult or dangerous circumstances, are providing significant help to those suffering abroad. It is essential that the Bush Administration and Congress give FBOs a major role in combating the AIDS pandemic while respecting their independence and religious missions.
President George W. Bush's attention to the AIDS crisis in Africa, emphasis on FBOs in fighting social ills, and recognition of the cultural roots of the AIDS pandemic have helped create a policy environment in which Uganda's success could be replicated in other nations ravaged by the disease. The ABC approach was designed and developed by Ugandans and is, in a sense, unique. But is it a basis for global HIV prevention policy?
"There are common elements which characterized all the successes against HIV, which have been transferable in widely different situations," explain researchers Low-Beer and Stoneburner. All the major success stories in HIV prevention share the Ugandan emphasis on delivering clear cultural messages about the disease and the importance of behavior change to avoid it.
Senegal, Thailand, Zambia, Jamaica, the Philippines, and the Dominican Republic are already witnessing success by embracing at least some of the principles of the ABC program. A UNAIDS multi-center study in four African cities found that fewer sexual partners and delayed sexual debut were associated with lower levels of HIV prevalence--more so than any other behavior change.58 The Uganda strategy, researchers conclude, strongly suggests that a "social vaccine" against HIV/AIDS can be developed--one as potent as a medical vaccine.59
The Philippines has adopted a campaign that emphasizes responsible sexual behavior and enlists the religious community as a key partner. A significant percentage of the population works outside the country, which contributes to higher rates of infection as workers often return carrying the disease.
The national infection rate, however, has held steady at about 0.01 percent, despite very low condom usage in the general population. Why? A USAID study found that the population has low levels of multi-partner sexual activity and high levels of abstinence, especially among youth. According to the report, "the Catholic Church must be credited with influencing sexual behavior."60
A Mixed Bag in
Those who are skeptical of Uganda's success invoke Brazil as the model response to the AIDS pandemic. To its credit, Brazil has taken its AIDS crisis seriously. The government has greatly increased public awareness of the disease and moved aggressively to treat those already infected--an essential task in the fight against AIDS.
However, Brazil's experience is of limited value to the much poorer nations of Africa. The country's strict emphasis on treatment therapies and condom distribution--and its inattention to destructive lifestyles--is leaving large numbers of Brazilians vulnerable to the disease. The prevalence of HIV in Brazil is still higher than in most Latin American and Caribbean countries. For high-risk groups, the HIV prevalence is an astonishing 42 percent, a level comparable to countries such as Zimbabwe and Botswana.61 In short, Brazil does not offer policymakers the most effective model for HIV/AIDS prevention.
The New Cultural
Many U.S. and international public health officials consider the promotion of "behavior modification" a kind of "cultural imperialism." They argue that it is either arrogant or ineffective to encourage foreign cultures to adopt "traditional" or "conservative" sexual lifestyles.
How well the Ugandan approach can be implemented in other countries remains to be seen. Not all governments are prepared to deliver a unified prevention message. The low economic and social status of women in many underdeveloped countries can make it difficult to achieve a safer sexual lifestyle. Moreover, the strength of civil society varies greatly from nation to nation: Religious communities must be trained to face the AIDS issue soberly, have extensive social networks, and be able to exercise a measure of cultural influence. That will not be the case in every country struggling with the disease.
Nevertheless, imposing the programs endorsed in San Francisco and New York--especially given their problematic results in reducing HIV/AIDS--on traditional, religious societies makes little sense. The dominant prevention paradigm of massive condom distribution and access to anti-retroviral drugs simply disregards the priorities and resources of many of the world's poorest nations. Moreover, it ignores the results accomplished in Uganda with its emphasis on behavior change. "Unlike the Ugandans themselves, foreign researchers had been surprisingly reluctant to highlight the precise changes in basic sexual behavior," one study concludes. "The neglect and misanalysis of the data on Uganda for almost a decade...seems a serious issue in a situation of severe epidemic."62
Now is the time to end such neglect. The Ugandan government designed the ABC model as the strategy most likely to be endorsed by the nation's general population and its civic and religious groups. It was an appeal to the country's older tradition of marriage and fidelity; it did not rely on either advice or technology from Western experts.
There is no reason to assume that a similar approach would fail in other nations battling HIV/AIDS.63 The real cultural imperialists are those who would impose on non-Western cultures a uniquely Western, medicalized approach to fighting AIDS.
There are, nevertheless, several serious obstacles to the President's AIDS initiative. Any one of them could undermine the plan. Together, they could transform it into a multibillion-dollar boondoggle.
Access to anti-retroviral drugs, effective testing programs, the establishment of clinics in rural areas, and expertise in endocrinology, virology, and pharmacology are all necessary parts of an intensely complex treatment regimen. This will require a carefully designed package of foreign investment and expertise. However, according to the World Health Organization, the track records of Africa's ministries of public health are so abysmal that the billions of dollars in foreign aid to date has made little difference.65
"President Bush's initiative will only work if African governments are serious about tackling the AIDS epidemic, and are willing to undertake their own domestic initiatives to combat the disease," economist George B. N. Ayittey recently told the Presidential Advisory Council on HIV/AIDS. "Absent meaningful reform, the Bush initiative will induce another cycle of aid dependency."66
Representative Barbara Lee (D-CA), chairman of the Congressional Black Caucus (CBC) Task Force on Global HIV/AIDS, has argued that it is unwise for the United States to prioritize any approach over another: "We have to support the use of condoms as a realistic means to reduce the spread of HIV just as equally as we support the promotion of abstinence and being faithful."68 In the view of Adrienne Germain, president of the International Women's Health Coalition, any approach that de-emphasizes condom distribution "basically condemns people to death by H.I.V./AIDS. And we're talking about tens of millions of people."69 And Paolo Teizeria, director of Brazil's AIDS program, told participants at an international AIDS conference that "millions and millions of young people are having sexual relations. We cannot talk about abstinence. It's not real."70
Such views dominate international public health organizations--the groups that would likely be deeply involved in any HIV/AIDS programs for underdeveloped countries. The President's AIDS initiative will fail if it comes under the influence of public health bureaucrats who continue to ignore the most effective HIV/AIDS prevention programs.
Congress has authorized up to $3 billion per year for the next five years to combat AIDS. The legislation, signed by the President, authorizes the following distribution of funds: 55 percent for treatment of individuals with HIV/AIDS; 15 percent for palliative care; 10 percent for orphans and vulnerable children; and 20 percent for prevention, of which at least 33 percent is specifically reserved for abstinence programs.
An argument can be made for a significant multinational investment in HIV/AIDS treatment programs for Africa. Most of the continent lacks the health care infrastructure required to address AIDS and other deadly diseases effectively. In addition, treatment of those either afflicted or at risk of infection is only part of the solution: The AIDS pandemic has left behind a staggering number of orphans and at-risk children--11 million orphaned children in Africa alone.
This demands an international response to prevent millions of families from slipping into poverty and despair. A careful investment in community and faith-based groups assisting this population would be money well spent.
However, the Administration and Congress are under tremendous pressure to fund programs that treat only the symptoms of the disease and not the underlying causes of its pandemic spread--from reckless sexual behavior to illicit drug use. That approach can produce complacency among at-risk populations, as the recent increase in HIV/AIDS among American gay men suggests.
"I think the most compelling reason [for the increase in AIDS] is that people aren't scared anymore," says Harold Jaffe, director of the National Center for HIV at the Centers for Disease Control.71 In contrast, the first thing that Uganda did was to introduce a healthy dose of fear about contracting AIDS.
An important way to counter a drift toward complacency is to increase the portion of prevention money devoted to abstinence programs. First, the 33 percent figure simply fails to reflect what is known about the most effective prevention models. Second, it remains unclear whether even that sum would go to effective abstinence programs.
Both the intent and the letter of the law allow for a higher amount: At least 75 percent of prevention funding should be targeted specifically to programs promoting abstinence until marriage and marital fidelity (or partner reduction). As Uganda's success demonstrates, this could do the most to cut HIV transmission rates and save lives. Good public health policy, not ideology, must drive this process.
Uganda demonstrates that it is possible to bring about widespread changes in risky sexual behaviors and significantly reduce HIV rates. Indeed, reductions in casual sex have been linked to the major successes in HIV prevention in other countries, such as Senegal, Zambia, and the Philippines.72
The President and Congress should insist that America's global AIDS policy reflect the evidence of these successes: They should direct at least 75 percent of U.S. funding for prevention toward abstinence-only and fidelity-based education programs. This would signal a profound shift in U.S AIDS policy--and would be met with intense opposition. Nevertheless, unless much greater attention is devoted to preventing the transmission of HIV/AIDS, the disease will continue to ravage entire societies.
Programs that legitimize the commercial sex industry and the illicit drug culture amount to "death on the installment plan" for those engaged in these behaviors. As public health policy, they remain deeply flawed and morally objectionable. A more humane approach is to support programs that rescue women from the sex-trade industry and help addicts break free of addiction. Condom promotion might be part of such programs, but the emphasis should be on job training, education, family assistance, rehabilitation, and exposure to supportive faith communities--all with the aim of helping individuals abandon destructive lifestyles.
Furthermore, all NGOs--secular and religious--should be eligible for federal support without compromising their moral and religious beliefs. No group should be excluded because of religious objections to condom distribution. In fact, empowering NGOs would mean upholding previously established U.S. AIDS policy. For example, in 1992, USAID gave about $350,000 each to the three major religious groups working in Uganda: Anglican, Catholic, and Muslim. Partnering with the national government, they designed programs consistent with their religious values.74 The Bush White House says it supports "additional provisions" to protect the FBOs against government requirements "if such activities violate a tenet of their faith."
The U.S. Department of Labor recently announced the availability of $1 million in grants to community and faith-based organizations in Uganda to "[i]ncrease knowledge of HIV/AIDS prevention methods among Ugandan men and women as a first step to changing sexual behavior."75 That is the right approach to fighting the disease: a church-state partnership that focuses on effective prevention and allows the FBOs to do the job in a way that affirms their religious values. The Administration and Congress must uphold this principle of civil and religious liberty, which coincides with sound public health policy.
Nevertheless, the Global Fund--like UNAIDS and WHO--continues to devote much of its resources to the least effective means of combating HIV/AIDS. Equally troubling, these agencies suffer under complex and costly bureaucracies. A recent study shows that the average salary for Global Fund employees was $174,603 (a sum greater than the salaries of most heads of state).79
Thus, the U.S. contribution to the Geneva-based agency should be capped at $200 million per year until it reforms its policies and programs. Moreover, the U.S. contribution should be earmarked for effective treatment programs at the local level. To that end, Congress may approve bilateral assistance to governments with sound AIDS prevention strategies, but the majority of U.S aid should be directed to NGOs and private-sector companies already effectively fighting the disease.
The office of the Global AIDS Coordinator should have the authority to reject programs that flatly contradict the President's AIDS agenda and its emphasis on effective prevention. It is essential that Mr. Tobias fully endorse the ABC approach to confronting HIV/AIDS and work to implement it through all federal agencies involved in fighting the disease.
Not much is known about the retired Indianapolis pharmaceutical executive, but the director of an AIDS support group in Indianapolis claims that Mr. Tobias is "too practical" to support an abstinence-only approach to AIDS prevention.80 During the Senate confirmation process, Mr. Tobias must demonstrate his commitment to existing law and to the principles and the science guiding the President's AIDS policy.
The Bush Administration's AIDS initiative is a bold and ambitious plan to tackle a pandemic that is ravaging the lives of millions of people across Africa and the Caribbean. The White House seems to understand that the favorite solution of Western public health elites--a "condom airlift" for the continent--would be a medical and moral disaster.
President Bush told President Museveni during his recent Africa trip: "You have shown the world what is possible in terms of reducing infection rates." As the Administration and Congress implement America's new AIDS initiative, it is vital that they use the example of Uganda as a yardstick for effective policy.
There are tremendous pressures--political and economic--to export deeply flawed AIDS strategies to vulnerable populations. They must be resisted. To do otherwise is to allow interest groups and ideology to trump sound public health policies. The time is ripe for a new, effective approach.
Actor and AIDS activist Harvey Fierstein recently lamented that many of his friends were again involved in high-risk lifestyles, apparently unconcerned about contracting AIDS. "HIV is an almost completely avoidable infection. You need to be compliant in some very specific behaviors to be at risk," he wrote in The New York Times. "I am calling us to take back our lives and culture and stop spreading the virus."81
It was a summons that could have been issued by the Ugandan president--and was, in fact, the substance of his own appeal. "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," Museveni told drug company executives during a June meeting in Washington. "The alternative was decimation."82
Joseph Loconte is the William E. Simon Fellow in Religion and a Free Society at The Heritage Foundation and the author of Seducing the Samaritan: How Government Contracts Are Reshaping Social Services (Boston: The Pioneer Institute, 1997). John D. Pitts, Jr., a former intern at The Heritage Foundation, served as a research assistant for this paper.
2. Prevalence is a measure of the proportion of people in a population affected with a disease at a given time. Incidence is the number of new cases of a disease occurring in a given population over a certain period.
3. Ministry of Health of Uganda, "HIV/AIDS Surveillance Report," STD/AIDS Control Programme, June 2001. The number reflects sentinel surveillance of pregnant women, ages 15-19, at 15 sites nationwide. The main surveillance system in Uganda, as in other countries, involves testing samples of blood taken routinely at antenatal clinics. Of the various population groups tested for HIV/AIDS, pregnant women generally are considered the most representative. Surveillance was initiated in 1989 at six sites in major cities and was expanded throughout the country to include rural areas.
4. Edward C. Green, Ph.D., Harvard Center for Population and Development Studies, testimony before the Subcommittee on African Affairs, Committee on Foreign Relations, U.S. Senate, May 19, 2003. See E. C. Green, V. Nantulya, Y. Oppong, and T. Harrison, "Literature Review and Preliminary Analysis of `ABC' Factors in Six Developing Countries," paper to be presented at the annual meeting of the American Public Health Association, November 2003.
9. See E. C. Green, V. Nantulya, R. Stoneburner, and J. Stover, "What Happened in Uganda? Declining HIV Prevalence, Behavior Change and the National Response," U.S. Agency for International Development, September 2002, at www.usaid.gov/pop_health/aids/Countries/africa/uganda_report.pdf.
12. Rob Stein, "AIDS Cases in U.S. Increase," The Washington Post, July 29, 2003, p. A1. Unlike Uganda, the HIV rate in the United States did not decline during the 1990s, but has hovered at about 40,000 new infections every year since 1993.
13. Daniel Low-Beer and Rand L. Stoneburner, "Behavior and Communication Change in Reducing HIV: Is Uganda Unique?" African Journal of AIDS Research, Vol. 3 (2003). Low-Beer, who formerly worked for the World Health Organization in its HIV surveillance unit, studies behavior and communication change in relation to HIV in East and Southern Africa. Stoneburner is an epidemiologist who has worked with the Centers for Disease Control and the World Health Organization. See also David Wilson, "The `ABCs' of HIV Prevention: Report of a USAID Technical Meeting on Behavior Change Approaches to Primary Prevention of HIV/AIDS," U.S. Agency for International Development, September 17, 2002.
19. Priscilla Akwara and Ruth Bessinger, "Sexual Behavior, HIV, and Fertility Trends: A Comparative Analysis of Six Countries," U.S. Agency for International Development and U.S. Department of Commerce, 2003.
21. Rand Stoneburner, Ph.D., "The `ABCs' of HIV Prevention: Report of a USAID Technical Meeting on Behavior Change Approaches to Primary Prevention of HIV/AIDS," U.S. Agency for International Development, September 17, 2002.
28. Elizabeth Madraa, "Experience from Uganda," in Ann Malcolm and Gary Dowsett, eds. and comps., "Partners in Prevention: International Case Studies on Effective Health Promotion Practice in HIV/AIDS," UNAIDS report, March 1998.
32. Green, testimony before the Subcommittee on African Affairs. See also E. C. Green and A. Conde, "Sexual Partner Reduction and HIV Infection," Sexually Transmitted Infections, Vol. 76, No. 2 (2000), p. 145.
45. "The Secretary of State and the Administrator of the United States Agency for International Development, in consultation with appropriate nongovernmental organizations, shall establish and carry out programs and initiatives in foreign countries to assist in the safe integration, reintegration, or resettlement, as appropriate, of victims of trafficking and their children." See Victims of Trafficking and Violence Protection Act of 2000, Public Law 106-386.
48. In Botswana, median HIV prevalence among pregnant women in urban areas was nearly 45 percent in 2001. See UNAIDS, "Report on the Global HIV/AIDS Epidemic, 2002." See also Allen, "Uganda v. Condoms."
50. Virtually every study of Uganda has affirmed the important role of religious organizations in fighting AIDS, except for the 1999 UNESCO/UNAIDS report "A Cultural Approach to HIV/AIDS Prevention and Care: The Uganda Experience," which strangely omits any mention of the nation's religious communities.
58. B. Auvert and B. Ferry, "Modelling the Spread of HIV Infection in Four Cities of Sub-Saharan Africa," paper presented at "ABC" Experts' Technical Meeting, Washington, D.C., U.S. Agency for International Development, September 17, 2002.
59. Low-Beer and Stoneburner, "Behavior and Communication Change in Reducing HIV: Is Uganda Unique?" See also Dorothy Brewster-Lee, MD, "The `ABCs' of HIV Prevention: Report of a USAID Technical Meeting on Behavior Change Approaches to Primary Prevention of HIV/AIDS," USAID, September 17, 2002.
63. Dr. R. L. Stoneburner, who advises South Africa on AIDS policy, believes the ABC model could save millions of lives in Africa. "According to the modeling we've done," he says, "3.2 million lives would be saved between 2000 and 2010" if South Africa had adopted the ABC program at the same time Uganda did. For the entire continent, Stoneburner predicts that the ABC approach could reduce the AIDS rate by up to 80 percent. See Allen, "Uganda v. Condoms."
65. George B. N. Ayittey, Ph.D., Department of Economics, American University, "Leadership in the Campaign to Fight AIDS in Africa," presentation before the Presidential Advisory Council on HIV/AIDS, July 18, 2003.
73. Eric Voth, as chairman of the International Drug Strategy Institute and a leading addiction specialist, put it this way: "Once they [addicts] start pumping their system with drugs, judgment disappears. Memory disappears. Nutrition disappears. The ability to evaluate their life needs disappears. What makes anybody think they'll make clean needles a priority?" See Joe Loconte, "Killing Them Softly: Why Needle Exchange Programs Won't Save Lives," Policy Review, July-August 1998.
79. Representative Cliff Stearns (R-FL) inserted an amendment to the U.S. Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003 that prevents disbursement of any funds to the Global Fund "if any employee of the fund was paid a salary higher than that of the vice president of the United States. The vice president's salary is now $175,000."