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. 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.
These facts carry political as well as
moral implications: Failure to confront the pandemic in nations
ravaged by AIDS is a recipe for economic decline and social
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 ABC Model
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. 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. How did Uganda do it?
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.
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:
- High-risk sexual behaviors can be
discouraged and replaced by healthier lifestyles.
- Abstinence and marital fidelity appear to
be the most important factors in preventing the spread of
- Condoms do not play the primary role in
reducing HIV/AIDS transmission.
- Religious organizations are crucial
participants in the fight against AIDS.
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." 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."
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.
promote the most effective AIDS policy for developing nations,
effective prevention policy by insisting that AIDS funding uphold
the ABC program emphasis on abstinence and marital fidelity;
that programs for high-risk groups, such as commercial sex workers
and drug addicts, make rescue and recovery a major program
non-governmental organizations (NGOs) while protecting their right
to fight AIDS without compromising their moral and religious
limit the U.S. contribution to international AIDS
organizations until their policies reflect the best AIDS prevention
and treatment programs available; and
that the President's nominee for Global AIDS Coordinator fully
endorse the ABC prevention model.
The Success Of Uganda
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.
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."
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
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. 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. As a 2002 USAID report
states, "This dramatic decline in prevalence is unique worldwide,
and has been the subject of...intense scientific scrutiny."
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. Yet, in the United States, the
incidence of HIV/AIDS is again rising, prompting health officials
to warn of "a resurgent epidemic." 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
The Lessons of Uganda
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.
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.
Based on the best research data available,
several lessons can be drawn from Uganda's experience.
Lesson 1: High-risk sexual behaviors can
be discouraged and replaced with healthier lifestyles.
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.
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
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. 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
researchers admitted that the findings took them by surprise: Many
assumed that teenagers, driven by "raging hormones," would be
immune to abstinence messages. 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. 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
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
study expressly noted that "something of a large magnitude took
place" in terms of messages and changes in sexual behavior among
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. The same was true for Ugandan women:
At least 98 percent were reporting either abstinence or no sex
partner outside their regular partners. 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.
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.)
Lesson 2: Abstinence and marital fidelity
appear to be the most important factors in preventing the spread of
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.) The strategy appears to have worked:
Research data suggest a causal link between changes in sexual
behavior and the drop in HIV prevalence.
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." 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
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."
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. "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."
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." 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
Taken together, these studies strongly
support the view that abstinence and fidelity were the most
important factors linked to the reduction in the HIV/AIDS rate in
Lesson 3: Condoms do not play the primary
role in reducing HIV/AIDS transmission.
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."
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."
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."
Although there is some evidence that
condom use has increased among those who are sexually active, several studies
conducted during the previous decade strongly suggest that condoms
played only a marginal role in lowering Uganda's HIV/AIDS rate:
- The condom usage rate in Uganda is only
average for Africa.
- Even after distribution campaigns, condom
usage remains stable at low rates.
- Of the condoms distributed to high-risk
groups in Uganda, 91 percent went unused.
- In one rural population-based cohort,
there was "no overall protective effect against HIV acquisition in
women who reported condom use."
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
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. 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
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.
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."
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."
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. 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
Lesson 4: Religious organizations are
crucial participants in the fight against AIDS.
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
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."
National religious groups, such as the
Islamic Medical Association of Uganda (IMAU) and the Anglican
Church Human Services Prevention Program, mounted serious education
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
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.
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
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. Says Liebowitz:
"Religious leaders and government officials seem to have pursued
their approach on parallel tracks rather than as opponents."
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:
- Teaching abstinence and fidelity,
- Publishing educational and promotional
- Providing home care and counseling,
- Operating clinics and hospitals,
- Providing spiritual comfort to the victims
of AIDS, and
- Promoting discussion and openness.
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.
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."
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.
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.
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
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
Can Uganda's ABC Model be Exported?
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
"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
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
The Uganda strategy, researchers conclude, strongly suggests that a
"social vaccine" against HIV/AIDS can be developed--one as potent
as a medical vaccine.
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.
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."
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
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. 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.
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."
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
There is no reason to assume that a
similar approach would fail in other nations battling HIV/AIDS. The real cultural
imperialists are those who would impose on non-Western cultures a
uniquely Western, medicalized approach to fighting AIDS.
Roadblocks to Reform
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
- Most African
countries lack the health care infrastructure required to address
AIDS and other deadly diseases effectively. The public
health care system now reaches only about 10 percent to 20 percent
of the people in Africa. HIV is an especially drug-resistant
virus, and sound methodologies and therapies must be imposed in
nations now lacking the resources.
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.
- African leaders
have been slow to admit the seriousness of the AIDS crisis and
develop treatment strategies to confront it. Some have
even dismissed AIDS as a racist conspiracy plot. President Thabo
Mbeki of South Africa claimed in 1999 that AIDS is not caused by
HIV but by poverty--a statement he has since abandoned. Many
African governments are wholly unaccountable, either to
international organizations or to their own citizens. Without
reforms, international assistance could easily be squandered
through corruption and mismanagement.
"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."
- Many health care
organizations and activists continue to promote AIDS prevention
strategies that are deeply problematic. In July 2002, the
Global HIV Prevention Working Group, convened by the Bill &
Melinda Gates Foundation and the Henry J. Kaiser Family Foundation,
issued a "blueprint for action" that emphasizes sex education,
condom distribution, needle-exchange programs, and better access to
anti-retroviral drugs. The example of Uganda's success, though
mentioned briefly, was mischaracterized as an "extensive condom
promotion" campaign--without a word about changes in sexual
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." 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." 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."
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.
What Needs to be Done
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.
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.
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.
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. In contrast, the
first thing that Uganda did was to introduce a healthy dose of fear
about contracting AIDS.
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
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
the President's global AIDS initiative is to succeed, he and the
Congress should pay careful attention to the success of the Uganda
model. Specifically, they should:
effective AIDS prevention policy that emphasizes abstinence and
marital fidelity. Most international AIDS "prevention" and
"behavior change" programs do not protect individuals from the
disease because they fail to discourage the high-risk sexual
behaviors that invite its spread. These approaches, which typically
concentrate on condom distribution, are dramatically failing to
combat AIDS and save lives.
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.
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
- Support rescue
and recovery programs for high-risk groups. Without
aggressive intervention, individuals such as commercial sex workers
and intravenous drug users are unlikely to give up lifestyles that
regularly expose them to AIDS. Although condom use among sex
workers has increased in Uganda and perhaps slowed transmission of
HIV, this is no argument for relying primarily on condom
distribution. Likewise, advocates of needle-exchange programs claim
that they prevent addicts from contracting AIDS from sharing dirty
syringes. Such "risk reduction" approaches may delay the onset of
HIV infection, but they do nothing to truly protect people from the
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
- Empower NGOs
while protecting their civic and religious freedom.
Community and faith-based organizations that uphold the principles
of the ABC model should be given the lead in implementing HIV/AIDS
programs in developing nations. These organizations, working at the
local level with community and religious leaders, have the
knowledge and experience to design the most effective strategies.
Wherever possible, the Administration and Congress must bypass
corrupt and inefficient governments and distribute AIDS money
directly to NGOs or intermediary organizations.
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. 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." 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.
- Sharply limit
U.S. contributions to international AIDS organizations that fail to
support the most effective programs. There is little
evidence that international health institutions have absorbed the
medical and moral lessons of Uganda. "As late as 2002," observes
Daniel Low-Beer, formerly with the World Health Organization, "all
the major organizations denied the role of declines in casual sex
and partner reduction in Uganda." There are encouraging signs, however,
that some officials at the Global Fund for AIDS are willing to enlist faith-based
organizations involved in sound prevention programs. The appointment of
Dr. Vinand Nantulya, an advisor to Ugandan President Museveni, as a
senior health advisor to the agency, is also a promising step.
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
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
- Insist that the
Global AIDS Coordinator fully implement the ABC prevention
model. President Bush recently nominated Randall Tobias,
former chief executive officer of Eli Lilly, to serve as Global
AIDS Coordinator. In this position, Mr. Tobias will report directly
to the President and oversee the appropriated funds.
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
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.
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."
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."
Critics of the Administration's AIDS
policy for Africa should meditate long and hard on that
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