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