AIDS in Africa��a betrayal: there was one success story; Its lessons were embraced by the Bush administration; Now U.S. aid bureaucrats are subverting it

For many years, there was an open secret in the battle against AIDS in Africa. A few of us knew about, and earnestly sought to publicize, crucial findings indicating the most effective approach to AIDS prevention. Yet the "experts" in the field didn't want to hear. Our secret was that the country that had best succeeded in curbing the spread of HIV--Uganda--had achieved this result without following the formula the experts had been pushing for over 20 years, namely, condoms, drugs, and testing. Instead, Uganda had achieved its unparalleled decline in the prevalence of HIV with a home-grown, low-cost program built around something offensive to conventional experts: promotion of sexual abstinence and fidelity, with condoms promoted only quietly, to high-risk groups and those already infected.

The figures are startling. Through a public-information campaign backed by local medical personnel, pastors, and imams and reinforced in schools, Uganda reduced its HIV rate from 15 percent to 4 percent between 1991 and 2004, according to a U.N. calculation.

Not surprisingly, information about what was actually working in Uganda was unpopular. Condoms have been regarded as the first line of defense for everyone, everywhere, and anyone who disagrees with this orthodoxy has been dismissed as a religious fanatic with "an agenda." Hundreds of millions of dollars have been spent on condom social marketing (a field I myself worked in for several years) and on related medical-pharmaceutical solutions. How infuriating that an approach not funded by the big donors and scoffed at by foreign experts should prove to be the very thing that worked best.

Abstinence and fidelity, of course, are precisely what religious conservatives have always argued for, and partly for this reason predominantly secular or liberal AIDS experts dismissed the possibility that they might work. For the fact is, as I learned during my lonely battle to broadcast the truth about Uganda, abstinence and fidelity challenge core values and attitudes enshrined by the Western sexual revolution, which taught that people, whether straight or gay, have the right to express their sexuality however they wish, as long as all participants are consenting adults and no one is hurt. Finally, few AIDS experts wanted to accept the evidence from Uganda because people do not like to admit they might have been wrong, especially in a matter involving countless millions of dollars and the lives of millions of people.

Consider this vignette, from the global AIDS conference in Bangkok in July 2004. When Simon Onaba, a 22-year-old Ugandan university student, told an audience of AIDS experts that he had abstained from sex for three years and intended to continue doing so until his wedding night, he was loudly jeered. "Oh, how nice for you!" went one reaction. "You may be able to abstain, but what about a 13-year-old Somali girl forced into marriage and subjected to genital mutilation? She doesn't have the luxury to abstain!" (As if, by choosing abstinence, Simon were somehow failing to take a stand against genital mutilation.) The experts also hurled hostile questions at Simon: How often do you masturbate, and with whom? What's your real agenda for trying to make people believe you are abstaining?

These critics seem to believe that since abstinence and fidelity may not be workable options for 5 percent of the population, they should be rejected altogether, even if they are the best option for 95 percent of the population. These numbers are not arbitrary: By 1995, only 5 percent of Ugandan males and females were reporting casual sex.

As that last figure suggests, reality is very different from the Western experts' perception. Surveys today suggest that more than half of African males and females between the ages of 15 and 19 are abstaining from premarital sex, and increasing proportions of adults are having sex with only one partner. Yet few who work in AIDS prevention have called attention to these important trends, perhaps because they contradict the image of the hypersexed African that Western AIDS experts have been selling since the beginning of the AIDS pandemic. They depict Africans as "polygamous by nature," and supposedly so driven by hormones and poverty that commercial and transactional sex, and the inability to make responsible decisions about sex, are simply part of what it means to be African. If you accept this condescending view, condoms seem to be the only realistic solution to AIDS.

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The trouble with the image of the hypersexed African is that it was never true for most Africans. Meanwhile, sexual behavior in Africa has changed. Not only in Uganda, but also perhaps in Senegal, Kenya, and elsewhere, abstinence and faithfulness have worked better than condoms. I document the evidence for Uganda and Senegal in detail in my 2003 book Rethinking AIDS Prevention. I also show that in about 1999, Kenya switched to a Uganda-style approach. In the past four to five years, casual sex on the part of Kenyan men and women has declined by about 50 percent, and HIV infection rates have fallen.

The prevention component of President Bush's Emergency Plan for AIDS Relief is based on Uganda's "ABC" model: Abstain, Be faithful, or use a Condom, with condoms the last line of defense. When Congress passed the United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003, it stipulated that a third of all prevention money appropriated under the bill be spent on abstinence programs. The law also allowed faith-based organizations to be funded by the U.S. government for AIDS-prevention without being required to promote condoms.

Reactions to these provisions in the professional AIDS community were immediate and highly emotional. There were predictions of mass death, since a dollar spent on abstinence meant a dollar less for condoms. The drumbeat for condoms continued, even though at about the same time a U.N. AIDS report concluded, "There are no definite examples yet of generalized epidemics that have been turned back by prevention programs based primarily on condom promotion." The U.S. Agency for International Development itself published a study in 2003 showing that HIV infection rates in "generalized epidemics" simply do not decline unless there are "A and B" behavioral changes--that is, increases in abstinence and fidelity.

Now, more than a year after the administration's AIDS program became law, one would expect the ABC model to have been replicated around the world. Sadly, it is not so. Instead, even in its country of origin, the model has fallen into disrepair.

Visitors to Uganda in recent years have found an AIDS-prevention program that looks more and more like that of any other country in Africa: condom social marketing, supplemented by treatment of sexually transmitted diseases, testing, and provision of nevirapine to pregnant mothers. Relentlessly pressed by Western donors including USAID to favor condoms, Uganda has started to abandon its highly effective "Be faithful" intervention strategy. A USAID officer in Uganda admitted to me (in front of the U.S. ambassador, in November 2004) that there are currently no plans for interventions that promote fidelity or partner reduction. I wrote three follow-up letters to the U.S. ambassador providing evidence that Uganda's ABC model "has been diluted and marginalized since the early '90s, largely because the international donors have exclusively or primarily promoted 'risk reduction' (condom) interventions, and have not put actual resources into abstinence/delay or faithfulness/partner-reduction interventions." (The U.S. ambassador is the head of the Bush AIDS-relief team in every participating country.) My letters went unanswered.

Already in December 2002, when I was part of a delegation that visited Uganda, we sat through a two-hour presentation by staff of USAID and the Centers for Disease Control and Prevention stationed in Uganda. The title of the presentation was "What Happened in Uganda?" Not once did these American government personnel mention abstinence or faithfulness, or even partner-reduction or the decline in casual sex. They spoke exclusively about latex, drugs, vaccine research, and hopes for more medical products in the future.

Last summer I was back in Uganda. Conspicuously missing from the national AIDS strategy and other planning documents was any sign of A or B interventions. Not missing was C: Condom initiatives were plentiful and ubiquitous. Prior to 2001, AIDS planning and policy documents were full of A and B objectives and program indicators. One of the early AIDS-prevention manuals produced by the Ugandan government, Control of AIDS (1989), was mostly about abstinence and faithfulness. Condoms were not even mentioned until page 32, and then the booklet originally cautioned, "The government does not recommend using condoms as a way to fight AIDS." UNICEF, which paid for the booklet, was so unhappy with this anti-condom statement that it pasted a new, more pro-condom page 32 over the original one before releasing the booklet.

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Uganda is a poor country, still rebuilding its economy after the havoc wreaked by two dictators. Like other subSaharan nations, Uganda relies heavily on Western aid. Because they pay the bills, foreign donors have a great deal of influence on national strategy, and they have been systematically undermining Uganda's uniquely successful AIDS-prevention model. Indeed, with rare exceptions, they have simply refused to pay for programs that promote abstinence, fidelity, and reduction in the number of sexual partners. This is supposed to change under the 2003 emergency AIDS relief legislation. But change, always slow in coming, is being vigorously resisted by major AIDS donors.

A member of the Uganda AIDS Commission, after describing the central role of abstinence and faithfulness in his country's success at controlling the disease, observed to me that messages promoting abstinence and faithfulness "have somehow faded since the early 1990s. We sometimes see faded billboards that used to have AIDS messages. Now they just have messages about condoms." And during a meeting of top religious leaders in Uganda in November 2004, one cleric after another complained that they had become increasingly marginalized, while foreign experts scoffed at abstinence and faithfulness as prevention strategies.

Western donor organizations and many of the groups they support that are doing the work on the ground simply continue to promote condoms and avoid addressing sexual behavior. Even USAID, an agency I have worked under for 25 years, has failed to support adequately the goals of President Bush's plan, often awarding funds earmarked for abstinence to condom social marketing companies (especially in Uganda, of all places). This simply ensures business as usual. Most of the people and organizations who actually implement AIDS-prevention programs do not believe in or support the new ABC policy.

Senator Sam Brownback recently visited Uganda. In his trip report he confirms that Western donors, including the U.S. government, are undermining the once successful ABC model. The vast majority of prevention funds have gone to condoms, Brownback says, and "PSI, a well-known condom social marketing NGO, is still the largest U.S.-funded HIV prevention contractor in Uganda." Further, Ugandan president Yoweri Museveni, the original champion of ABC, "is in a battle with Western donors to keep condom promotion out of his innovative AIDS education program in public primary schools,... [and] African leaders are growing resentful that U.S. dollars are contingent upon acceptance [of condoms as the main prevention strategy]."

Because of the problems Brownback and I have pointed out, the senator calls for congressional and GAO oversight over future spending under the Bush AIDS initiative, a cumbersome precaution that could easily have been avoided had USAID (and the Centers for Disease Control) simply had the humility and good sense to allow Uganda to continue an indigenous program that had already proven successful.

Last November, a number of colleagues and I published a statement in the Lancet about what works best in preventing sexually transmitted HIV in Africa. It reflects Uganda's ABC prevention strategy in the early years, when sexual behavior changed most dramatically. Some 150 scientists and the president of Uganda endorsed the statement. Unfortunately, it is by no means clear that empirical evidence can overcome ideological blinders or compete with the big business in pharmaceutical products that AIDS prevention has become. As a result, not only the improved AIDS situation in Uganda, but also the integrity of President Bush's entire global AIDS-prevention strategy, are in jeopardy.

Edward C. Green, a medical anthropologist and senior research scientist at the Harvard Center for Population and Development Studies, is a member of the President's Advisory Committee on HIV/AIDS.

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