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The Propaganda War and HIV Prevention

Which programs are truly saving lives?

by Mark DeYoung

George W. Bush left the White House one of the most unpopular presidents in U.S. history. Costly and controversial wars, excessive government spending, the Wall Street collapse and the Abu Ghraib scandal, among other things, all contributed to an embarrassing departure.

However, while we may argue for years about President Bush’s true legacy, everyone seems to agree that his commitment to the HIV/AIDS epidemic in Africa was truly groundbreaking.

According to one study, the President’s Emergency Plan for AIDS Relief (PEPFAR), saved more than 1.2 million lives and reduced AIDS-related deaths by over 10 percent during Bush’s second term. What can’t be agreed upon is which programs are the most effective at saving the most lives, especially when it comes to the area of HIV prevention.

With a renewed general commitment by the Obama administration to Bush’s AIDS relief plan, it is worth looking at the controversial area of prevention. What programs have been successful, and what methods should we encourage the White House to pursue?

Uganda is the country most often cited for implementing a successful HIV prevention strategy. Most are familiar with what is known as the ABC (Abstain, Be Faithful or Use Condoms) strategy recognized for producing a dramatic drop in HIV infection rates during the 1990s (from 15% of the population to 6%).

Many social scientists have stated that the cornerstone of this success was a Ugandan government campaign called “zero grazing” initiated in the late ‘80s. Through public messaging and grassroots efforts, the government encouraged the men of Uganda to be faithful to a regular partner or partners (wives and mistresses), and to avoid casual sexual encounters. During this campaign, the number of casual sexual encounters among men and women dropped by 60%. In the mid-‘90s, the zero grazing policy was scaled back while programs intended to encourage condom use were ramped up. At first, HIV rates fell more slowly; by the year 2000 they began to rise again.

In 2003, President Bush asked Congress for $15 billion to establish the PEPFAR plan to fight AIDS in Africa. A contentious debate ensued. The Democrats were seeking condom-centered prevention, and Republicans were demanding abstinence-only programs. In the midst of it all, Uganda’s first lady, Janet Museveni, came to Washington and made a compelling case for abstinence-based programs. (In the end, Congress voted to earmark $1billion of PEPFAR for abstinence-only-until-marriage efforts.

Towards the end of Bush’s second term, almost everyone could agree that the drug portion (distribution of antiretrovirals) of PEPFAR was extremely successful, even eliciting support from the likes of Bono and Bob Geldof. But there was still controversy over what made for successful HIV prevention.

During Obama’s run for the presidency he made it clear he would continue the good work that had been started with PEPFAR. However, he indicated his desire to “rewrite much of the bill to allow best practices – not ideology – to drive funding for HIV/AIDS programs” (i.e., return to condom-centered efforts), and in late 2008, Congress stripped PEPFAR of its abstinence-only earmark. It appears that Obama will continue the long legacy of HIV prevention utilizing technical approaches such as HIV testing and condom distribution. His administration has also stated their intention to reintegrate HIV prevention with other reproductive health programs that include abortion and contraceptive services.

Those on the left insist that broad condom distribution is the best method for reducing HIV prevalence; while those on the right argue for abstinence only. In terms of success rates, though, the reality on the ground is more nuanced than many in America realize.

While condom distribution has been a staple of U.S. foreign aid for HIV prevention and reproductive health for decades, the evidence points to a fairly universal failure among the general populations. The only meaningful data we have suggests that the consistent use of condoms within the sex industry can have a major effect on reducing new AIDS cases in those sub-communities.

Earlier this year, Pope Benedict XVI drew much criticism for his comment that condom distribution has actually heightened the HIV crisis in Africa. But Harvard’s own director of the AIDS Prevention Research Project, Dr. Edward Green, has repeatedly confirmed, empirical evidence is on the pope’s side.

On the flip side,  it’s important to remember that abstinence-only efforts are a recent phenomenon in the fight against HIV, so we simply don’t have enough information to draw complete conclusions about their effect over time. Abstinence-only programs have had success with young people delaying their first sexual experience – they just haven’t had a demonstrable effect on overall HIV rates in the short term.

Still, abstinence in Africa doesn’t have the connotation it has the States, especially when it comes to mean a “delay” of sexual activity – as it did in Uganda.  As Green points out in his book “Rethinking AIDS Prevention” (Praeger, 2003), “the political meaning of abstinence in the United States has blinded the global community to the appropriateness of this response, or the related response of partner reduction, in Africa, even when Africans themselves have developed such responses and they have worked stunningly well.” 

So what does work?

In the summer of 2008, Science Magazine printed a large scale analysis on HIV prevention. They showed that the most effective on-the-ground efforts are those that encourage reduction in multiple sexual partnerships. They cited Kenya, Zimbabwe, Ethiopia, Malawi, Cote d’Ivoire and Swaziland for implementing programs similar to Uganda’s zero grazing policy, all with demonstrable success. They also pointed out that each program had unique attributes to address distinct cultural norms, stating that a one-size-fits-all approach on the global level just doesn’t work.

From a policy standpoint, an HIV prevention strategy that depends largely on condom distribution falls drastically short of the proven “best practices” President Obama has pledged to pursue. From a moral standpoint, it likewise falls short of willing the good for the whole human person, not just his physical health.

As Catholics, we can proudly highlight the fact that our church cares for every one in four HIV patients worldwide. In March of this year, Pope Benedict XVI declared that addressing HIV/AIDS requires a two-fold solution: “The first is a humanization of sexuality, spiritual renewal which brings with it a new way of behaving ... secondly, a true friendship, especially for those who are suffering, a willingness to make personal sacrifices.”

The Church has a unique responsibility to invite people to live the better way, encouraging lifestyles that recognize and embrace our human dignity. In solidarity with our brothers and sisters around the world, we also have the responsibility to protect and save human lives. In the face of policy changes by  a new administration, we need to be shrewd and creative enough to promote grassroots efforts that truly save lives, while not directly contradicting our Catholic sexual ethics.

 

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(The views expressed in this column are those of the author and do not necessarily reflect the positions of Headline Bistro or the Knights of Columbus.)