Friday, July 27, 2007

HIV: the Invisible Cure

A new book by Helen Epstein uncovers the Invisible Cure for HIV: behavioral changes. She documents the impressive decline in HIV in Uganda during the 1990's. She discovered the seminal paper by Maxine Ankrah that showed that reductions in the numbers of sexual partners were crucial in containing the spread of the disease. This paper was downplayed or overlooked completely in UN reports. This book sounds like an important breakthrough in the discussion about AIDS prevention, when even the NYT is willing to read it objectively.
While I'm glad that she has done this, I must say that I remember reading about the success of the Ugandan program well before this. The Weekly Standard did an article on the subject, back in 2005, by Edward Green, also an AIDS researcher. He wrotes:
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.
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.

This "follow the money" logic only partially explains the reluctance of the AIDS establishment to give full credit to the Ugandan model. They don't really beleive that "partner reduction" is a realistic stratgey. Green tells this story:
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.

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.

I wish Helen Epstein every success with her book.

No comments: