The Greening of AIDS Prevention
Don’t bet the house and farm on drugs and condoms.


LOPEZ: Is your book — and increasing research, including the recent Lancet piece the New York Times reported on — a vindication, too, for the direction that George W. Bush took with funding, with his PEPFAR program? How much of that is still intact?

: Well, this is not easy to answer. PEPFAR (created under George W. Bush) and USAID adopted the ABC policy (Abstain, Be faithful, or Use a condom) for the so-called generalized HIV epidemics of Africa, and perhaps part of the Caribbean as well. But policy changes at the top do not change the culture of organizations such as USAID (to which I remain indebted for a long, satisfying career as a consultant) or the CDC overnight, or even over an eight-year period. USAID, from which PEPFAR pretty much sprang, more or less specialized in family planning, and when the U.S. government first geared up to address AIDS in Africa and beyond in the mid-1980s, it naturally thought about such things as promoting condoms for “dual purpose”: avoiding unwanted pregnancy and death from AIDS. That seemed like a no-brainer, but alas this approach didn’t work in AIDS — and it didn’t work very well in family planning either.

I go into all this in detail in my book. Suffice it to say here that the first two components of the ABC policy were vigorously and effectively resisted by many in USAID and PEPFAR. Condom supply and promotion greatly increased during the two Bush administrations. In spite of our wrongheaded policies, most people have common sense, and so many or most Africans changed their sexual behavior in the direction of greater caution and fewer partners. HIV prevalence has been declining in Africa since about 2000. Curiously, in the Institute of Medicine’s “assessment” of PEPFAR, nobody thought to mention this decline in infection rates.

The weak argument was “we are not sure we can take credit for such changes.” True, but this report went even further and stated that “the rate of new HIV infections continues to grow.” Not true! Even the U.N. quietly admitted this on its website not too many months after this IOM report.

: But isn’t “fidelity” quite idealistic about human behavior? Dangerously so?

GREEN: Not at all. As I say in my book, what we see in the first seven or eight countries in Africa where HIV prevalence has declined is that a few years earlier, the proportion of men and women reporting more than one sex partner in the previous year had declined significantly. Monogamy in fact is the norm pretty much everywhere, except maybe in southern Africa, where significant minorities of men and even women have multiple and concurrent partners. And contrary to Western, quasi-racist stereotypes, Africans tend to have a lower lifetime number of partners than Americans, Brits, or Western Europeans. Even The Lancet got around to acknowledging this a few years ago (although the article, by Wellings et al., concluded that this just goes to show, we need more condoms!).

: Have you seen minds change on AIDS policy over the years?

: Yes, but not nearly as many as one would want to see. Faithfulness or “not having multiple and concurrent sex partners” is now part of what PEPFAR, USAID, and some other donors promote and fund. There are currently programs to promote fidelity in the dozen or so countries in Africa with the highest HIV rates. Alas, these programs are threatened by the current promise that we can eradicate AIDS if only we put enough money into drugs. I am talking about “treatment as prevention,” the belief that if we get everyone on ARV drugs, we can lower viral loads (degree of infectiousness),and this is how we can best prevent AIDS.

Don’t get me started on this topic, but you may remember my colleagues and I wrote something for National Review Online last June.

: How can aid groups use this information constructively?

: What we need to understand is that eradicating AIDS by somehow getting everyone on treatment (and note that we cannot find all of the HIV-infected even in America, let alone in remoter parts of the Third World) — oh, and part of this idea is to get expensive ARV drugs to those at high risk of becoming HIV infected, before they are infected — well, this is just a pipe dream. We couldn’t eradicate syphilis a few decades ago, and that required only a single injection. If this didn’t work in America, how can we expect something that is much more complicated and expensive to treat (AIDS) to be a candidate for eradication in Africa and everywhere else in the world?

Now because I myself have loved ones who are HIV-infected, I like to say: Keep on trying with the drugs and with condoms, but don’t bet the house and the farm on this approach. Do what Uganda and a few other places once did (before “we” interfered), which was to promote faithfulness in marriage — or let us say in partnerships, the virus doesn’t know whether partners are married or not — and encouraging delayed sexual debut, or later age of first sex.


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