The predominant Western approach to preventing the spread of AIDS in Africa has failed. Though in theory the risk reduction strategies favored by Western governments and aid agencies—handing out condoms, promoting counseling and testing, and treating other sexually transmitted infections (STIs) to block HIV transmission—can “work” in theory, they have not done so in practice. In Africa, despite years of promised improvements, they have not brought any downturn at all.
But a handful of African countries have actually forced down the AIDS rates, each of them by changing behavior—particularly reducing sexual partnerships—not through the heavily promoted risk reduction measures.
Well before western donors and condoms arrived on the scene, Uganda had cut its level of casual sex by two-thirds and subsequently its HIV rate by two-thirds. Several years later, Kenya replicated this success. A few other countries have also done so, with partner reduction always the most important factor.
In sharp contrast, South Africa has maintained high rates of multiple (and concurrent) partnerships and, despite its vigorous promotion of condoms, still suffers from persistently high rates of HIV infection. The same can be said of many of its neighboring countries, which lead the world in the prevalence of HIV, with some 15 to 35 percent of all adults infected.
These successes and failures are, tellingly, too often treated in a manner inversely proportional to their merits. Behavior change, though responsible for success, remains the least emphasized approach, while risk reduction invariably receives the benefit of the doubt despite its failure to deliver as promised. Its disappointing results always mean that efforts—along with funding—must simply be doubled.
Many in the AIDS Establishment will only unreservedly applaud success if it comes through the technical means promoted by Western governments and activist groups. In a 2005 PBS documentary, UNAIDS’ executive director Dr. Piot refused to concede that behavior change played the paramount role in Uganda’s unparalleled success. “But we also know,” he added, “that no country has been successful in bringing down the number of new infections of HIV without strong condom promotion.”
To viewers who have never had reason to think twice about the issue, this might sound like a sober assessment. Human sexual behavior, we tend to assume, is hard to change and so the most effective way to reduce the number of people getting sexually transmitted diseases must therefore be to reduce the risk of sexual activity. That appears to many people just common sense.
But Uganda clearly refutes Piot’s claim, as does the fact that the countries with the most robust condom promotion programs have some of the most severe AIDS epidemics in the world. The evidence suggests that common sense may be wrong.
For starters, people tend to take greater risks when they feel protected by technical innovation. In a state of the art program in Uganda, for example, those explicitly encouraged to use condoms ended up at greater risk than the control group not exposed to the sophisticated intervention, because they had more sexual partners than those not told to use condoms. People have also been seen to take greater risks when antiretroviral therapy for HIV/AIDS became available.
This “risk compensation” or “behavioral disinhibition” is now, fortunately, receiving more attention in scientific circles. It is one reason why vigorous promotion of risk reduction—even if it “works” in isolated cases—can do more harm than good. The “common sense” presupposition that condoms will decrease infection rates does not easily give way to the common sense observation that promoting devices capable of reducing risk encourages people to take more risks.
But risk reduction measures have a deeper and more damaging defect: a deflating absence of hope. They too often imply that we cannot influence behavior—that the best we can hope for is reducing and controlling the damage of behavior people will engage in whatever we say. More damagingly, they too often imply that we cannot change our behavior, that in matters of sexuality in particular we are doomed to live dangerously, that we are too weak to do what is best for us.
Thoughtful strategies to change behavior, on the other hand, reinforce the human capacity to recognize and choose what is good. As the Ugandan experience has proved, all people—especially the young—respond to this message when it is sincerely delivered.
The hopelessness at the heart of the risk reduction philosophy is rarely noticed and its effects almost never described or included in the evaluation of the methods for reducing AIDS in Africa. The scientific literature and the popular press instead portray technical, risk reduction measures as the only enlightened and the only truly practical approach to reducing AIDS in Africa. But that reflects a profoundly elitist and patronizing philosophy, which is an insidiously destructive one because people threatened with AIDS most need hope for the future—hope to live free of disease, discord, fear, and inner turmoil.
A colleague of mine in Africa put it like this: “Ideals are like the stars. We may not reach them, but we set our course by them.” If we hope for nothing, as someone has said, we will get what we hoped for. Advocates of risk reduction, though, seem threatened by such an ideal, maybe because it implicitly reproaches the modern autonomy project or seems to support “traditional morality.”
In fact, UNAIDS had itself commissioned, a couple years before Piot’s remark, a revealing comprehensive study of the impact of condom promotion on HIV transmission in the developing world. I presume Piot got a copy of the results. I did. Many of my colleagues did. It found, quite plainly, that “prevention campaigns relying primarily on the use of condoms have not been responsible for turning around any generalized epidemic.”
These results, according Norman Hearst, a highly respected epidemiologist at the University of California at San Francisco who led the study (and is to this day called upon to give testimony before Congress), were not what “UNAIDS wanted to hear at all.” Instead of welcoming the findings and adapting HIV prevention strategies accordingly, UNAIDS first tried to alter them, and then refused to publish them. The results were finally published in a peer-reviewed journal, Studies in Family Planning.
UNAIDS is usually very eager to insist on “the right to accurate information” about condoms; such flagrant suppression of its own highly relevant findings in this case fails others miserably. This is important to drive home, since it is the Catholic Church that is routinely portrayed as holding fast to dogma at the expense of human lives.
UNAIDS’ burial of disinterested research could be considered a public distortion—by omission—of “scientific evidence.” Dr. Piot’s remark on PBS could fairly be characterized as an “outrageous and wildly inaccurate statement”—precisely the charges that the prestigious English medical journal The Lancet baselessly leveled at the Pope last year, after he suggested condom promotion isn’t the solution, and might even do harm.
But the downsides are getting harder to ignore. Even in Uganda, HIV prevalence has gone back up in recent years, as Western donor demands for risk reduction replaced the country’s own original emphasis on behavior. We are at an important juncture—and not just for Africa, where a fortunate minority are now able to access treatment, but where two million more people get HIV infections every year.
The number of new HIV cases in the Unites States has remained constant for the last decade, suggesting that our HIV risk reduction strategies are not working that well here either. High rates of other common STIs persist unabated or are even rising; one in four teenage girls (aged fourteen to nineteen) has an STI, according to the Center for Disease Control. Other Western countries have seen some STIs double or triple over the past two decades.
Despite these grim trends, we are constantly told that reducing the risk of sexual behavior, not limiting the practice of it, is the answer. It has be the answer, when the West’s mix of utilitarianism, individualism, and relativism puts addressing behavior off limits. Changing behavior is not only a valid and sensible public health message, it is the most urgently needed one.
We should expect our public health authorities not to pass on the prevailing strains of cultural thought uncritically, but to speak against them when people’s futures and their lives depend upon their speaking the truth.
Matthew Hanley is the author, with Jokin de Irala, of Affirming Love, Avoiding AIDS: What Africa Can Teach The West, recently published by the National Catholic Bioethics Center. He is also a regular contributor to The Catholic Thing. His "Should Catholic Charities Settle for Harm Reduction" appeared in March.