Agreed: The Bush administration’s response to AIDS in Africa is a failure. Disputed: The reasons why. An argument with the mainstream press narrative.

By Bob Smietana

In a joint report for Rolling Stone and Salon, Geraldine Sealey argues that moving away from “tried-and-true” methods of preventing HIV is “a deadly game of Russian roulette that could mark a calamitous turn in Africa’s attempts to get a handle on the AIDS.” Those “tried and true” methods include “aggressively promoting condom use and sex education,” which, Sealey claims, helped Uganda reduce drastically reduce and made it “Africa’s biggest success story” when it comes to fighting AIDS.

But Uganda’s success is in danger, Sealey says, because of Bush administration polices that place “religion over science,” and promote “abstinence and monogamy over comprehensive sex education that includes information about and access to condoms.”

“This emphasis on morality is being driven by social conservatives who have made spreading the gospel of abstinence and monogamy to Africans their primary mission,” Sealey writes.

She offer as proof quotes from Focus on the Family and Republican congressman Henry Hyde, as well as this comment from a “Democratic staffer”: “All [conservatives] can think about is making Africans abstinent and monogamous . . . It’s the crassest form of international social engineering you could imagine.”

In disgust, Sealey writes that it is “shocking to observe an administration that claims to be acting in the name of morality consigning tens of thousands, perhaps millions, of people to death because of its policies.”

But Sealey is wrong.

First, the idea of fighting AIDS with abstinence and monogamy in Uganda wasn’t dreamed up by conservative Republicans acting as social Darwinists. It originated with Ugandans themselves and later was adopted by the U.S.

More importantly, fighting AIDS with a focus on abstinence and monogamy has worked in Africa, a fact demonstrated by scientific research, not the wishful thinking of evangelical moralists. In the mid 1980s, when AIDS first hit Uganda, the country’s health care system was in drastic shape, with even basic supplies like aspirin in short supply, says Dr. Edward Green, senior research scientist at the Harvard Center for Population and Development Studies.

In response, the Ugandan government created what’s known as the “ABC” method of AIDS prevention — Abstain, Be faithful, use a Condom. The ABC approach did not consist of a “just say no” approach, says Green, who has been studying AIDS prevention in Uganda since 1993. Instead, Uganda government mobilized all sectors of Ugandan society –government, education, religious groups, entertainment — to change sexual practices. One of the main focuses was promoting fidelity in a monogamous relationship, otherwise known as “Zero Grazing.”

The idea was to make sure that “everybody understood that there is a threat of AIDS. You will die if you get it so you must change your behavior,” says Green.

That behavioral change, according to epidemiologists Rand Stoneburner and Daniel Low-Beer, acted as a kind of social vaccine for HIV, reducing AIDS prevalence from a high of 21 percent to less than 6 percent. Most of the reduction in prevalence occurred before the widespread introduction of condoms or major funding from AIDS donor groups.

As Low-Beer, a former HIV forecaster at the World Health Organization (WHO) now at Cambridge University, noted in an editorial that appeared in the Financial Times, the Ugandan AIDS program cost only $21,676,000 over five years to implement.

Stoneburner (who worked with Low-Beer at the WHO and at Cambridge), Low-Beer, and Green are among the most vocal initial advocates for the ABC model — based on scientific study, not on moral agenda. While most of the debate over ABC focuses on “abstinence versus condoms,” a study published in the April 30, 2004 issue of Science by Low-Beer and Stoneburner indicates that the “Be faithful” component was most effective.

As Helen Epstein of Princeton University reported in a feature story called “The Fidelity Fix” for The New York Times Magazine, “As experts come to understand more about the African AIDS epidemic, it seems clear that regular sexual contact with more than one person is the key human behavior that enables the rapid spread of H.I.V.”

The spread of AIDS in Southern African is exacerbated by what Epstein called “concurrence” — long term sexual relationships with more than person, which are common in the region. This concurrency “links sexually active people up in a giant network, not only to one another but also to the partners of their partner’s partners—and to the partners of those partners, and so on—via a web of sexual relationships that can extend across huge region.” When one person in the web gets AIDS, they can quickly infect the whole web.

Promoting fidelity in monogamous relationships — through “Zero Grazing” — can cut those webs, and hamper the disease’s ability to spread. That’s a point Epstein makes forcefully in “God and the Fight Against AIDS,” which ran in the April 28 edition of the New York Review of Books.

Epstein’s detailed reporting, which puts Sealey’s to shame, takes both abstinence and condom advocates to task for overlooking the research that show the effectiveness of promoting monogamy. She wrote: “But there may be other reasons why Zero Grazing is unlikely to be revived. For one thing, there is no multimillion-dollar bureaucracy to support it. For condoms, there are the large contractors like PSI with headquarters in Washington and thousands of employees in plush offices all over the world. Abstinence-only education is supported by a similarly well-endowed network of faith-based and abstinence-only education organizations, mainly in the US. Zero Grazing was devised by Ugandans in the 1980s, when they were facing a terrible problem, and had to deal with it largely on their own. Now that AIDS is a multibillion-dollar enterprise, donors with vast budgets and highly articulate consultants offer health departments in impoverished developing countries a set menu of HIV prevention programs, which consists mainly of abstinence and condoms. Beleaguered health officials have no time, money, or will to devise programs that might better suit their cultures.”

This is the kind of reporting that can save lives.

USAID has adopted the ABC method — at least in its official publications — because it works. There’s no doubt that social conservatives have jumped on the ABC bandwagon because it fits their religious and moral view of the world. Focus on the Family’s Citizen magazine, for example, published a major report on Green, Stoneburner, and Low-Beer and the pro-abstinence Medical Institute for Sexual Health produced a monograph on their findings.

But, as Green pointed out in a 2003 editorial for The New York Times, just because conservatives favor the ABC approach “doesn’t mean it doesn’t work.” The statistics on the AIDS pandemic are grim. Some 40 million are infected worldwide. More than 20 million people have died from the disease, leaving behind 12 million orphans. The stakes are too high to ignore scientific evidence, as Sealey does.

On a least one point, though, Sealey’s piece from Rolling Stone and Salon is dead on — the massive gap between President Bush’s words and his deeds when it comes to AIDS.