|
Rethinking AIDS Prevention: Learning from Successes
in Developing Countries. Edward C. Green, Westport, CT: Praeger, 2003. 374 pp.
In
Rethinking AIDS Prevention, Edward Green controversially calls for a
paradigm shift away from donor myopia concerning condoms in favor of a focus
on Primary Behavior Change (PBC), which includes fidelity, partner reduction,
and delay of sexual debut. Although it isn’t an entirely new argument, Green
presents excellent evidence of the inadequacies of condom campaigns in Africa and successes of PBC in developing countries around the world.
Condoms, though certainly appropriate only for high-risk groups such as
commercial sex workers and truck drivers, are unfortunately touted as the
only realistic prevention for mainstream society even though they are
exogenous, inconsistently used, and less than 100% effective. Green argues
that PBC is actually a better method of disease prevention for most Africans.
The goal here is behavior change, which runs much deeper than simply turning
society on to condoms and/or drugs, two technological solutions that may in
fact actually increase risky behavior. Studies have shown that by delaying
sexual debut of young adults, their lifetime number of partners greatly
decreases. Therefore, a wider range of programs that focus on PBC yet still
incorporate condoms when appropriate, are desperately needed.
If the evidence presented by Green is accurate, then why is so much
international aid being dumped into these ill-suited programs? His answer is
that donors overlook it, ignore it, or do not want to believe it. Some of the
problems include biased surveys that focus on condom usage at the cost of
questions on other forms of AIDS prevention; the ease of monitoring condom
usage compared to the difficulty of measuring PBC; and programs that are
based on western post-sexual revolution ideology. This last excuse means that
“those who work in public health are loathe to
appear to make value judgments about sexual behavior. Therefore they are more
comfortable promoting condoms and treating STDs than advocating having fewer
partners” (62). The pre-AIDS American sexual revolution instigated free love
and the desire to avoid sexual judgments. This openness was reflected in
policy decisions affecting a continent that had not undergone the same
revolution. In the race to avoid association with the religious right, donors
missed the fact that socio-cultural variables are just as important as
medical. The only way to turn this 20-year oversight around is to overcome
biases against partner reduction and abstinence and actually listen to
Africans because they, like many Americans, are indeed choosing Abstinence
and Being Faithful over Condoms (ABC). Green argues that PBC in Africa is cheaper than anti-retrovirals and can be achieved for less than
US$ 1.80 per person. He presents a compelling argument for both the health
behavior specialist and the layperson in search of an alternative take on the
behavioral potential to overcome high rates of HIV transmission. He mixes
academic research with international articles and profiles in order to
present a colorful, informative account of a topic too many other authors
paint in redundant shades. The point is that programs must reprioritize and
expand further than the promotion of condoms, and although the argument is
certainly persuasive, it does require minor work.
To begin with, Green ties in several case studies (Zambia, Senegal, Thailand, Jamaica) but focuses mainly on Uganda’s success with PBC
programs, which is attributed to the government’s ‘zero grazing’ campaign in
the 1980s. By the time the donors entered and insisted on condom promotion,
infection rates were already declining. USAID and the World Bank supported
much of President Museveni’s approach, so Uganda has had more PBC than other countries. Education
began in the late 1980s and the government advocated female empowerment,
media usage, and the mobilization of religious leaders. It also promoted open
discussion of the disease and allied with NGOs, political leaders, teachers,
and traditional healers. The 1990s brought to Uganda much of what occurs in the rest of Africa: condom marketing, decentralization, salaried workers, and special
programs for high-risk persons.
This part of his analysis is not problematic. But there is a difficulty in
measuring which variables had the most influence, and it is entirely possible
that Uganda’s success is due not to the message, but the messengers and their
quick response. The government coordinated quickly to avoid ambiguity, it
promoted stigma-free discussion and created alliances, and there was an
autonomous, non-sectarian women’s movement. These combined factors are
virtually invisible elsewhere on the continent, even now. Other countries
instead offer confusing and overlapping messages. Politicians are unconcerned
with the disease, equal rights laws that are not enforced, and competition
between AIDS-prevention organizations is prevalent. We cannot know if
decreased rates would have followed anything other than a PBC message, but
the possibility must be kept in consideration, especially since some people are
using condoms.
Green too briefly touches on the role of interpersonal communication and the
use of discussion forums even though these are activities that target
tailored messages to each region. Outside studies show that behavior change
stemming from local developmental theatre is difficult to measure, yet small
scale, personal drama of this sort can be more effective than mass media,
which overlooks particularities. Often included in this form of education are
Life Skills programs that teach women how to negotiate. Uganda’s
implementation of these was effective, yet South African school programs
(such as that of the organization DramAide),
although successful in doses, seem not to have permeated enough of society to
stop the infection rate from climbing.
Governments should certainly take note of Rethinking AIDS Prevention
because the role of poverty here is two-fold. The HIV infection rate is
driven by affluent men; those with “cash, car and [a] cellphone” who attract
more partners (313). But female poverty leads to transactional sex since
women are subordinates due to economic dependence and traditions of male
dominance. Governments must make a stronger effort to affect change through
employment opportunities for women and the enforcement of rape and marriage
laws, otherwise women are stuck in a situation where saying no is at best financially
unsound, and at worst, deadly.
More research is certainly needed into the PBC hypothesis, but it’s on the
right track thus far. Green is currently advising the Bush administration,
which brings up the curious question of whether or not there is any real
danger of placing the end goal above the intentions (which occurs when
programs refuse or are banned from discussing truthfully all possible routes
of prevention). It may be a difficult pill for many in AIDS work to swallow,
but in this case the end must justify the means. Too much money has been
spent recklessly in pursuit of something that simply does not work. But Green
notes that the condom and anti-retroviral companies stand to lose a chunk of
money if PBC takes precedence over condoms, and it follows that if the
international patent rights battle is any indication, these companies will
not relinquish this control without a fight. This has, sadly, become the norm
in the field of AIDS policy in Africa today.
Kenly Greer Fenio
University of Florida
|
