The Magazine

The ABCs of AIDS

The importancee of the Ugandan experience.

Oct 27, 2003, Vol. 9, No. 07 • By JOSEPH LOCONTE
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RANDALL TOBIAS, President Bush's pick to oversee his $15 billion AIDS initiative for Africa and the Caribbean, sailed through his recent confirmation vote in the U.S. Senate--only to find himself at the center of a controversial bid to reshape America's AIDS policy overseas.

President Bush invokes the experience of Uganda--the most successful country at confronting the disease--as the paradigm for key portions of his AIDS initiative. Uganda has "shown the world what is possible" in preventing the spread of HIV, Bush said when Ugandan president Yoweri Museveni visited the White House. Indeed, a decade's worth of research confirms a result that has startled the AIDS establishment: From 1991 to 2000, Uganda reduced its national HIV infection rate from about 21 percent to 6 percent among pregnant women. In Kampala, the rate dropped from 30 percent to 10 percent.

How did a poor, war-torn nation with a tiny health care budget take the lead in HIV/AIDS prevention? The answer goes to the heart of the political fight likely to ensnare Tobias and the administration.

When the epidemic emerged as a problem in Uganda, President Museveni, who came to power in 1986, launched an all-fronts campaign to discourage behavior that spreads the AIDS virus. Government officials enlisted religious leaders to join them in delivering a consistent AIDS message: Abstain from sex or be faithful to your partner. Failing that, use a condom--or die. They called the campaign "ABC"--Abstain, Be faithful, or, as a last resort, use a Condom. Within a few years, Uganda had developed what researchers call a "social vaccine" against HIV: cultural norms about sexual responsibility, preached in clinics and public schools, as well as churches and mosques.

Proud of his country's achievement, Museveni rejects the Western priority on condom distribution--as if "only a thin piece of rubber stands between us and the death of our continent." Rather, he says, "we made it our highest priority to convince our people to return to their traditional values of chastity and faithfulness or, failing that, to use condoms." Ugandans have a colorful term for their goal of fidelity to a single partner: "zero grazing."

Research confirming the effectiveness of Uganda's behavior-based model comes from an unlikely quarter: the very health organizations that champion "safe sex" and condom distribution. The list includes the U.S. Agency for International Development, the Joint United Nations Program on HIV/AIDS (UNAIDS), the World Health Organization, and the Harvard School of Public Health. Most researchers now agree that 9 out of 10 Ugandan adults changed their behavior to avoid the disease.

Abstinence and marital fidelity were the most important changes, according to a recent study by Daniel Low-Beer and Rand L. Stoneburner in the African Journal of AIDS Research. Even teenagers, in large numbers, delayed having sex. Condom use among high-risk groups, such as those involved in commercial sex, apparently played a much smaller role. "Many of us in the AIDS and public health communities didn't believe that abstinence and faithfulness were realistic goals," says Edward Green, a medical anthropologist at Harvard with 30 years' experience in Africa and Latin America. "It now seems we were wrong. The Ugandan model has the most to teach the rest of the world."

The question still outstanding is whether the rest of the world is willing to listen.

The president's Emergency Plan for AIDS Relief, approved by Congress earlier this year, challenges wealthy countries to focus on 14 nations, most of them in Africa, where 29 million people are dying of AIDS or infected with the HIV virus. Most of the U.S. money (55 percent) goes toward treatment. There's also money for a previously ignored group, AIDS orphans, of whom some 11 million live in Africa.

The White House plan, however, sets aside at least 20 percent of the funds for prevention, one-third of it earmarked for abstinence-based programs--at a time when most health organizations and donor agencies are flooding countries with condoms, needle-exchanges, HIV test kits, and safe-sex media campaigns. The Global HIV Prevention Working Group, convened by the Bill and Melinda Gates Foundation and the Henry J. Kaiser Family Foundation, omits any reference to the ABC program in its 2002 report describing Uganda. Amazingly, it credits the government's success to "extensive condom promotion."