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AIDS in Africa: Behavior change is the key

UGANDA (BP)–HIV prevalence has now declined in seven countries hit hard by AIDS, and two experts from Harvard University attribute the progress to behavioral changes such as an increase in abstinence and partner reduction rather than to widely-touted condom distribution.

“In every case, a few years before we notice prevalence going down, we see that the proportion of men and women who report having more than one sex partner in the past year goes down significantly,” Edward Green, a senior research scientist at the Harvard School of Public Health, told Baptist Press.

“In almost all cases, we’ve seen the rate of premarital sex going down significantly. And condom use can either go up or down or stay the same. It doesn’t seem to make much of a difference,” Green said from Uganda, where he was conducting more research.

The seven countries that have shown signs of declining infection rates include Uganda, Kenya, Zimbabwe and urban Zambia, Ethiopia, Haiti and Malawi, Green said.

Foreign donors continue to push condom distribution and AIDS testing as prevention methods while disputing the effectiveness of the ABC method that has seen so much success in Uganda and elsewhere, Green said. The method teaches abstinence, being faithful to one partner and using condoms in high-risk situations.

“The major donors are putting all this money into condom promotion, HIV testing, treating STDs and trying to develop microbicides — which have not shown to be effective,” he said. “All of these much-touted interventions have not been shown to have any impact in generalized epidemics in Africa.

“The sad thing is that even in Uganda, the national AIDS program has been largely redesigned by foreign donors to no longer emphasize the messages that were successful in reducing Uganda’s epidemic — faithfulness and partner reduction, and abstinence for young people.

“Condoms have had impact in certain high-risk groups, such as prostitutes in Thailand and Cambodia. But condoms have not had an impact in any general population or in any country where HIV is mostly in the general population, such as most of those in Sub-Saharan Africa,” Green said.

Allison Herling Ruark, a research fellow with the AIDS Prevention Research Project at the Harvard Center for Population and Development Studies, told Baptist Press that foreign donors often refuse to believe that abstinence and faithfulness messages work and instead contend that behavior is ingrained and efforts to change it are futile.

“I think people just aren’t aware that there’s good evidence of behavior changes,” Ruark said. “Even in Uganda where those changes happened 20 years ago and they’re so well-known, they’re not always as well known as they should be.

“People often think it’s difficult to measure behavioral changes, but we really don’t think it is. You can ask people questions about their sexual behavior, and you can look at trends over time,” she said. “We have been doing this for condom use for many years.”

Organizations that distribute condoms or provide treatment for sexually transmitted infections are easily able to keep a numerical tab of their efforts, Ruark noted, whereas the links between informational messages and behavior change are more challenging to substantiate.


Green, director of the AIDS Prevention Research Project, said the continued mainstream push for condom distribution and HIV testing and treatment also is fueled by an industry built around such services. But as Green’s colleague Daniel Halperin wrote in a Washington Post Op-ed Oct. 22, there is little evidence indicating that testing for HIV alters behavior.

Most studies show that people continue their risky behavior after being tested and some worsen their behavior if they learn they’re not infected.

“HIV testing, in fact, does not appear to have played a crucial role in the declines in HIV rates observed in a number of countries and settings …,” Halperin wrote. “[V]irtually everywhere in Africa where HIV rates have fallen, these declines were preceded by steep declines in multiple partnerships.”

Halperin went on to conclude that the “most rigorous evidence suggests that there needs to be a vigorous expansion in Africa of behavior-change programs.”

Green pointed to Uganda as evidence that an ABC-type campaign works.

“There was an amazing behavior change, both by people having more partner fidelity and young people delaying the age of sex,” Green, a medical anthropologist, told BP. “Some girls who were sort of coerced into sex at an early age returned to secondary abstinence. There was a lot of behavior change in Uganda, and it became the world’s great success story in AIDS, bringing down infection rates by two-thirds.

“You couldn’t call it an abstinence-only program,” he added. “For example, the schools taught all the different ways one could prevent AIDS. They talked about condoms, but what most people don’t usually do is be very candid about condoms.

“Condoms, if you use them each and every time, are about 80 to 85 percent effective in reducing HIV transmissions,” Green said. “But they’re rarely used each and every time, particularly in Africa where they’re hard to get and people run out and they’re not handy.”

Green said the rates of casual and multi-partner sex have been on the rise for about 10 years in Uganda as foreign donors have pushed people away from the behavior change message.

“The men and women who report more than one sex partner in the last year has gone up pretty steadily since the mid-90s,” he said.

Ruark said the change may be due to feelings of fatigue.

“When AIDS was first perceived as a crisis in Uganda, people were really scared and willing to make changes in their behavior,” she said. “Now we’re 20 years on in the epidemic and people are not dying as frequently. There are drugs now that keep people alive, which is a wonderful thing but it does lead to some complacency.”

There’s a tendency for a perception of reduced risk to make risk-taking more attractive, Ruark said, referring to a public health term called disinhibition.

“People adjust their behavior in response to the increased sense of personal safety that comes with protective behaviors such as wearing a seatbelt or using a condom,” she said, adding that when treatment is available, “suddenly people feel that AIDS is not such a death sentence, so are not so afraid of it and motivated to change their behavior to avoid infection.”

While there is a negative element to the Uganda story, Ruark said she sees reasons for optimism.

“These cultures are resilient, and certainly the church and many other community-based organizations are hard at work in a lot of places even when you don’t hear about it,” Ruark said. “You look at a country like Zimbabwe, which in some ways is going through a complete meltdown with a very repressive government, high inflation and social services breaking down, yet they’ve seen some success against AIDS.”


She also expressed confidence in some positive changes in the United States.

“Most people think that youth now are having more sex than they were 10 years ago, but in fact there is less teen sexual activity than there was 10 years ago,” Ruark said. “Teen pregnancy is down compared to 10 years ago and it seems to be for a combination of reasons — increased contraception but also increased abstinence.”

From some qualitative field research she conducted with youth in Uganda, Ruark saw that social norms had shifted and peer groups where teens could encourage each other not to have sex were thriving.

“I think the role of social networks and social support is huge for adults, but especially for young people,” Ruark told BP.

She also emphasized that AIDS prevention is not just a youth problem but is something that depends largely upon adults changing their sexual behavior.

“I think at times, especially for faith communities, there’s a tendency to just focus on youth and abstinence, which is really important, but actually, epidemiologically, it’s adult behavior that’s much more important,” Ruark said.

“One reason for that is that people spend much longer in the adult, sexually active part of their lives than they do as youth. It’s a fairly short period of years we’re asking youth to abstain, and in fact, last year most unmarried youth in Africa did abstain from sex. What’s more important is the behaviors that people practice over their lifetimes, and that adults practice faithfulness.

“What’s really fueling HIV in Sub-Saharan Africa is not young people having sex. It’s adults having sex with multiple partners and the creation of sexual networks where HIV can spread like wildfire,” Ruark said.
Erin Roach is a staff writer for Baptist Press.

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