New Challenges to the AIDS Prevention Paradigm

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From the September 2003 Anthropology News, p 5-6

New Challenges to the
AIDS Prevention Paradigm

Edward C Green
Harvard School of Public Health

This poster was intended by the Uganda Ministry of Health for teenage girls to discourage them from getting involved with older men who might be HIV+.

Evidence is mounting that the global model of HIV/ AIDS prevention, designed by Western experts, has been largely ineffective in Africa. The model is based on risk-reduction or “remedies” interventions (condoms, treating Sexually Transmissible Infections with drugs), rather than on risk avoidance (mutual monogamy, abstinence or delay of age of first sex). This dichotomy is imperfect because reduction in number of sexual partners would have to be classified as risk reduction, not avoidance. The remedies-based global model does not promote partner reduction, nor even address multi-partner sex.

John Richens proposed the term primary behavior change (PBC) to denote fundamental changes in sexual behavior, including partner reduction, that do not rely on devices or drugs. He, I and a very few others have suggested treating AIDS as a behavioral issue that calls for behavioral solutions, although not to the exclusion of risk reduction remedies. The dominant paradigm model treats AIDS as a medical problem requiring medical solutions. PBC deals with the problem itself, getting at what is needed for primary prevention, while the medical model deals with symptoms.

Risk-Reduction Model
The dominant prevention paradigm was developed for high-risk groups in US cities like San Francisco. Part of the risk reduction model was to not address sexual behavior. It was argued that this would amount to making value judgments, which is unscientific and would only drive away those who needed to be reached. AIDS experts settled for risk or harm reduction approaches, which assume that behavior is difficult or impossible to change, therefore efforts ought to be made to mitigate the consequences of risky behavior. Thus condoms and clean needles (if legal) were provided to reduce risk of sexually transmitted and blood-to-blood HIV infection respectively. There was and is no discouragement of any form of sexual behavior, or injecting drug use. AIDS experts applauded themselves for their open-mindedness and realism.

This approach might have been suitable for San Francisco or Bangkok. But when exported to Africa and other parts of the world, and despite claims to the contrary, there was little attempt to adapt the model to other cultural settings or epidemic patterns. In the US, Europe and most of Asia, HIV infections are concentrated in a few fairly well-defined high risk groups. In (sub-Saharan) Africa, most infections are found in the general population. Actually, many are opposed to this distinction, arguing, “Let’s not single out particular risk groups. That will stigmatize them—blame the victims—and make the general public feel that they are not at risk. So our message should be, “We are all at risk of AIDS.” This has a nice, egalitarian ring; we are all in this thing together. Nevertheless, differences in epidemiological patterns and cultural settings are real, calling for—among other things—different approaches to prevention.

AIDS Prevention in Africa
How has the Western risk-reduction model fared in Africa? Most efforts have focused on condoms. There is no evidence to date that mass promotion of condoms has paid off in decline of HIV infection rates at the population level. The UNAIDS multi-center study, published in a special edition of AIDS in 2001, found that condom user levels made no significant difference in determining HIV prevalence levels. And a 2003 UNAIDS review of condom effectiveness, by Hearst and Chen concludes, “There are no definite examples yet of generalized epidemics that have been turned back by prevention programs based primarily on condom promotion.”

Some argue that not enough condoms are being used in Africa to have made a difference yet, that condoms would have an impact if only we exported them in the billions instead of the mere tens of millions. Maybe, but what we do know from recent USAID data is that, after 15+ years of intense condom social marketing in Africa, the result today is an average of only 4.6 condoms available (not necessarily used) per male per year in Africa. That figure was actually a bit higher in the mid-1990s; it has declined somewhat even since then in spite of the explosion of AIDS in southern Africa. The problem seems to be low demand.


	This poster was intended by the Uganda Ministry of Health for teenage girls to discourage them from getting involved with older men who might be HIV+.

Uganda’s Approach
In addition to condoms, the other relatively expensive AIDS prevention programs currently funded by major donors are mass treatment of STIs, voluntary counseling and testing and prevention of mother-to-child transmission through Nevirapine. Like condom marketing, remedies rather than behavior change. These programs, along with condom social marketing, had not yet started in Uganda when infection rates began to decline in the late 1980s. Yet Uganda has experienced the greatest decline of HIV infection of any country. Its home-grown prevention program was based largely on behavioral change. Reacting to Western advice, President Museveni said in 1990, “Just as we were offered the ‘magic bullet’ in the early 1940s, we are now being offered the condom for ‘safe sex.’ We are being told that only a thin piece of rubber stands between us and the death of our continent. I feel that condoms have a role to play as a means of protection, especially in couples who are HIV-positive, but they cannot become the main means of stemming the tide of AIDS.”

Uganda’s largely home-grown approach to AIDS led to a delayed age of first sex, less casual sex, and relatively high condom user rates among the few who still engage in casual sex. Uganda also pioneered approaches in reducing stigma, bringing discussion of sexual behavior out into the open, involving HIV-infected people in public education, persuading individuals and couples to be tested and counseled, and improving the status of women. The genius of Uganda’s ABC program (Abstain, Be faithful, or use Condoms) is that it focuses on what individuals themselves can do to change (or maintain) behavior, and thereby avoid or reduce risk of infection. But it also tackled the difficult social and institutional problems that only committed governments can impact in the near- to intermediate-term. These programs were led by the government (especially the ministry of health) but also involved many NGOs and community-based local organizations.

Providing More Options
It has been difficult for Western donor agencies and consulting firms involved in AIDS prevention to accept evidence that suggests what they have been doing may not have been very effective in Africa; meanwhile something they have not supported has worked better. Some have dismissed the ABC approach as simplistic or narrow. Yet the ABC approach adds primary behavior change (the A and B of ABC) to existing programs that, for the most part, do not go beyond “C,” beyond condom (and drug) remedies. Adding primary behavior change provides people with more behavioral options for preventing HIV infection than are currently available, and these are sustainable options that do not depend on relatively high-cost Western imports.

Edward (Ted) Green, is a senior researcher at the Harvard School of Public health. He has applied anthropology for 30 years in Africa and Latin America/Caribbean. His new book, Rethinking AIDS Prevention, is due in November. See p 54 for his recent AIDS policy work.

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