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| From the October 2003
Anthropology News, p 7-8
HIV/AIDS and Behavior Change: Barbara Pillsbury Edward Green, one of the lead anthropologists contributing to the struggle against one of this century’s greatest plights, makes a case for primary behavior change (PBC). “The dominant paradigm,” criticizes Green, “treats AIDS as a medical problem requiring medical solutions.” Green urges instead a focus on direct factors that determine sexually-transmitted HIV infection–which concern sexual intercourse itself–thus emphasizing the ABC approach (Abstinence, Be faithful, or use a Condom). But AIDS also requires political solutions. Thus I urge: let us add PC—political commitment—to the ABC. What is desperately needed beyond ABC is political commitment. Beyond a doubt, political commitment is the “PC”, politically correct, approach–but, in most countries, a missing ingredient. This too is important behavior change that is essential, but that gets less attention in the search for solutions. It should not be forgotten in the present discussion either. Two countries illustrate the importance of political commitment: Brazil and Uganda. Brazil The Brazilian National AIDS Program is exemplary in combining aggressive HIV prevention campaigns with care for people living with HIV/AIDS. In May 2003 the Bill and Melinda Gates Foundation awarded its prestigious million-dollar Gates Award for Global Health to the government of Brazil, the first time ever that this award has gone to a government. The award was made in recognition of the political commitment on the part of the Brazilian government to a bold all-encompassing National AIDS Program. Jurors for the Gates award made this decision because they considered the Brazil program a model for combating HIV/AIDS elsewhere and hoped that the political commitment shown by the Brazilian government would inspire leaders of other AIDS-challenged developing countries to show the same political commitment. Brazil received international attention in 1996 when it guaranteed all citizens free access to antiretroviral drugs. The government greatly reduced treatment costs by negotiating lower prices with drug companies and by manufacturing generic versions of some drugs. The government estimates that, since 1996, its treatment program has reduced AIDS mortality rates by nearly 50% and opportunistic infections by 60-80% and prevented nearly 360,000 hospital admissions between 1997 and 2001, resulting in savings of more than $1 billion. Brazil’s treatment program is closely integrated with countrywide HIV prevention efforts, including education campaigns, HIV counseling and testing, condom marketing, and drug treatment programs, all addressing and serving all segments of society. In a recent report, “Access to HIV Prevention: Closing the Gap,” the Global HIV Prevention Working Group cited Brazil as “the clearest example of the potential synergy between prevention and treatment initiatives.” The success is also attributable due to the partnership between the Brazilian government and civil society. Noteworthy too is the fact that, although Brazil is a Catholic country, political commitment remained strong and included collaboration with sex workers, men having sex with men, and other groups often excluded in other Catholic countries. “Brazil has shown that with perseverance, creativity, and compassion, it is possible for a hard-hit country to turn back its AIDS epidemic,” said William Foege, senior fellow at the Bill and Melinda Gates Foundation. “Brazil is saving lives and saving resources at the same time, and that should be an inspiration to countries around the world.” Director of the Brazilian National AIDS Program, Paulo Teixeira, responded, “We are so thankful for this recognition of Brazil’s commitment to the basic human rights of people infected and affected by HIV and AIDS. We want to show the world that it is possible to provide care and prevention in developing countries” (www.aids.gov.br). Uganda Uganda also is widely lauded for its success in reducing HIV/AIDS. (Some sources cite a decrease as great as 15% to 5% between 1991 and 2001. Others cite a turnaround from 30% in the urban population to 8% in 2002.) Reasons for Uganda’s success have been heatedly contested. As summed up by Tina Rosenberg of The New York Times, "The religious right is convinced that it knows Uganda's secret: “abstinence” (April 29, 2003). Green is emphatic, however, that data show the main change was not abstinence but basic behavioral change–primarily drastic reduction in the numbers of sexual partners. "The most significant…appear to be faithfulness or partner reduction behaviors by Ugandan men and women, whose reported casual sex encounters declined by well over 50% between 1989 and 1995” (USAID, “The ABCs of HIV Prevention,” June 2003). Indeed then it is not abstinence at all that should be highlighted but rather Uganda’s President Yoweri Museveni for his committed leadership leading to the broad social mobilization that has been crucial to Uganda's success. Museveni decided early on that it was essential to tackle AIDS directly and openly, breaking the ancient taboos of Africa and elsewhere that keep people close-mouthed and hypocritical about sexuality. He co-opted powerful interest groups in Uganda to join the battle against AIDS. While other African leaders were maintaining a deafening silence on the emerging epidemic, or blaming it on foreigners, Museveni crisscrossed Uganda alarming, shaming, and cajoling Ugandans to face AIDS openly, to adopt the ABC strategy, and to stop stigmatizing those living “positively.” Museveni also made another bold political decision, unprecedented in Africa: to directly confront gender discrimination and inequities. He oversaw gender-positive revision of the constitution, appointed the first female vice president in Africa, gave women numerous senior cabinet positions, and appointed women to head strategic government agencies and assume senior ambassadorial posts. Rosenberg continues: “Only by understanding the entire program can one grasp Uganda's success and build models for other countries…. Any embrace of the Uganda strategy must include the full spectrum of its anti-AIDS efforts. Perhaps the most essential aspect of Uganda's response is the fact that the country has reacted to the epidemic as if it were World War III” (April 29, 2003). As Green writes above, the genius of Uganda's approach is that it “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.” Nowhere else in Africa have leaders shown such commitment. Elsewhere, where leaders turned their backs on the problem, rates have soared. The contrast between Uganda and Zimbabwe is painful. While Museveni led his country in openly confronting the scourge, Mugabe of Zimbabwe was attacking homosexuality, with mounting numbers of infected persons and AIDS orphans a consequence. Let’s add PC to the ABC. Barbara Pillsbury specializes in the evaluation of reproductive and sexual health programs in developing countries. She heads a consulting firm, International Health and Development Associates, which has worked on AIDS and reproductive health around the globe for organizations such as the World Health Organization, USAID, World Bank and the Ford and Rockefeller foundations. She was a founder of the Pacific Institute for Women's Health and is a board member of the Global Health Council. |
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