AIDS Prevention and Paradigms: An Electronic Discussion
This is an archive of a discussion held on the Aids and Anthropology Research Group's electronic discussion list spanning March 25th to April 20th, 2003 although the bulk of the messages were during the first ten days of April, 2003. I have quickly edited it to "get it out" to the interested public. If here are any errors or exclusions I will be happy to amend the text. If you would like to join in the discussion please consider joining our organization! Thanks to Ted Green who assembled the comments on behalf of AARG.
Debate over AIDS prevention paradigm, on AARG (AIDS and Anthropology Research group)
This should be read from top-down.
From: dfeldman@brockport.edu
Reply-to: aarg@creighton.edu
To: aarg@creighton.edu, bucko@creighton.edu
Sent from the Internet (Details)
Hi AARGers,
Since Ted has gone ahead and posted his "What Really Happened In Uganda" article, I should let you know that I respectfully and cordially disagree with his policy conclusions and believe he and others have significantly misinterpreted the data. In his article (edited by Janice Hogle), he argues that faith-based initiatives, abstinence, and marital fidelity (but not particularly condoms) are the answer for HIV prevention in Africa. He, and political conservatives, are touting the Uganda model as the centerpiece for how the proposed $15 billion allocation to mostly Africa over the next five years should be spent. Even though Ted tells me he is a liberal, religious right congressmen have last week invited him to testify before Congress (which he did), and he has become their hero, cited in the National Review and the Washington Times. He maintains that a strengthening in fundamentalist religion increased abstinence and fidelity before condoms were distributed in Uganda, resulting in a substantial reduction in HIV seroprevalence, and that this model should now be replicated for the rest of Africa.
But what really, REALLY happened in Uganda? I believe it is this: The Ugandan government and President back in 1986 took a bold step of breaking down the wall of denial about AIDS, worked with WHO and international HIV researchers, worked with the media to create a national anti-HIV campaign (ABC Campaign), destigmatized the disease, and urged every Ugandan to talk about sex and AIDS publicly and often. The result was not necessarily abstinence or marital fidelity, but substantial partner reduction among multipartnering Ugandans who took a short-term solution out of concern for their personal safety. When condoms were social marketed in the mid-1990's, the lowered HIV seroprevalence was sustained, and became their long-term solution. The reason why other African countries with social marketing of condoms did not produce lowered HIV rates was because the governments and national media never attempted in the first place to break down their impenetrable walls of denial, instead their silence kept the stigma of AIDS intact.
Trying to impose a sex-negative morality across all African cultures will not only fail to reduce HIV seroprevalence, but it will only bolster the rapidly growing danger of fundamentalist religion on the continent, and take Africa on a downward spiral into sexual repression and hostility. We need, instead, good qualitative research to find out what will it take for men to use condoms before and outside of marriage, culturally appropriate HIV intervention programs, government and national media campaigns about AIDS and condoms, research on effective spermicides, cooperation with local traditional healers, encouragement of masturbation as a substitute for risky sex among youth, HIV education programs among elderly who lead ritual initiations, ethnobotanical research to assist in the treatment of opportunistic infections, and collaboration with those (unfortunately few) progressive churches and mosques that do not believe that persons with HIV are sinners.
Thanks.
Doug
Dear AARGers,
I knew an attack was coming from my old pal Doug. A Kenyan anthropologist who gave a paper at SFAA told me that Doug has been quite upset by the implications of Uganda's ABC approach. Plus Doug and I have had some e-mails about such topics as: Can African really change behavior? Are all religious groups fundamentalists?
My basic thesis is that we on the Western donor side need to move from consensus based to evidence-based AIDS prevention. Why? Because AIDS prevention programs designed by Western experts have been largely ineffective in Africa. Among those who don't want to hear this message are the pharmaceutical industry, the beltway bandit organizations, and all those who for years have been repeating the mantra "the condom is the only proven intervention for AIDS."
I am talking about AIDS prevention here, not treatment, so please be clear about that. (Don't say "Ted Green is against ARVs for the poor!"). The condom-pill solution (pills being for treating STIs) to what is largely a behavioral problem just has not worked. I am a former condom social marketer myself, as Doug knows. There was a time when I thought our current approach of promoting the maximum number of condoms for the maximum number of people (that was and is the basis of getting contracts from donors) would actually work. Look at the data in Africa and you will see otherwise. See my congressional testimony for some of this:
http://energycommerce.house.gov/108/hearings/03202003Hearing832/hearing.htm
Incidentally, the UNAIDS multicenter study (published in a special edition of AIDS in 2001) found that condom user levels made no significant difference in determining HIV prevalence levels. But the condom solution has become big business, so few mention this finding of the multicenter study.
Indeed, the Western solution to AIDS has to a large extent incompatible with the cultures of Africa and other resource-poor parts of the world. The export of Western models of "behavior change" (which assume Africans are misbehaving and therefore need to change their behavior) has not had much impact on the ultimate measure-national HIV prevalence. Meanwhile, AIDS prevention and behavior change models that are largely indigenous and are aimed at actually changing behavior seem to have impacted national HIV prevalence.
This is becoming too long, and it may not even get posted on AARG (who wants to get on the wrong side of the guy who started the list?) But a few clarifications are in order.
Doug mentions some conservative media that have quoted me. However he chooses not to mention liberal media that also quote me, e.g. the NY Times and the New Republic :
http://www.nytimes.com/2003/02/02/weekinreview/02STOL.html?ex=1045212267&ei=1&en=61bfca898fea7807
http://www.thenewrepublic.com/doc.mhtml?i=20020527&s=allen052702
He also gives the wrong title for the paper I co-authored (adding the word "really")
He also assumes that all religions found in Africa are fundamentalist and condemners of HIV+ people. As I have tried to tell Doug before, the religious groups that worked in AIDS prevention in Uganda were the "big 3" for that country: Anglicans, Catholics and Muslims. These are not terrorists missionary groups who just want to spoil fun; they are groups with great influence in Africa whether Doug and I like it or not, and they promoted the A and B of the ABC approach. They also helped reduce stigma. The Anglicans and Muslims also promoted condoms, as I explained during Q and A in congress. But they refused to be reduced to condom promoters only.
As to "what really, REALLY happened in Uganda?" Doug says it was reduction in multi-partnering and reduction in stigma. That's exactly what I say in my congressional testimony! Its right there; read it for yourselves.
All the rest in Doug's posting really amounts to raising dark suspicions about what really, REALLY motivates Ted Green? I say: don't worry about the messenger; just look at the data. And do not try to reduce the genius of Uganda's approach to "abstinence only." This reflects obsession with an American debate. Uganda has a balanced ABC approach. Or at least it HAD. Since all the Western advisors began arriving starting in the early 1990s, Uganda's program had been brought more in line with Western views of how AIDS should be prevented. The donors with the money call the shots. National HIV prevalence has just climbed slightly in Uganda for the first time in a decade. Maybe it means nothing. But what if it reflects the diluting of Uganda formula for success by well-meaning outside experts? In fact, since 1995, there has been a slight return to older patterns of high-risk sex.
Ted
Edward C Green
Harvard Center for Population and Development Studies
9 Bow Street
Cambridge, MA 02138
Hi Ted,
Yes, I've read the NY Times article, and it is true that you support "partner reduction," not "abstinence." But the article also correctly points out that you have become "a hot property" among conservatives. It is important to realize that your ideas may be taken (perhaps wrongly) and used to advance, in this case, a very religious right political agenda. As far as partner reduction goes, it depends what you mean by it. If it means reduction down to no partners, that's abstinence; down to one partner, that's monogamous fidelity. While I also support the general principal of partner reduction (and I mean here perhaps an annual reduction from 20 to 10, or from 10 to 5, partners), it is more important to me that each intercourse be done with routine and proper condom use.
I agree that the whole debate of A (absintence) and B (be faithful) vs. C (condoms) avoids the more important prevention approaches of breaking down the wall of denial, national media campaigns and government support to raise awareness about AIDS while destigmatizing the disease, government programs to support anti-discrimination legislation and provide quality care and treatment for persons with AIDS, and the need to conduct nationwide culturally appropriate HIV interventions targeting subgroups. If we work with churches or mosques, we need to be selective to ensure that they would not condemn the very people they need to assist.
It has been 15 years since I've been to Uganda involved in AIDS research, but I've been to Zambia nine times from 1989 - 1999 working on three funded HIV prevention studies there. During that period, I saw a growing religious fundamentalism working closely with the government and media to condemn people with HIV/AIDS and to downplay to usefulness of condoms. Pat Robertson brought his TV/radio empire to Zambia in a big way, and President Chiluba, a born-again Christian, declared the nation a "Christian nation." Articles written about AIDS in the government-owned newspaper, the Times of Zambia, could not be published unless they included references to the Bible. And throughout the 90's, the HIV rates rates soared in Zambia. It is only now, since the end of the 1990's, that the HIV rates among teenagers (but not yet adults) have begun to decline as routine condom use through intelligent social marketing and other culturally appropriate targeted HIV interventions has increased.
While I cannot speak about how progressive the churches and mosques of Uganda are, as you suggest, I am aware that the American fundamentalist websites of Christian Broadcast News (Pat Robertson's 700 Club) and Sammy Tippit Ministries boast of the enormous success and inroads that they have been making in Uganda in the last few years. And the Ugandan President's wife recently attacked condom use at a religious right conference that was held. Indeed, the last two heads of the Ugandan HIV national committee were both clergy.
By the way, you are right that the title of the SYNERGY/USAID article is "What Happened in Uganda?" The conclusion of the text does, however, ask "what really happened in Uganda." Really!
Best,
Doug
Douglas A. Feldman, Ph.D.
Professor
Department of Anthropology
SUNY Brockport
350 New Campus Drive
Brockport, NY 14420 USA
(585) 395-5709
dfeldman@brockport.edu
In a message dated 4/1/2003 12:06:44 PM Eastern Standard Time, dfeldman@brockport.edu writes:
I agree that the whole debate of A and B vs. C avoids the more important prevention approaches of breaking down the wall of denial, national media campaigns and government support to raise awareness about AIDS, while destigmatizing the disease, government programs to support anti-discrimination legislation and provide quality care and treatment for persons with AIDS, and conduct nationwide culturally appropriate HIV interventions targeting subgroups.
Doug
I agree, but don't forget the empowerment of women. That was a major part of what Uganda did to realize both an AIDS prevention and a social/political agenda. Ugandan women today are more likley than ever to (1) be employed, (2) be in higher eduction; (3) say no to unwanted sex ; (4) insist on condom use; (5) serve in Parliament.
I am sorry if conservatives like some of the data I have been bringing to light. I don't have control over the political use of empirical findings. All I can do is try to say the right thing myself...and move AIDS prevention in a more evidence-based direction.
I do think we need to keep our own views and values from possibly coloring what we say professionally. I don't have any agenda regarding sexual behavior or religious groups. Whatever works to save lives is what I like. But I do have the comments below that you posted a couple of years ago on sex and religion. Do you think these personal views might keep you from being sympathetic to partner reduction--which on the face of it contradicts polyparterism--and focused on condom solutions to AIDS?
1. Douglas Feldman=20
Re: [944] Condoms and Abstinence
******************
Unlike gibbons and some other mammals, humans are not naturally monogamous.
Some major religions make polypartnering (having sex with several partners) a sin in order to promote monogamy. However, there is nothing intrinsically wrong with polypartnering. Indeed, polypartnering allows participants to enjoy a greater variety of sexual behaviors with a greater number of persons, to enhance their lovemaking skills, and it can be very enjoyable for both participants.
Imagine if religions were to dictate that it was morally wrong for people to eat out at different restaurants, requiring its adherents to stick to one restaurant for their entire lives; or to stick to one movie -- seeing the same film over and over again, never being allowed to see a new movie or to broaden one's experience.
The ideology of the sexual revolution which occurred in North America and Western Europe during 1965-75 was very important in breaking down the Victorian morality of the past, allowing people to become more sexually free.
I believe this was a positive change in human growth, and we should not use the HIV/AIDS crisis as an excuse to revert back to a monastic view of sex. We need to be more sex positive, and encourage people to feel they can become open to sexual experiences with different people. There is nothing wrong with sex with different partners. The problem is not the sex, but the failure to prevent unwanted pregnancies and sexually transmissible diseases.
Responsible polypartnering requires condoms and birth control as a given at all times. We need to teach those who engage in the joys of polypartnering how to effectively protect themselves from potential dangers.
Douglas A. Feldman, Ph.D.
Consulting Anthropologist, Florida
E-mail: Dafeldman@aol.com
---------------------------
Ted,
Well, you certainly know how to save those old e-mails! If I'm not mistaken, I believe I wrote that much more than two years ago, but I'll take your word for it. In any event, while my comments were general and not about Africa per se, after reading what I had written, I wouldn't change a word of it today (although I now prefer the term multipartnering instead of polypartnering). Having now confessed to being ideologically sex-positive and supportive of those who choose to multipartner (with condoms), let me add that others may, of course, choose to be abstinent, or faithful in a life-long monogamous relationship. My concern is that those who are abstinent and faithfully monogamous, anywhere in the world, should not dictate or denigrate those who multipartner. Additionally, (and here's proof that even I have limits) I support abstinence for those under 18 and for those over 18 who refuse to use condoms properly each and every time, and those in a faithful monogamous or faithful closed polygamous relationship where both or all parties are committed to being honest/trustworthy and have agreed to abandon the use of condoms, there should be an expectation that they would remain strictly faithful. My concern is that we should not spend $15 billion (or the 20% of that to be set aside for HIV prevention)to dictate a sexually repressive policy in Africa over the next five years. Right now, the Congress is debating this very issue (A and B vs. C), and I just hope that the bill won't be tied up there indefinitely because of this issue. However, I do support "partner reduction" with condoms as an alternative strategy for those concerned about further reducing their risk.
As far as the empowerment of women in Uganda assisting HIV prevention goes, I couldn't agree with you more. Certainly, the long-term solutions to AIDS in Africa will be solved by changes in the political economy and the empowerment of women. I was not aware that this was part of the Ugandan government's explicit strategy to prevent HIV (I have not seen it stated in any literature about AIDS in Uganda, or elsewhere in the world). But if it were, or even if it wasn't intended, this would go far in explaining the decline of HIV numbers during the 1990's in Uganda, probably more than any other single factor -- including fundamentalist religious indoctrination in support of abstinence and fidelity ideology. I think, if your facts are correct about the growing and significant empowerment of women in Uganda, you may have inadvertently stumbled on what REALLY happened in that nation!
Doug
Subj:
Re: [aarg] RE: What Really Happened in Uganda
Date:
4/1/2003 2:02:50 PM Eastern Standard Time
From: doug_goldsmith@HOTMAIL.COM
Reply-to: aarg@creighton.edu
To: aarg@creighton.edu
CC: egreendc@aol.com
Sent from the Internet (Details)
I see AARG as essentially an absolutely open forum and information exchange for all anthropologists concerned about HIV/AIDS. We always have open meetings at the AAA and SfAA, primarily to encourage all to take part, and keep the energy flowing. For the first 10 years or so we also had support groups at those meetings for any anthropologists dealing with personal stress and grief from working with and living with AIDS.
Once anything of interest is posted on our list, eg. a request for info, a job, a meeting, a source, etc. (which we all welcome as a way to inform and help out each other, and also as a good way to further the prime mission of AARG, which is "outward' as much as "inward" -- to help and encourage all anthropologists to address the AIDS/HIV pandemic everywhere in the world), I would say that any reply, response, correction, further discussion, from anyone, AARG member or not, is useful, dynamic, and, if from one of the central parties involved, perhaps vital. I'd like to say "Let's hear it all, from all. Let's cast our "net" wide -- I don't think we're afraid to hear any message from any messenger!" That boast said, the one thing I am afraid of is SPAM, which I guess is useless messages from ill intentioned messengers, or worse. I bow to our webmaster's earned wisdom to protect our list from that horror, and if that means restricting! postings to members, who each can with good intentions cross post things from nonmembers, then that's way it has to be. So our wide cast becomes an appeal to write us, or join us to be us. As Pogo, or Walt Kelly, quipped, "We have met the enemy and he is us."
Subj: RE: condoms only???
Date: 4/1/2003 2:42:36 PM Eastern Standard Time
From: EOnjoro@OSOPHS.DHHS.GOV
To: EGreendc@aol.com, dfeldman@brockport.edu
CC: DHalperin@usaid.gov, BdeZ@tvtassociates.com, bucko@creighton.edu, JanHogle@meadowrocks.com, JanieS@hispanichealth.com, iphexm@gwumc.edu Sent from the Internet (Details)
Ted and Daniel
I guess our friend Doug is taking the stand that he knows more about Africans sex life and behavior than Africans themselves. Better yet, that sexual behavior must be understood by the standards set by his own culture. OR mirrors his own culture. For God's sake what happened to diversity!!!!!!!!!. As an anthropologist, I am perturbed to see that many in our profession still evaluate and narrowly interpret culture through their own ethnocentric ideals.
The article by Doug only depicts that his school of thought is driven by luck of understanding of the TRUE African, (or let me limit it to Kenyan since that is where most of my experience lies), sexual behavior and culture. Africans are not the crazed sexual animals we have been portrayed - by professionals like Doug - as running wild with desire to poke any hole in sight. It may appear that way on the surface but underneath, that sex life is very well organized.
Polygamy does not mean everyone in the block is screwing one another. Polygamy predates many STDs in Africa. When Europeans came to Africa they brought much of the STDs we see today. They did not find these polygamous humans spreading some sexual diseases among themselves like fire. I hope Doug takes the time to spend more years of close living in Africa to begin to understand what our sex behaviors REALLY are. I do not mean spending six months talking to some group of Africans. I grew up in Africa and as anthropologists, I have a totally different belief of what Africans sexual behaviors are. Abstinence is build into many African cultures as part of various ritauls. The term or practice did not came to Africa from the conservative Christian wing as it seems to be the case here in America.
With that said, I must add that culture changes constantly with time and space. Through time Africans have changed various aspects of their cultures to fit circumstances. I could list pages of some of those changes in my own culture. Taking the stand that if Africans choose to adjust their sexual behavior as a response to a calamity such as AIDS, then they are repressing their true desires is, without a doubt, a short sighted perspective on the cultural evolution process. American's have money so thinking of condoms as a solution may fit their environment. Many African nations are economically deprived and taking a non-commercial approach to solving AIDS was and still is their only main hope of saving the continent. Uganda had no choice but to come up with a non-commercial solution to the AIDS crisis. Why is this so hard for other people to understand? If the process is not high tech then it is inadequate regardless of the evidence?????????.
Africans love sex and I do not believe they will suppress their sexual desires in a million years, however they are faced with a calamity to which they must respond. Liz
Subj: Re: [aarg] Re: FW: ABC in Uganda
Date: 4/1/2003 4:05:17 PM Eastern Standard Time
From: Anthro8566@aol.com
Reply-to: aarg@creighton.edu
To: aarg@creighton.edu
Sent from the Internet (Details)
I wanted to respond to two comments in Ted Green's posting. The first is this:
AIDS prevention programs designed by Western experts have been largely ineffective in Africa.
This is a problematic way of phrasing the work that has been done, which often has been collaborative and has not involved taking off the shelf models from the US and implementing them in Africa. An example is Project RESPECT which was first developed in the U.S. and then adapted for use in 5 African countries. The outcome data has been widely published and the model--which promotes condom use within a broad frame--has been proven effective in outcomes research.
Ted's second comment: "This is becoming too long, and it may not even get posted on AARG (who wants to get on the wrong side of the guy who started the list?)" Members are free to express their opinions on the AARG listserv. Not surprisingly, we will not agree on all issues. Debate of the sort that has gone one with regard to AIDS prevention in Uganda is precisely one of the primary functions of this mechanism. What has happened, in other words, is a good thing. Perhaps you have not noticed by the SMA has desperately hoped for this kind of active, enlivened exchange on its website, but has largely failed to get it. So, as long as new points are being made, and real engagement is happening (as opposed to again and again repeating precisely the same point) then there is no issue about the debate going on too long. Let a thousand similar debates bloom.
Merrill Singer
Subj: Re: [aarg] Re: FW: ABC in Uganda
Date: 4/2/2003 12:31:07 PM Eastern Standard Time
From: Anthro8566@aol.com
Reply-to: aarg@creighton.edu
To: aarg@creighton.edu
Sent from the Internet (Details)
This issue in the current (very active) AARG debate is not condoms per se, or who is for them, who is against them (even though this seems, at times, what is being debated). Nor, should the sincerity, commitment, or integrity of the participants in the debate be the issue in question (unless there is something I don't know about), although this too has seemed like a primary issue under discussion at times. Nor should who can post on this listserv be the issue, as long as we can make sure that the listserv is about AIDS and Anthropology and not an outlet for spammed ads for penis enlargement (I am on AOL and already get all of those I can use). The real issues, I believe, are effective AIDS prevention in local context, community participation in setting prevention agendas, community/research collaboration, and cultural imperialism. One of the issues under discussion is: do condoms really work in Uganda? This is an empirical question not a moral one. So far, the facts are in dispute. When facts are in dispute (and, of course, even when they are not), it is easy for those engaged in debate to cite their favorite studies and data bases. As anthropologists, I doubt that there is anyone in this discussion who is not strongly in favor--in principle--of community participation in all steps of the decision-making and implementation process in AIDS prevention. Nor, would any anthropologist I know of (okay, I don't know everyone) favor pressing an intervention model on a group/society/population/country/individual against their will or with an awareness that is is culturally inappropriate. As has been pointed out in the medical anthropology literature, the road to hell is paved with the good intentions of outside interventionists. But, we are generally blind to our own cultural assumptions. The culture in them is hidden to us, because they seem to make so much damn sense. And so we screw-up, thinking what we are doing is right and appropriate when it is just our culture using us as its agents of diffusion (that was said tongue-in-cheek for fans of bio-evolutionism). So where does this all lead? I would strongly urge someone organize a panel for the AAA on these issues, something like Is Culture a Threat to AIDS Prevention. Perhaps our in-coming AARG president (hint, hint) might be inclined (before you ask, because I have 5 "re-write and resubmit articles" sitting on my desk daring me to take on one more thing and not attend to them).
Merrill Singer
Soon to be ex-prez
Hi Doug Feldman and AARGers
You wrote:
My concern is that we should not spend $15 billion (or the 20% of that to be set aside for HIV prevention)to dictate a sexually repressive policy in Africa over the next five years
Thanks for your last note. I was a little reluctant to post your polypartnering note because it seemed like I was raising the stakes in this debate. But since you had posted it before, and you re-endorsed the views yesterday, I guess it was OK to do so.
And I am encouraged by the open, cordial atmosphere (so far!) I have found at AARG.
As for dictating policy in Africa, there are a growing number of us who have come to view the West's policy of funding prevention programs that focus on condoms as just that. Lets not pretend to ourselves that the condom is an indigenous African solution to AIDS. If it were, there would be more than 4.6 condoms per male per year in Africa now (Shelton, J. & Johnston, B. (2001). Condom gap in Africa: evidence from donor agencies and key informants. BMJ, 323, 139). And that is a measure of availability, not actual use, which would be lower since not all condoms we export are used.
I could give you so many ex's of what I mean by the West dictating its priorities to Africa, even apart from the record of where most of our prevention funding has gone to date, and the condom-heavy nature of program impact indicators.
Since Liz Onjoro is Kenyan and she is part of this discussion, let me use a recent ex. from Kenya. I received the following note, quoted here with permission, from the founding Chairman of the Kenya National AIDS Control Council, Muhammad Abdullah (10/31/02):
"I am sure you are aware that at times help comes with strings attached. We received US $10 million aid but it had to be (used) only (for) condoms. We had two options: to accept all the US $10 million worth of condoms or refuse. If it was our choice, we would have spread this help to other forms of prevention as well and particularly advocacy for behaviour change in schools. The ministry of education is looking for help to print its syllabus, and book aids to help the teachers and the children to learn about HIV infection and how to prevent it. No one wants to help to prink books and teaching aids... So you can see the mismatch in emphasis between the needs perceived by locals and those of our collaborators. We have adopted an attitude that anything that helps is welcome, even if it is not priority, since we may not get what we call priority (help) if we insist on having it our way (paren. mine)."
This speaks for itself (and what polite language!). Although we cannot quantify it adequately, few funds actually go to behavioral or primary prevention interventions, in fact to any interventions other than condoms or drugs. Thus I don't think Africa is in immediate danger of a sexually repressive policy being dictated to them.
I'll bet you that most money will continue to go to condoms and pills over the next 5 years. The pharmaceutical companies and beltway bandits are worried that the business of AIDS might change, but let my bet stand and we shall see.
cheers, Ted
Harvard Center for Population and Development Studies
9 Bow Street, Cambridge, MA 02138
Ted and Daniel:
I wonder how many of you have a copy of the AIDS Initiatives bill that was proposed three weeks ago and the amendments that followed. This bill is not saying the $15 billion should be used for abstinence programs. It is saying that all parts of the A-abstinence, B-be faithful, and C -condoms should be given equal strengths in HIV prevention. Unlike in the past were the CDC and USAID had a tinny A and B and huge C as their only strategy to prevention. For once US funding can be used to promote a strategy that works for everyone - those who wants to use Condoms can get them, those who prefer other ways also can use A or B.
Part of what Uganda and Senegal did in their programs was advocate ZERO Grazing (ZG). ZG can be done within polygamy without reducing the number of wives or partners, as is being advocated in the gay community (as noted by Doug) in the US. The Ugandan model also called for having fewer partners, especially among teens and the unmarried adults. If a man has 5 wives and he sleeps only with them and they with him - that is what being faithful also means. My age mates and I learned about ZG in 1986 and 87 long before we knew or saw a condom. Would we have faired better if we had access to condoms? - I do not know for sure, but I do not think so.
Africans have not, and I believe will not, in the near future be monogamous. In my mind as an African, being faithful is not necessarily equal to being monogamous.
Have you ever thought - what if, what if the CDC and USAID had promoted ABC in equal strengths in Africa????? What if, what if they promoted political will as well!!!!!!!! What if field officers did not impose their ideological beliefs about prevention on the African continent? What if!! Has anyone stopped to think why this did not seem to work for Africans? Do you know how many lives have been lost because the US had to uphold their ideological ideals of prevention. If it worked in NY, San Francisco, Florida then it must work in Africa.
Today you must be aware that this ideal is failing here in your own backyard. With 8-12% increase in new infections for year 2002, where is the miraculous condom when all these people were being infected. Why did they not use one? Condoms are now available in incredible flavors, colors, sizes, and strengths all over the US. They have become a part of wallets and pocketbook contents. Surely, could it be ignorance of the people? No, we cannot argue that anymore. Then what???? We need a diversified approach to prevention and ABC provides that.
Have you wondered what would have happened if what took place in Uganda had actually occurred in FL or MD? Would it be a national mandate for policy? But since it was Uganda and not an innovation of USAID or UNAIDS or CDC it seems harder for the "experts" to absorb and build into policy to lead the world in the fight against HIV AIDS.
ABC is an African owned response, an indigenous and western knowledge integrated approach to HIV prevention - and I am hearing that this is not good for Africans - we should follow the American approach of reducing partners and learning to use condoms - only. In Uganda and Senegal's "A" did not come from the Christian wing. I am sorry the US's - "A" did have these religious roots. This is important in order to understand the context in which A is being perceived in both continents. The Christian wing here just happens to agree with that philosophy because it suits their belief system. As anthropologists we must not narrow ourselves to understanding culture based solely on our own belief system. I learned abstinence from my parents not from the church. The goal was to keep us from getting pregnant not STDs. So to me the A is nothing but a familiar term that has no religious connotation.
Are we going to fail at taming the spread of HIV as has happened with so many past development endeavors? Haven't we learned that a Western model is not always the best for everyone? What happened to giving Africans a chance to come up with their own ideology and models that work for them? They have done so, and what I am hearing is that it is wrong and that it should not be funded because in the US that means Christian right wing ideology? Folks - those of you who are familiar with the development literature should be wary of history repeating itself because our funding must follow the funder's philosophy.
I must say that we have to be cautious as we use the Human Relations Area Files data. Let me put it this way. How would you feel if I told you that I understand American sexual behavior and want to advise policy in that regard based partly on 1850-1950 archival data? Better yet, 98% of which was collected, written, and interpreted by non-Americans (lets say European invaders, religious groups saving heathens souls, and Africans). These people were like many researchers of today who analyze African behavior. They in fact held very ethnocentric epistemological perspectives as travelers and colonialists collecting information on groups they saw through their own cultural lens as perverted heathens and primitive wild sex maniacs who kept many wives without the ability to limit themselves to one partner. While data from HRAF has some good background information on African sexuality, you do not want me to believe that the US is still living in the sexual environment of the 40s, 60-70s. Many things may remain the same, but many have changed as well.
HRAF information is not a source I want as reference data on African sexual behavior in the year 2000. The $15 billion is on the table for policy direction in 2003. If cultures change then, we should use today's African sexual beliefs and behavior to inform that policy.
How do we expect to effectively inform policy if we ourselves are relying on spurious data to understand other human groups? HIV is a public health issue driven to a great degree by human behavior. As anthropologists, we claim to be knowledgeable on cultural and behavioral understanding. It would do our profession a better service if we apply that knowledge to effectively inform policy. I mean policy to improve public health not to hinder or slow its progress. People are dying and children are left to fend for themsleves while we bicker as what is good or not good for them. Why don't we ask them and find out.
Thanks
Liz
Daniel,
Yes, I would like to get a copy of your op ed article. You can either e-mail it to me, or mail it to me at: Dept. of Anthropology, SUNY Brockport, 350 New Campus Drive, Brockport, NY 14420. Thanks.
Actually, my very first study on AIDS back in 1982-83 in NYC among the gay community taught me that the immediate reaction by gay men in the US (and apparently by Ugandans as well) to confronting the AIDS epidemic was partner reduction. Gay men reported a reduction from a mean of 6.8 sexual partners per month before they heard of AIDS down to a mean of 3.6 sexual partners per month at the time of the survey (I published this in Human Organization back in 1985). Reducing the number of partners in the face of a lethal STI is reasonable and to be expected. However, I'm glad the government did not spend $15 billion back then to coerce gay men to give up sex altogether.
Doug
Dear AArgers,
For once I find myself heartily agreeing with Doug Feldman that sex-positive and anti-fundamentalist approaches have more to recommend them than abstinence/fidelity backed by moralist preachments AND the stigma that fallss on those who do/cann not comply. Some will remember my articles on this, including the chapter in ten Brummelhuis and Herdt, Culture and Sexual Risk (1995) and in Locke and Kauffert, Pragmatic Women (1998). The first refers to struggles for control in Uganda, and comes from my experience 1992 in drafting UNICEF's plan to protect youth from AIDS, as well as similar work in Tanzania in 1991. In both settings I was able to do particip-observ with host country counterparts, including two women (Christian and Muslim) utterly opposed to condoms for youth until our joint field visits brought them face-to-face with the reality of girls' vulnerability. In my most recent pub, I reviewed the UGA data and came up with dif conclusions than Green. The news of his testimony before Congress, if true, is appalling. As is his book touting THs for their theories of contagion assumed to be like ours.
We already know several ways to bring African men to use condoms, even = at home. Is anybody listening???
Let's keep talking.
Brooke G. Schoepf
(from Ted)
Well folks, this has been relatively non ad hominem until Brooke G. Schoepf jumped in and called my efforts to bring to light the ABC approach as appalling as my last book! It had to happen: one does not challenge business-as-usual and get off lightly.
I will resist the temptation to be pulled into such exchanges and just take the time here to deal briefly with her argument (framed in a Western-biased manner) that:
"sex-positive and anti-fundamentalist approaches have more to recommend them than abstinence/fidelity backed by moralist preachments AND the stigma that falls on those who do/can not comply"
If this statement were true, we would see more stigma and discrimination in Uganda, which took an unusually "A and B" approach, than elsewhere in Africa. Yet the opposite is true. Uganda was the first SSA country to fight stigma successfully. Plus the DHS shows that women feel they are able to refuse unwanted sex in Uganda than in other African countries. Sorry if that is "sex-negative."
Brooke, I am sorry that Uganda did not prevent AIDS the way you wanted them to. I am sorry that most Africans are religious (don't they know any better?? Don't they realize that religion is sex-negative??). But can't we both be happy that what they did worked? Think of the hundreds of thousands of lives that have been saved. I find it hard to argue with success.
Or perhaps you think it was condoms that did the trick? In fact, by 1995, after incidence and prevalence had been declining for a few years, 6% of all Ugandans 15-49, M+F, reported condom use during last intercourse with any partner. Meanwhile 95% reported one or zero sex partners in the past year.
The latest UNAIDS review of condom effectiveness (Hearst and Chen 2003) concludes, "There are no definite examples yet of generalized epidemics that have been turned back by prevention programs based primarily on condom promotion." I think we all have to admit that things are not turning out the way we expected.
Ted
Subj: RE: [aarg] Fwd: What Really Happened in Uganda
Date: 4/2/2003 9:29:46 PM Eastern Standard Time
From: mattsteinglass@YAHOO.COM
Reply-to: aarg@creighton.edu
To: aarg@creighton.edu
Sent from the Internet (Details)
Hello Ted,
It's been fascinating to watch this story develop over the last couple of years; I remember you first suggesting when I interviewed you 2 years ago that condoms are a favorite of Westerners because we like technical solutions, but they might not turn out to be the answer for Africa. And now this seems to have become a crucial debate in the US's expanding global anti-AIDS program. How the worm turns...
Anyway, here's a question I think is important for the average bystander and taxpayer in this debate. If the key to HIV prevention in Africa is partner reduction and other forms of non-condom behavior change following indigenous cultural models and led by autochthonous religious, community and political leaders, then why does Africa need foreign aid for HIV prevention at all? Just how much money does it take to get imams, ministers and traditional healers or chiefs to encourage faithfulness and prolonged virginity? It seems to me Yoweri Museveni, who has the resources to organize and equip very effective armed forces, probably has the resources to organize and equip an effective autochthonous HIV prevention effort, if it really is such a priority for him to maintain local control over how the money is spent.
I mean, isn't the point of foreign aid precisely to support programs which local governments and communities either lack the resources or expertise to carry out, or are unwilling to carry out for political or cultural reasons? If they have the expertise (because behavior change should be based on indigenous cultural resources), and they have the will (because we should be following their lead, not imposing solutions from the outside), then why do they need us, or aid, or USAID?
Matt Steinglass
mattsteinglass@yahoo.com
+84 904 223 676
Hi Matt
I forgot you are on this list. Long time no see. Maybe you can provide the URL of the great cover story you wrote for Lingua Franca, so others on the list can read it.
You asked a crucial question: " If the key to HIV prevention in Africa is partner reduction and other forms of non-condom behavior change following indigenous cultural models and led by autochthonous religious, community and political leaders, then why does Africa need foreign aid for HIV prevention at all?"
The only thing that could possibly make me less popular than questioning condoms and suggesting we need to move more toward evidence-based AIDS programs, would be if I suggested that mega-bucks MAY not be needed for effective prevention. Especially now when e.g., the Gates Foundation has "declared war" on AIDS in Botswana and is going in with all kinds of drugs, devices and medical tests.
I will say this much: it did not cost Uganda very much to turn around its exploding epidemic in the last 1980s. I say this because seroinicidence peaked in the late 1980s, before the expensive programs we all associate with AIDS prevention (condom social marketing, treatment of STIs, VCT, PMTCT) even began.
On the other hand, it did cost something. And there is no reason that "zero-grazing" cannot be "marketed" through mass media, use of (hopefully paid) community health workers, etc. In fact, this is part of how the Zero Grazing message got out in the 1980s and later.
In my new book, out late this year, I conclude with a section that discusses some of the ways that "primary behavior change" can be promoted--based on how this has actually been done in Uganda, Zambia, Senegal, Jamaica, etc, not on any theories on my part.
But Matt, you really asked a really good question.
What I would like to see is the new $15 billion dollars of Bush administration money NOT being spent on only 14 countries. I'd like to see at least the prevention part of these funds spread out over many more countries in need, and for donors to move more toward effective prevention. A country like Guyana (where I have worked designing a national AIDS program) does not need a billion dollars for AIDS. Meanwhile Congo (DRC) is not on the list of 14 countries. So I say: do prevention better and spread the money around more!
Ted
Hi Bill Weintraub and AARGers,
My comment, that I am glad that the government back in the early 80s did not spend $15 billion to coerce gay men in the US to give up sex, was not intended to imply that they either did or tried to do that. Between 1981-1985, the federal government's contribution to fighting AIDS among gay men probably totaled somewhere less than a dollar. My comment was said in the context of our discussion about the $15 billion being allocated to fight AIDS in 12 African, one Caribbean, and one South American nation. I am very pleased to learn (Jim Abrams, Associated Press, 4/3/03) that the House International Relations Committee only two days ago (on April 2nd) thwarted an effort by conservative Republican Congress members to add an amendment stating that, while condoms could be a part of AIDS strategies, abstinence and monogamy should have priority. But the vote was nervously close, 24-20, with an amendment, by Rep. Barbara Lee that does not give preference to any one preventive method, passing instead. But we need to watch closely as it comes up for a full vote before the House and as it passes through the Senate in the next few days and weeks.
I fully support non-penetrative sex, including frottage (interfemoral sex or on the partner's stomach or back), mutual masturbation, self-masturbation, deep kissing, licking, and cuddling, among both gay and straight people in the US and Africa (and elsewhere). I also support less risky sex, such as fellatio, cunnilingus, anilingus with a thin transparent barrier, digital vaginal or anal penetration. Certainly, if gay or straight people wish to enter into a faithful permanent relationship with one or more partners that should be encouraged (I suspect that in only 30 short [LOL] years, gay marriages will finally be legalized in the US). And no one should feel peer pressure to engage in either vaginal or anal sex if they don't want to.
Having said that, I also support gay or straight people worldwide who wish to either engage in vaginal or anal multipartnering sex with a condom. Admittedly, multipartnering with a condom does have a failure rate of about 15% (according to the report just circulated to the AARG list by Elizabeth Onjero). But that also means a busy gay man in the US or an equally busy heterosexual man in Uganda who has 100 partners a year with a condom is only half as likely to become HIV infected than someone having 30 partners a year without a condom. Encouraging partner reduction with condoms would reduce the risk, but foisting American religious fundamentalism and abstinence/fidelity messages on all of Africa as an excuse to control HIV is not the way to go.
Doug
Douglas A Feldman, Ph.D.
Professor
Dept. of Anthropology
Ted (and AARGers),
I certainly agree that we should not be dictating HIV policy for Africa from the West without an understanding of cultural factors. And I agree that far too few anthropologists have been involved (or hired by the "beltway" organizations) so far, and this has resulted, I believe, in such poor results as only 4.6 condoms available per person per year in Africa. Applied cultural anthropologists need to take the lead in finding out how to design culturally appropriate interventions that would make proper condom use routine among all sexually active multipartnering males in sub-Saharan Africa. We need to make our interventions targeted to specific cultures and ethnic groups, male/female, age cohorts, income/social class differences, etc. Rather than imposing a Western format, we need to do the qualitative research to find out what would actually work in the local population. We need to learn which of their values, norms, and beliefs could be effectively used to their reduce sexual risk in a successful multi-dimensional (meaning not just condoms) intervention (see my Social Science & Medicine paper, 1997). My concern is that the first and loudest voices we hear are those who advocate abstinence and fidelity and condemn the sinners who multipartner. We need to seek out those (especially the men) who are neither abstinent nor faithful, and perhaps not that religious, and "RAP (rapid assessment procedures) them" until we learn exactly what it would take to get them to practice safer sex. Then you will see routine and proper condom use go way up and HIV rates go way down.
Condoms are the single most important thing Africans can do to reduce HIV transmission on the continent. The fact that only 4.6 condoms are available per person per year in Africa tells me that it hasn't actually been tried. The last I looked, condoms were about a nickel each in bulk at cost, and is one of the cheapest interventions available for men; of course, we desperately need an effective microbicide for women now that nonoxynol-9 is no longer recommended. It is hard for me to belief the story of the Kenyan AIDS Committee Chair, since the math doesn't add up. With $10 million just for condoms, that's 200 million condoms at a nickel apiece, or 23 condoms for each of the 8.8 million males between 15-64 in Kenya (World Factbook), far more than the 4.6 condoms per year. Perhaps if there were 23 condoms per male per year, or maybe 100-200 condoms, the HIV rates in Kenya would plummet.
The whole ABC debate (ABc, ABC, or abC), however, avoids the focus of what needs to be done in Africa. Rather than an ABC Campaign, I would promote an ACCDGLMT Campaign (if we add some vowels and re-arrange the letters, it might spell out something)! A (Anti-discrimination), C (Condoms, and lots of them), C (Culturally appropriate and ethnographically researched [maybe by an actual anthropologist!] interventions), D (Destigmatization of the disease), G (Government involvement and commitment to a secular and humanitarian solution to the health crisis), L (Less risky sex - encouraging self-masturbation among youth, perhaps oral sex, and non-penetrative sex [interfemoral, mutual masturbation, etc.] as substitutes for vaginal or anal sex), M (media campaigns directed to both the general public and targeting specific at-risk populations, providing unambiguous information and promoting understanding of persons with HIV/AIDS), and T (Traditional healers, since they are the primary health providers in most of Africa). Sometimes solutions don't come in only three letters, it may take eight or more.
Doug
Douglas A. Feldman, Ph.D.
Bill Weintruab asked me to post this since he does not on AARG but he has been in this discussion.
[AARG POST 2]
Hi Doug and other AARG list members,
Doug, you say that "My comment, that I am glad that the government back in the early 80s did not spend $15 billion to coerce gay men in the US to give up sex, was not intended to imply that they either did or tried to do that. Between 1981-1985, the federal government's contribution to fighting AIDS among gay men probably totaled somewhere less than a dollar."
I'm glad that you agree that the government didn't try to coerce gay men into giving up sex, but you're wrong about the federal government's dollar contribution in the early years of the epidemic.
I know, because from 1981-84 I was the NYC metro area coordinator for Gay Rights National Lobby, and in that capacity I facilitated, among other things, the first meeting between GMHC and a member of Congress, Rep. Bill Green, a Republican who was on the House appropriations committee.
In other words, the meeting was about money -- federal money -- it took place in late November of 1982, Paul Popham and Larry Kramer were there, Green promised to help, and indeed he did from that time forward.
So while it's true that the Reagan administration behaved shamefully throughout, that's not true of the Congress, and particularly not the House, which is where the money comes from. Representatives like Henry Waxman fought hard for money into research about cause and treatment.
For example, in July of 1983 Waxman got emergency funding of $30 million through the Congress, and in October of '83 Congress okayed a new AIDS budget of $41.4 million, a $16 million increase over the previous year, and far in excess of the $17 million requested by the Reagan administration.
So the federal contribution to fighting AIDS had been far more than $1 by 1985, and though we now recognize that the amount budgeted was inadequate, we need to keep in mind that in '83 the incidence of AIDS was still very low -- Larry Kramer published a polemic titled "1,112 and Counting" in March of 83, and that 1,112 refers to cases, not fatalities -- to date there'd been only 418 deaths, and many people, including many AIDS activists like Michael Callen and Richard Berkowitz, were not convinced that AIDS was spread through an infectious agent.
Of course today we know better, and that's why it's so important, in light of what we do know, that we make accurate assessments of pleasure and risk when we look at sexual behavior.
In that respect I'm concerned, Doug, that you don't understand what frottage is nor the hierarchies of risk, because you say "I fully support non-penetrative sex, including frottage (interfemoral sex or on the partner's stomach or back), mutual masturbation, self-masturbation, deep kissing, licking, and cuddling, among both gay and straight people in the US and Africa (and elsewhere). I also support less risky sex, such as fellatio, cunnilingus, anilingus with a thin transparent barrier, digital vaginal or anal penetration."
In point of fact, frottage is far less risky than fellatio, anilingus, or digital anal penetration.
Further, nowadays frottage, or as we now call it "frot," is not commonly thought of nor practiced as "interfemoral sex or on the partner's stomach or back."
Rather, frot (rhymes with hot) or frottage is phallus against phallus sex, and that's the reason Chuck Tarver and I have been putting it forward:
Frot is intensely and *genitally pleasurable for both partners* because the genitals stay in contact throughout the act, and it's the only MSM sexual act which involves direct genital-genital contact.
That's what makes frot so different from anal penetration. For while it's common for people to, as you did, make an equation between vaginal and anal sex, genitally there's a big difference: penile-vaginal sex is genital-genital sex, penile-anal sex is not. Neither the anus nor the rectum are genital organs, they are not vaginas, and what a man being anally penetrated feels is not remotely comparable to what a woman who is vaginally penetrated feels.
The only way men can have direct, mutually pleasurable genital-genital sex is through frot.
Given then that frot is so much more pleasurable than anal, and so much less risky, does it really make sense for us to, as you said, "support gay or straight people worldwide who wish to ... engage in ... anal multipartnering sex with a condom."?
Since, as you also say, "Admittedly, multipartnering with a condom does have a failure rate of about 15%."
In other words, is the pay-off in sexual pleasure worth the very real risk?
No.
Indeed, it seems to me that given the recent discussions in Barcelona about the extent of anal transmission among heterosexuals, we should not be supporting anal penetration among gay or straight people.
That doesn't mean banning anal -- but it does mean looking very hard at condom campaigns and the role they play in shaping MSM and other sexual cultures.
Once again, that's what Chuck and I have suggested doing.
Because we need to know why people are engaging in anal penetration.
And for MSMs, we believe the answer is "culture."
And that's not just our answer. That's what CAPS researchers said as far back as 1997 in a study labeled QIS II (this is from the Executive Summary): "In QIS II, individual formulation of gay male identity and self-worth to a significant degree was based on adherence to specific sexual performance standards and practices within gay male culture. Men in QIS II frequently described anal sex, and particularly anal sex without condoms, as a means to affirm their gay identity, experience intimacy, and feel a broader social and cultural connection."
Chuck Tarver and I maintain that safer-sex condom campaigns are major players in the shaping of that cultural identity, that identity of gay with anal.
Is that something we want to export to Africa? Is that something we have a right to export to Africa?
Africans themselves, on this board, have spoken up in defense of Ted Green's work and in defense of their right to self-determination -- including sexual self-determination.
That should be everyone's right, without interference from anyone, no matter how well-intentioned, who thinks that Western ideas about multipartnering and pansexuality should be part of the cultural baggage of all humankind.
For when we look at the history of the sexual revolution in the Western world, what's apparent is that it has not been an unmixed blessing, that while liberating to some, it has brought disease and psychological pain to many.
So I believe that condom campaigns have from the first, in the US, been ideologically-driven, that they've had an impact on MSM and nongay culture which, though perhaps unintentional, has been harmful, and that the last thing we should do is export them to other countries and other cultures.
Rather we should be working to reverse their destructive effects here.
In that regard, you say, Doug, that you "fully support non-penetrative sex." And that reducing partners reduces risk. Would you then support our program of "frot fidelity," which is a combining of non-penetrative sex and partner reduction designed to reduce risk to near zero?
Isn't that a lot better and doesn't it make a lot more sense than reducing risk to a 1.5 chance of contracting HIV, HPV, and who knows what else per every 10 encounters?
And if so, what percentage of safer-sex spending would you be willing to allocate to such a campaign?
Bill Weintraub
bill@man2manalliance.org
http://www.man2manalliance.org/
Doug and all
The 2003 Cochrane condom review to follow concludes "This review indicates that consistent use of condoms results in 80% reduction in HIV incidence."
That is when used consistently. But we know consistent condom use is the exception in Africa.
Africans and others should not pin upin all their hopes on condoms, even if they are using them consistently. I suggest that we need other interventions as well. Partner reduction has worked. Lets not dismiss it as "abstinence and spreading stigma" because some of us persist in seeing it though an American lens.
Ted
From The Cochrane Library, Issue 1, 2003. Oxford: Update Software Ltd. All rights reserved.
Condom effectiveness in reducing heterosexual HIV transmission (Cochrane Review)Weller S, Davis, K.ABSTRACT Order full review View and/or submit comments
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About The Cochrane Library
A substantive amendment to this systematic review was last made on 19 November 2001. Cochrane reviews are regularly checked and updated if necessary. Background: The amount of protection that condoms provide for HIV and other sexually transmitted infections is unknown. Cohort studies of sexually active HIV serodiscordant couples with follow-up of the seronegative partner, provide a situation in which a seronegative partner has known exposure to the disease and disease incidence can be estimated. When some individuals use condoms and some do not, namely some individuals use condoms 100% of the time and some never use (0%) condoms, condom effectiveness can be estimated by comparing the two incidence rates. Condom effectiveness is the proportionate reduction in disease due to the use of condoms.
Objectives: The objective of this review is to estimate condom effectiveness in reducing heterosexual transmission of HIV.
Search strategy: Studies were located using electronic databases (AIDSLINE, CINAHL, Embase, and MEDLINE) and handsearched reference lists. Selection criteria: For inclusion, studies had to have: (1) data concerning sexually active HIV serodiscordant heterosexual couples, (2) a longitudinal study design, (3) HIV status determined by serology, and (4) contain condom usage information on a cohort of always (100%) or never (0%) condom users. Data collection and analysis: Studies identified through the above search strategy that met the inclusion criteria were reviewed for inclusion in the analysis. Sample sizes, number of seroconversions, and the person-years of disease-free exposure time were recorded for each cohort. If available, the direction of transmission in the cohort (male-to-female, female-to-male), date of study enrollment, source of infection in the index case, and the presence of other STDs was recorded. Duplicate reports on the same cohort and studies with incomplete or nonsepecific information were excluded. HIV incidence was estimated from the cohorts of "always" users and for the cohorts of "never" users. Effectiveness was estimated from these two incidence estimates.
Main results: Of the 4709 references that were initially identified, 14 were included in the final analysis. There were 13 cohorts of "always" users that yielded an homogeneous HIV incidence estimate of 1.14 [95% C.I.: .56, 2.04] per 100 person-years. There were 10 cohorts of "never" users that appeared to be heterogeneous. The studies with the longest follow-up time, consisting mainly of studies of partners of hemophiliac and transfusion patients, yielded an HIV incidence estimate of 5.75 [95% C.I.: 3.16, 9.66] per 100 person-years. Overall effectiveness, the proportionate reduction in HIV seroconversion with condom use, is approximately 80%.
Reviewers' conclusions: This review indicates that consistent use of condoms results in 80% reduction in HIV incidence. Consistent use is defined as using a condom for all acts of penetrative vaginal intercourse. Because the studies used in this review did not report on the "correctness" of use, namely whether condoms were used correctly and perfectly for each and every act of intercourse, effectiveness and not efficacy is estimated. Also, this estimate refers in general to the male condom and not specifically to the latex condom, since studies also tended not to specify the type of condom that was used. Thus, condom effectiveness is similar to, although lower than, that for contraception.
Citation: Weller S, Davis, K. Condom effectiveness in reducing heterosexual HIV transmission (Cochrane Review). In: The Cochrane Library, Issue 1 2003. Oxford: Update Software.
This is an abstract of a regularly updated, systematic review prepared and maintained by the Cochrane Collaboration. The full text of the review is available in The Cochrane Library (ISSN 1464-780X).
The Cochrane Library is prepared and published by Update Software Ltd. All rights reserved.
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File Reference: AB003255
Dear Doug Goldsmith
I accidentally deleted your posting which suggested possible names for an AAA panel. You may already know this from communicating about this debate with Jan Hogle, namely that USAID hired Jan as an editor/writer for the 4 papers that were summarized as What Happened in Uganda (and I don't know if I'd call this a volume...its just a very short paper!). I am not sure Jan wants to get into the debate defending the papers technically that she summarized as editor/writer. We could ask Jan.
The only anthropologists I can think of at present who might be willing to raise questions about the condom solution and the current prevention paradigm, in such a forum, are African. Or they work for the US government and so may be hesitant to participate. Elizabeth (Liz) Onjoro could hopefully participate. It was Liz's debate with Doug Feldman at SFAA that I think really tripped off the current debate on AARG.
So we need to get at least Liz. Otherwise I might be the only voice on one side of the debate. I am not sure I want to step into that furnace. In fact, fairness would suggest that there be an equal balance between the two highly polarized (esp. in America) viewpoints.
By the way, from Doug F's last posting, let me say yet again that he and I have no disagreement about fighting stigma and discrimination, the role of traditional healers (I have worked in traditional healer programs for over 20 years), poverty being a bad thing, etc. It comes down to the disagreement over the role of condoms and that of partner reduction (which cannot be reduced to "abstinence" and "shaming") in population-level HIV prevalence reduction.
While I am thinking about DF's last message, that figure of 4.6 condoms per male per year in Africa (Shelton and Johnston 2001) actually peaked in the mid-1990s, before the major explosion of AIDS in southern Africa. That figure even may have declined somewhat. The problem seems to be with low demand; it is not on the supply side. The donors would like nothing better than to supply more condoms. Doug and the Donors (that could be 1960s rock band) couldn't agree more (and I am talking about DF not necessarily DG).
DF also wrote: "It is hard for me to belief the story of the Kenyan AIDS Committee Chair, since the math doesn't add up. With $10 million just for condoms, that's 200 million condoms at a nickel apiece, or 23 condoms for each of the 8.8 million males between 15-64 in Kenya (World Factbook), far more than the 4.6 condoms per year. Perhaps if there were 23 condoms per male per year, or maybe 100-200 condoms, the HIV rates in Kenya would plummet."
I knew it would be hard for some to believe, which is why I quoted the Kenyan official directly (with his permission). Although if the issue is how many condoms we can distribute for $10 million, we need to recognize that the cost of distribution--even through social marketing--has little to do with the cost of condom themselves. Most distribution costs go to Western marketing experts and the like (not that Africans do not also work in social marketing).
I can't believe I am doing this on an early Sunday morning. I should be out playing in the snow (I am in Maine)
Ted
As simple as ABC?
When I was involved in the research and design of a national prevention brochure for secondary school students in the former Zaire, we took the ABC approach and incorporated local knowledge and practices within the behavior change messages. We (Doctors Without Borders) worked with the religious school systems and the government. To us, ABC didn't seem all that innovative (in 1995). Reviewing the available successes of HIV prevention, we thought the Ugandan example or the "fleet of hope" framework of ABC showed the most successful behavior change models for youth. The model gives different youth different messages and provides support both for those who are sexually active and those who are not. The work in Zaire was not always easy: headquarters in Brussels pushing us a bit to be more direct and the religious authorities in Kinshasa trying to restrain the "pornography" of the brochure (a drawing of a young couple in bed, under cover, or the drawing on correct condom use).
I am still trying to fully comprehend what happened in Uganda. I am worried that some of the current news stories and/or analyses present a history that is too simplistic, turning a complex interplay of events and actions into a simple AB vs. C (or ABc) framework, which may in turn become a technocratic policy strategy. At times, the presentation of numbers is done rather quickly. In the NY Times article, Ed Green states that in 1995 95% of Ugandans reported either one or zero sexual partners in the past year. What does this number represent? All Ugandans, only the sexually-active ones, or the married ones, ...? In the Washington Times article, it says "Ugandan boys" aged 13-16 showed increasing abstinence (to the point that only 5% reported being sexually active in 2001). It should state that these boys are in schools of the Soroti district with specific IEC programs. One cannot extrapolate such figures to national levels: according to the 2000 DHS, for adolescents aged 15-17, 34% reported having been sexually active).
I don't believe in simple answers about what is a highly complex phenomenon. Highlighting one element (condoms, faithfulness, STI control, empowerment of women, political will, reduced stigma, etc.) as a main cause of HIV decline negates the complexity and the rich context of Uganda's success. Neither should one element be foregrounded in future prevention activities. As an anthropologist, I like "thick descriptions". The Alan Gutmacher Institute (Singh, Darroch, Bankole 2002: www.agi-usa.org) looked at the Uganda DHS data, compiled a thick memo with more complex answers, and argues that all three factors (abstinence, monogamy and condom use) plus broader social factors (like political involvement and NGOs fighting stigma) contributed to the decline in HIV. Its analysis of ABC is more nuanced: abstinence, monogamy, and condom use play a role but do so variably. Especially young women are abstaining more (15-17 year-olds more than 18-19) and have less partners, while changes among other age-groups are more variable and do not always follow a trend of increased abstinence/monogamy. E.g., current sexual activity actually increased among sexually experienced young men from 1995 to 2000 (along with condom use). Condoms may have mattered less early on (but how reliable was behavioral data then?). Nevertheless condom use among groups with higher-risk behavior (CSW, truck-drivers, military) is/was very high, which is an important point. Their increased use generally in the 1990s certainly contributes to the continued decline in HIV.
We should not forget the politics involved (in Uganda and the US). US conservatives may like simple ranked answers that prioritize the A and B, but will they like the fact that Uganda has had a fairly comprehensive sexuality education program in primary schools since the late 1980s (and consequently provide funding for its extension to other African countries, maybe even to Texas)?
So it's not just ABC, but also other elements like P(olitics and wide community Participation), S(upport, STI control, School Sex Education), and frank D(iscussions). Shouldn't we advocate for extending that comprehensive approach and further highlight the thick context of Uganda's success? Pieter Remes HIV/STI Research & Intervention UnitInstitute of Tropical MedicineNationalestraat 1552000 Antwerp - Belgiumtel +32-3-2476531fax +32-3-2476532email premes@itg.be & mnyonge@yahoo.com
As simple as ABC?
When I was involved in the research and design of a national prevention brochure for secondary school students in the former Zaire, we took the ABC approach and incorporated local knowledge and practices within the behavior change messages. We (Doctors Without Borders) worked with the religious school systems and the government. To us, ABC didn 't seem all that innovative (in 1995). Reviewing the available successes of HIV prevention, we thought the Ugandan example or the "fleet of hope" framework of ABC showed the most successful behavior change models for youth. The model gives different youth different messages and provides support both for those who are sexually active and those who are not. The work in Zaire was not always easy: headquarters in Brussels pushing us a bit to be more direct and the religious authorities in Kinshasa trying to restrain the "pornography" of the brochure (a drawing of a young couple in bed, under cover, or the drawing on correct condom use).
I am still trying to fully comprehend what happened in Uganda. I am worried that some of the current news stories and/or analyses present a history that is too simplistic, turning a complex interplay of events and actions into a simple AB vs. C (or ABc) framework, which may in turn become a technocratic policy strategy. At times, the presentation of numbers is done rather quickly. In the NY Times article, Ed Green states that in 1995 95% of Ugandans reported either one or zero sexual partners in the past year. What does this number represent? All Ugandans, only the sexually-active ones, or the married ones, ...? In the Washington Times article, it says "Ugandan boys" aged 13-16 showed increasing abstinence (to the point that only 5% reported being sexually active in 2001). It should state that these boys are in schools of the Soroti district with specific IEC programs. One cannot extrapolate such figures to national levels: according to the 2000 DHS, for adolescents aged 15-17, 34% reported having been sexually active).
I don't believe in simple answers about what is a highly complex phenomenon. Highlighting one element (condoms, faithfulness, STI control, empowerment of women, political will, reduced stigma, etc.) as a main cause of HIV decline negates the complexity and the rich context of Uganda's success. Neither should one element be foregrounded in future prevention activities. As an anthropologist, I like "thick descriptions". The Alan Gutmacher Institute (Singh, Darroch, Bankole 2002: www.agi-usa.org) looked at the Uganda DHS data, compiled a thick memo with more complex answers, and argues that all three factors (abstinence, monogamy and condom use) plus broader social factors (like political involvement and NGOs fighting stigma) contributed to the decline in HIV. Its analysis of ABC is more nuanced: abstinence, monogamy, and condom use play a role but do so variably. Especially young women are abstaining more (15-17 year-olds more than 18-19) and have less partners, while changes among other age-groups are more variable and do not always follow a trend of increased abstinence/monogamy. E.g., current sexual activity actually increased among sexually experienced young men from 1995 to 2000 (along with condom use). Condoms may have mattered less early on (but how reliable was behavioral data then?). Nevertheless condom use among groups with higher-risk behavior (CSW, truck-drivers, military) is/was very high, which is an important point. Their increased use generally in the 1990s certainly contributes to the continued decline in HIV.
We should not forget the politics involved (in Uganda and the US). US conservatives may like simple ranked answers that prioritize the A and B, but will they like the fact that Uganda has had a fairly comprehensive sexuality education program in primary schools since the late 1980s (and consequently provide funding for its extension to other African countries, maybe even to Texas)?
So it's not just ABC, but also other elements like P(olitics and wide community Participation), S(upport, STI control, School Sex Education), and frank D(iscussions). Shouldn't we advocate for extending that comprehensive approach and further highlight the thick context of Uganda's success?
Pieter
You wrote:
In the NY Times article, Ed Green states that in 1995 95% of Ugandans reported either one or zero sexual partners in the past year. What does this number represent? All Ugandans, only the sexually-active ones, or the married ones, ...?
the group here is all Ugandans 15-49. The data are from a table created by DHS for our USAID ABC study, based in 1995 DHS data. (If you think about it, the denominator could not be only the sexually active since some in the group had zero partners)
You also wrote:
"The Alan Gutmacher Institute (Singh, Darroch, Bankole 2002: www.agi-usa.org) looked at the Uganda DHS data, compiled a thick memo with more complex answers, and argues that all three factors (abstinence, monogamy and condom use) plus broader social factors (like political involvement and NGOs fighting stigma) contributed to the decline in HIV."
Thats just what we said in our USAID paper What Happened in Uganda?
You also made another point, asking whether US conservatives:
"will like the fact that Uganda has had a fairly comprehensive sexuality education program in primary schools since the late 1980s..."
Thats true, maybe they won't like this. Uganda probably had the first and best primary school program in Africa.
I had a maximum of 700 words in my NY Times article, so obviously I could not say much. In my new book, I have a lot to say about Uganda's school health education program (SHEP), which began in 1987. The aim of this program was to reach youth with AIDS prevention information before they become sexually active. It was also known that dropout rates after primary school were high. AIDS was not the only were component of SHEP, but it was an important one. The behavior change emphasis was on delay of debut, but condoms were also promoted. In fact, SHEP was very bold in this regard, for Africa in the 1980s, or for primary schools anywhere, anytime. I have seen a 1987 book used in this program; it shows an erect penis and shows how a condom should be worn.
I also write about Life Skills and other programs aimed at school and out-of-school youth
Thanks for contributing
Ted
Edward C Green, PhD
Harvard Center for Population and Development Studies
9 Bow Street
Cambridge, MA 02138
This is from Bill Weintraub
[AARG -- why a gay secularist supports ABC]
In one of his posts responding to me, Doug Feldman said that "foisting American religious fundamentalism and abstinence/fidelity messages on all of Africa as an excuse to control HIV is not the way to go."
I support abstinence/fidelity messages, as well as non-penetrative alternatives, and I'm not a religious fundamentalist -- I'm an old-time Gay Liberationist and secular Jew.
So why do I support fidelity among American MSMs and why am I sympathetic to those who support ABC in Africa?
Because I can do the math, and in regard to the US, I understand the difference between straight male multipartnering and gay male multipartnering.
My first lover, who was a gay-identified man, died of AIDS. But my current lover was until very recently straight-identified and had only heterosexual contacts -- and those were all vaginal.
Like a lot of straight-identified guys, my lover knows exactly how many women he's had sex with -- 30.
He's 45, and he became sexually active at 14 -- so that's about 1 partner per year for the last 30 years.
Some of that time, however, he was monogamously partnered, so that actually 28 of those contacts are distributed over 17 years -- but that's still less than 2 per year on average.
Let's compare that number to Doug's figure for San Francisco MSMs in 1983: 6.8 sexual partners a month -- or about 82 per year -- more than 40 times greater.
Using those numbers, we can posit a hypothetical gay man who comes out when he's 20 and engages in anal multipartnered sex for the next 30 years.
In that time he will have had 2460 partners -- more than 80 times as many as my straight-identified lover.
Assuming that our hypothetical gay guy uses a condom with each of those contacts, and taking the Cochrane figure posted on this board of a 20% failure rate, during that period he will have been infected 492 times with HIV, HPV, and whatever else is out there.
And that's assuming condoms were used "consistently" -- which, I know from my own MSM experience, they rarely are.
Furthermore, the Cochrane figure is for vaginal sex -- anal sex is rougher on a condom, and the failure rate is higher.
(See in that regard Halperin, Daniel, "Heterosexual Anal Intercourse: Prevalence, Cultural Factors, and HIV Infection and Other Health Risks, Part I.," AIDS PATIENT CARE 13 (12):717-730, December 1999.
Halperin observes:"...there are reports that condom breakage, slippage, and discomfort are more common during anal sex ... In fact, emerging research suggests the alarming finding that even "protected" receptive anal intercourse may present a relatively high level of risk for infection by HIV and some STDs, as well as HPV-related anal cancer.52, 97, 98")
[Halperin cites the following articles:
93. Thompson JL, Yager TJ, Martin JL. Estimated condom failure and frequency of condom use among gay men. Am J Public Health 1993;83:1409-1413.
94. Silverman BG, Gross TP. Use and effectiveness of condoms during anal intercourse: A review. Sex Transm Dis 1997;24:11-17.
95. Grady WR, Tanfer K. Condom breakage and slippage among men in the United States. Fam Plann Perspect 1994;26:107-112.
96. Reiss IL, Leik RK. Evaluating strategies to avoid AIDS: Number of partners vs. use of condoms. J Sex Res 1989;26:411-433.
97. Vittinghoff E, Douglas J, Judson F, McKirnan D, MacQueen K, Buchbinder SP. Per-contact risk of human immunodeficiency virus transmission between male sexual partners. Am J Epidemiol 1999;150:306-311.
98. Moscicki AB, Hills NK, Shiboski S, et al. Risk factors for abnormal anal cytology in young heterosexual women. Cancer Epidemiol Biomarkers Prev 1999;8:173-178.]
So I think it's reasonable to suppose that our hypothetical gay man will have had far more than 492 infections -- probably more like 700 to 800.
That explains why, as David Tuller reported in the NY Times, "Although anal cancer is rare in the general population, the risk for men with a history of anal intercourse can be more than 30 times as great, published studies have shown."
And it also explains why STI rates in general are so high among American MSMs, and why I'm opposed to supporting, as Doug said he does, "gay ... people worldwide who wish to engage in ... anal multipartnering sex with a condom."
I think that's a mistake, and I think the numbers clearly tell us so.
I believe that what's needed is on the contrary to debunk anal sex, to destroy its mystique, to attack the culture of promiscuity among MSMs, and to put forward non-penetrative alternatives and fidelity as the far healthier way to live.
I lost my first lover and more than 200 friends to anally-transmitted HIV -- there's virtually no one left in my life from the two decades between 1975 and 1995.
That's too high a price to pay for the hardly unalloyed joys of multipartnering, and you don't have to be a fundamentalist to think so.
Now, in my post yesterday, I asked Doug what proportion of safer-sex monies he'd be willing to allocate to non-anal alternatives.
He hasn't responded.
A couple years back I asked the same question of Tom Coates (CAPS). He didn't respond either.
Which is why I believe that condom campaigns and campaigners are ideologically-driven.
Clearly, if you want to reduce HIV prevalence, you need to reduce the prevalence of anal sex among both MSMs and heterosexuals, and you need to reduce the number of partners.
Yet when people like myself or Chuck Tarver or Ted Green endorse non-anal alternatives and ABC -- which is a moderate program -- we run into a hailstorm of criticism from people who appear to be determined to defend multipartnered anal or vaginal intercourse no matter what the cost.
Isn't it better to provide the undistorted facts and then let MSMs, Africans, and everyone decide for themselves?
Bill Weintraub
bill@man2manalliance.org
http://www.man2manalliance.org
Hi Ted --
another question you might be able to reply to before our interview. People seem to be treating the Ugandan ABC program as though it were exceptional in its emphasis on abstinence and fidelity, and on condom use only as the third alternative. But all the HIV prevention programs in Togo also used the ABC model, and seemed to have been doing so ever since they got started in the late 1980s. These programs had been in place long enough that KAP surveys showed adequate understanding of AIDS and its modes of transmission among 98% of youth -- I thinkw this was under 35, I forget the cutoff age of the survey, but the point is that exposure to AIDS education seems to have been fairly thorough over the past 15 years. Yet HIV rates were estimated at 6% in 1999, 8% in 2001, and climbing. It was my impression, in fact, that the ABC model was pretty much standard for all HIV prevention programs throughout Africa. So why do people claim that Uganda's success proves the efficacy of emphasizing fidelity, when programs with the same emphasis seem to have failed everywhere else?
Matt Steinglass
mattsteinglass@yahoo.com
+84 (4) 978-0173 tel
+84 904 223 676 cel
In a message dated 4/7/2003 10:25:44 PM Eastern Daylight Time, mattsteinglass@YAHOO.COM writes:
It was my impression, in fact, that the ABC model was pretty much standard for all HIV prevention programs throughout Africa. So why do people claim that Uganda's success proves the efficacy of emphasizing fidelity, when programs with the same emphasis seem to have failed everywhere else?
Matt
you always ask great questions. I deal with this in my book and can only outline a bit here.
1. ABC was/is often the name of the game, but funds go to the C and D of ABCD (D=drugs for treating curable STIs). This means the A and B are effectively left out, although Uganda and Senegal developed their ABC programs before many Western experts showed up--and they have maintained more independence in implementing prevention programs than most other African governments.
2. There actually used to be a bit more real ABC in Africa than there is nowadays. Somehow the A and B became defined by Westerners as "missionary terrorism" (e.g., Talbot 1990: 41). Some UNAIDS officials that are trying to keep partner reduction out of public discourse actually published their own data showing partner reduction in the mid-1990s. An investigative journalist needs to track down this story.
3. In spite of Western bias toward technological fixes (condom-pill solutions), there HAS been A and B behavioral changes. When Africans are asked in open-ended Qs if they have changed their behavior because of AIDS, and if so, how, they say: Yes...and usually "I am now faithful to one partner." Condoms are rarely mentioned in spite of all the social marketing, CBD, etc
In fact when there are behavioral data from Demographic and Health Surveys from the same country over a period of time, pertaining to age of sexual debut and proportions sexually active before marriage, as well as proportions reporting multiple partners, the behavioral trend is almost always in the direction of less risk. Condom use also rises (with some exceptions like Malawi).
4. Uganda and Senegal implemented more genuine culturally appropriate AB interventions than other SSA countries. I think that goes a long way in explaining why they are Africa's two success stories. In Uganda, there were signif. changes in A and B behaviors. In Senegal, there was less risk to begin with, plus high rates of male circumcision. But then Senegal implemented a balanced ABC program, and did this BEFORE HIV bridged into the general population. Today I think national HIV prev. (ANC data) is about 0.4%
cheers, Ted
Hi Ted,
I'll be glad to read more of your analysis of Uganda's sexual education program; it's an element that hasn't been discussed enough. My point about US conservatives not liking it comes from seeing what the US administration is doing with its federal dollars: according to a Newsweek article (International edition, Dec 9, 2002), all the new federal dollars in the US are going to a restrictive abstinence program which includes teaching that "sexual activity outside the context of marriage is likely to have harmful psychological and physical effects" and "a mutually faithful monogamous relationship in the context of marriage is the expected standard of human sexual activity." By law, these programs (falling under SPRANS Special Projects of Regional and National Significance) cannot promote or endorse condom use.
In that context, my worry is that a watered-down version of Uganda's prevention program turned into USAID policy will be further obstructed by the push in the current administration for restrictive abstinence. Daniel, maybe you can give us your perspective on the USAID side?
The AGI report is similar to "What happened in Uganda?", but it offers more nuances to the different trends in abstinence, monogamy and condom use, and leaves out any ranking of interventions in terms of what's been more effective in the HIV decline. In WHIU? the role of condoms early on is downplayed (but there's no DHS data for men in 1988). You do state that in the 1990s condoms play a role. I agree that WHIU? gives credit to all contextual issues, but are we not in danger of ending up with a simple AB and a very small c, in the current political environment? The media and conservatives single out the role of condoms and this may be counterproductive: youth in many African settings are already picking up on this debate and forego condoms, saying they're not 100% effective, they don' t protect against disease (which adds onto other rumors about condoms). Not only youth do this. I was recently in Kenya and Zambia, where adults (and even some community health workers) discourage condom use with this same argument.
In my notes, I found this quote : "the frequency of breaking chastity vows is much higher than the frequency of breaking condoms" (by Ira Reiss?)
Snow in Maine? I'm in hot, humid Lagos (with a slow internet connection so I don't spend too much time on the internet, otherwise I'd look at the ABC materials on the USAID website).
Pieter
Pieter Remes, Ph.D.HIV/STI Research & Intervention Unit
Institute of Tropical Medicine
Nationalestraat 1552000
Antwerp, Belgiumtel 3-2476531
fax 3-2476532
email premes@itg.be or mnyonge@yahoo.com
Hi Doug:
You say that "Using the same report you sent (see below), it is clear that condom slippage and breakage occurs only 1.6%-3.6% of the time (2000:9); there is an 85% reduction in HIV/AIDS transmission risk when infection rates were compared in always vs. never users (2000:14), and "these data provide strong evidence for the effectiveness of condoms for reducing sexually transmitted HIV" (2000:14).
While the statements above are all true from the research and debate I sent you, we need to understand that efficacy or effectiveness also heavily relies on whether the product is used or not used. Condoms can bring 85% reduction only if used consistently and correctly 100% of the time. While the Knowledge Rate of condoms stands very high in Africa, their Use Rate remains very low and only slightly above average among the high risk groups. The Use Rate of condoms is also becoming a problem in this country, with resurgence of several STD's such as syphilis, PPV, etc. and increases in new HIV infections. Do you know how ORT is fairing in Use Rate after over three decades?
While condoms may seem the next best thing in your mind, the question is how will you convince/influence Africans to use them consistently and correctly 100% of the time in order to achieve 85% effectiveness? Mass social marketing in that regard has not been able to achieve much in its 15 years plus spree.
The key message in the US today is, our prevention strategies and messages are not working anymore. That strategy is based on the public health policy founded on condoms-use to prevent STDs and HIV. This cry is coming from those at the frontline working on prevention. We need to think of something else. In addition, use of condoms does not prevent STDs that can be transmitted through kissing (Reuters Health 3/35/03 and Journal of Virology 77(6) by Dr Xuan Liu or Drew University.) and other bodily fluids through close contact.
Thanks
Elizabeth
Dear AARGers, Liz and Pieter I second what Liz Onjoro wrote to Doug Feldman re. condom effectiveness. And there is even more to keep in mind. One of the shortcomings of studies of condom effectiveness is that CUMULATIVE RISK OVER TIME is not usually factored into estimates. Yet think about it: whatever the risk of exposure per episode of sex with an infected partner, that risk will increase steadily with continued episodes of intercourse with an infected partner, or partners. Thus "…general statements about condoms being "80%, 90%, or 99% effective" for preventing STDs must be avoided. For such statements to be accurate, the number of exposures to a particular STD must be specified."(Mann, Stine, Vessey 2002). Here is where cumulative risk must be considered: "As the number of uses of any imperfect prevention intervention increases, the cumulative potential for intervention failure also increases (Mann, Stine, Vessey 2002). Fitch and colleagues point out that an intervention that is 99.8% effective for a single episode of intercourse can yield an 18% cumulative failure rate with 100 exposures (Fitch et al 2002: 812). Oh, and let me make a quick comment on a note Pieter sent (maybe I can respond further when I have more time): the Guttmacher paper was able to be more nuanced in its discussion of Uganda's program environment than we were in our USAID paper, because we had 10 pages to tell the story, while Guttmacher had about 30 pages! But the weakness of the longer Guttmacher paper is that it missed the Big Story. The behavior change that happened in the latter 1980s, which was mostly partner reduction. Thus the Guttmacher was able to reach conclusions such as "There has been no general pattern of increased abstinence among those who were sexually experienced" (Guttmacher 2002: 5.) This may be true if you only compare 1995 and 2000. During this period, the behavioral changes that appear to have been reponsible for reversing Uganda's exploding epidemic in the late 1980s and early 1990s were already starting to erode. Cheers, Ted Edward C Green, PhD Harvard Center for Population and Development Studies 9 Bow Street Cambridge, MA 02138
Subj: [aarg] Condoms vs Partner Reduction
Date: 4/8/2003 4:07:22 PM Eastern Daylight Time
From: ProfessorBolton@aol.com
Reply-to: aarg@creighton.edu
To: aarg@creighton.edu
Sent from the Internet (Details)
Dear Colleagues,
I am not an African specialist, nor have I had time to follow this "debate" here in detail. However, I would like to inquire if anyone could tell me how the study done by Reiss and Leik applies or does not apply to the African context. Reiss and Leik's computer modeling of transmission indicated that under almost all circumstances, condom use was a superior strategy for reducing HIV infection. Apparently many of the contributors to this discussion think this is not the case in Africa. Anyone care to clarify?
Ralph Bolton
Pomona College
Ralph
Modeling studies based on Africa (e.g., Auvert and Ferry 2002, Auvert et al 2000; Bernstein et al 1998; Robinson et al 1995) suggest that partner reduction has a more significant impact on reducing HIV infection rates at the population level than even consistent condom use (which may not be achievable in any case).
Beyond modeling, which relies on hypothetical assumptions, the UNAIDS Multicentre study (involving 4 African countries, and published in a special issue of AIDS) found that condom use made no significant difference in explaining widely differing levels of HIV infection.
Anyway, I wish we could get beyond "Condoms vs Partner Reduction" and agree to develop and support balanced ABCD programs that contain all needed interventions. People differ, so they need a range of interventions. Just as they do in family planning.
Ted
-----Original Message-----
Tuesday, April 08, 2003 3:40 PM
To: Lorie Broomhall
Ok, to quote Popeye, "It's all I can stands 'cause I can't stands no more!" I can't hold back! I am an anthropologist currently conducting ethnographic research on condoms, condom promotion and STIs in Kenya for one of those "beltway bandits."
If Ted is referring to STI meds when he says Western "technological fix", I have to say that I think that type of "fix" is a very important for HIV reduction, considering how much more vulnerable one is to HIV when infected with other STIs. In fact, some Western orgs have contributed to the absence of adequate STI treatment. The World Bank, for instance, used to fund the purchase and distribution of STI kits to public facilities in Kenya. In the past, STI patients could go to the public clinics and hospitals for free STI medications. Now those supplies have run out, and no other agency has stepped up to the plate. Given the 25-30% rate of HIV infection in Western Kenya, and the strong connections, both behavioral and biological, between STIs and HIV, the stopping of funding for STI kits is madness.
In my opinion, a major reason why condom use in Kenya has not increased significantly (except among some high risk groups like commercial sex workers) is that condoms are not heavily promoted by health providers in public clinics and hospitals, despite repeated trainings on HIV/STI prevention and condom counseling. Part of this situation is due to a crumbling medical infrastructure. From our study on condom promotion among STI service providers in Nyanza Province, providers said that they did not adequately promote condoms because they didn't have time and/or they were not well trained and/or supervised. In addition, clinics often were suddenly closed down due to labor strikes or drug stockouts. During our year-long ethnographic study, we discovered that STI providers were not promoting condoms because they felt that clients would not be receptive, so it was a waste of time. Some would only give condoms to married women, others gave to only unmarried women, and still others refused to give condoms to people under 18. Besides not counseling clients about condoms, it was not unusual for a provider to NOT counsel them about the fact that he or she had an STI. This was especially true for women who often were just told "Take these pills." We also interviewed traditional healers, pharmacy clerks , herbalists, and what we euphemistically referred to as "STI entrepreneurs" (the field team called them "quacks") who "diagnosed " and sold drugs to STI- infected people at market places, bus stops and other local venues). We wanted to determine if they did condom promotion and counseling and if so, what the content and quality of their condom counseling was. They of course fared even worse than the clinic staff.
My point here is that it's hard to tell if intensive condom promotion, esp. by health providers, would help to increase condom use and thus reduce the incidence of HIV and STI in Kenya because the health delivery system is in such bad shape, due to economic underdevelopment as well as years of bad national leadership and corruption, that it thus far has not seemed equipped to take it on. Elizabeth Onjoro says that Western behavior change and social marketing efforts haven't worked to increase condom use in Africa. I don't know if the strategy of condom use in itself is faulty, or if the interventions designed to promote them are not well implemented. But here's a scenario for the sake of comparison: in California, the Conservatives liked to say that the bilingual education programs in the public schools were a big waste of time because they didn't improve the quality of education for Spanish-speaking children. But the real reason behind this was that most of the bilingual programs were very poor. Often the local school boards, principals and teachers didn't care about them, the funding wasn't there, and the people hired to be bilingual teachers often were not qualified. The programs failed but not necessarily because bilingual education was a bad idea. The problem was that there was no collective will to make it happen.
There has to be a collective will to make condom use successful and that comes from the national leadership. It wasn't that long ago that President Moi and other national religious leaders burned condoms and condom promotion literature on the steps of the Capitol in Nairobi. Recently, Moi put forth his own AIDS prevention plan: to wipe out AIDS, everyone in Kenya should abstain from sex for two years. This suggestion trickled down the bureaucratic chain all the way to the tiniest of clinics with catastrophic results. With the new administration in power, hopefully this attitude will change.
One last thing to mention and you can take it for what it's worth. I've traveled to Kenya frequently in the last 3 years and each time I go, inevitably someone (who is Kenyan) will tell me they are glad that international NGOs are involved in the research and implementation of HIV/AIDS projects rather than handing the money to the Kenyan government, because some corrupt politician(s) would most likely siphon off a good portion of it. Are Westerners angels of mercy? Hell, no! Are we self serving? Hell, yes (ask me about the female condom!)! But we have a few good ideas, I think.
Hi Lorie
You wrote:
--I am an anthropologist currently conducting ethnographic research on condoms, condom promotion and STIs in Kenya for one of those "beltway bandits."--
I sympathize. I did that for many, many years. Now that I have raised critical questions, the beltway organizations may never hire me again (and I have worked for yours). I have spoken out at considerable personal risk.
If Ted is referring to STI meds when he says Western "technological fix", I have to say that I think that type of "fix" is a very important for HIV reduction, considering how much more vulnerable one is to HIV when infected with other STIs
I agree. I say we need BOTH technological/medical AND behavioral interventions (we could, I suppose, argue about the balance here). I wrote a book in 1994 arguing for more STI syndromic management interventions, linking up with traditional healers, who after all see most the STI cases in Africa.
Now, lets move to the role of condoms in Kenya. Dr. Mohammed Abdullah, outgoing Chairman of the Kenya National AIDS Control Council, made a presentation to USAID on 2/19/03 to show the current status of Kenya's AIDS epidemic and to outline its national response. The presentation showed that by far the major response to AIDS before 1999 was condom supply and promotion. A vast quantity of condoms were brought into Kenya before 1999 (and more since). Yet nothing happened to prevalence during all those years of increased condom availability and relatively high use. Finally, under intense political pressure, ex-President Moi began to take certain steps in 1999.
As you well know, Moi was very disliked in his country and everywhere by 1999. He certainly did not have the stature of President Museveni in 1986, i.e. the Liberator of the People, after the bloody years of Adi Amin and Milton Obote. This means that an African head of state not necessarily have to have credibility and charisma to sound the AIDS alarm bell.
And what did Moi do? According to Dr. Abdullah, Kenya implemented a balanced ABC program with some real emphasis on A and B; it mobilized the faith-based groups; it went into the schools with AIDS education; it underscored the seriousness of the epidemic, speaking in terms of a national emergency. Government officials were told that they must mention AIDS every time they had a public meeting, or else they'd be in trouble. According to Dr. Abdullah, national prevalence began to be impacted within a year or two. He claims that 2002 ANC data show a decline, although these data are not yet publicly available.
If the findings in his presentation are corroborated (have you seen the 2002 ANC data?), Kenya's recent experience tends to validate the ABC approach, Uganda-style, it seems to me. It appears that national HIV prevalence turned around quickly once Moi took the broad, general steps that President Museveni took in 1986, and that President Diouf of Senegal in 1987.
Any light you can shed on this account and the 2002 prev. levels would be appreciated
I remain,
perpetually polypartnered, pansexual and polymorphous perverse
Ted
Well, in case you'd thought everything had been said in this discussion... The drift of the following is very interesting indeed! The second reference has the abstract following so you can see where the authors are headed. I'm not sure "permits the interpretation that" is a real sound basis for inference, but this is a provocative argument.
Jim Stansbury
***********************************************
REVIEW Mounting anomalies in the epidemiology of HIV in Africa: cry the beloved paradigm. Devon D Brewer PhD1, Stuart Brody PhD2, Ernest Drucker PhD3,David Gisselquist PhD4, Stephen F Minkin BA6, John J Potterat BA5,Richard B Rothenberg MD MPH7 and Francois Vachon MD8 International Journal of STD & AIDS 2003; 14: 144-147
REVIEW Let it be sexual: how health care transmission of AIDS in Africa was ignored David Gisselquist PhD1, John J Potterat BA2, StuartBrody PhD3 and Franc ois Vachon MD41Hershey, PA, 2Colorado Springs, Colorado, USA, 3Institute of Medical Psychology and Behavioural Neurobiology, University of Tu¨bingen, Germany and 4University of Paris 7, France Summary: The consensus among influential AIDS experts that heterosexual transmission accounts for 90% of HIV infections in African adults emerged no later than 1988. We examine evidence available through 1988, including risk measures associating HIV with sexual behaviour, health care, and socioeconomic variables, HIV in children, and risks for HIV in prostitutes and STD patients. Evidence permits the interpretation that health care exposures caused more HIV than sexual transmission. In general population studies, crude risk measures associate more than half of HIV infections in adults with health care exposures. Early studies did not resolve questions about direction of causation (between injections and HIV) and confound (between injections and STD). Preconceptions about African sexuality and a desire to maintain public trust in health care may have encouraged discounting of evidence. We urge renewed, evidence-based, investigations into the proportion of African HIV from non-sexual exposures.
Keywords: HIV, Africa, nosocomial, iatrogenic, risk factors
International Journal of STD & AIDS 2003; 14: 148 -161
****************************
James P. Stansbury, PhD
Rehabilitation Outcomes Research Center
North Florida/South Georgia Veterans Health System
1602 Archer Rd., T-9
Gainesville, FL 32608
James.Stansbury2@med.va.gov
Hi Ray, hope I'm not too late to get my 2 cents in. Could you post this for me because I am a bad person and did not pay my dues (but I will)
I am an anthropologist currently conducting ethnographic research on condoms, condom promotion and STIs in Kenya for one of those "beltway bandits." I wholeheartedly agree with Doug's comments below - although in Kenya, I doubt the mutual masturbation advice would go over very well. In my opinion, most of the reasons why condom use has not significantly increased (except among certain high risk groups such as commercial sex workers) have been mentioned in the discussion so far. In Kenya, a major reason why condom use has not increased is that condoms are still not heavily promoted by health providers in public clinics and hospitals. Part of this is due to a crumbling medical infrastructure. From our study on condom promotion among STI service providers in Nyanza Province, providers said that they did not adequately promote condoms because they didn't have time and they were not well trained and/or supervised. In addition, the clinic was often closed due to labor strikes or ran out of medications and so was shut down.
Therefore, STI patients often were not counseled about condoms. In fact, often they were not even told they had an STI. This was especially true for women who often were just told " Take these pills." Other common reasons that were expressed by STI providers for not promoting condoms was that the clients would not be receptive, so it was a waste of time. For example, there are a number of cultural myths about the negative effects of condoms on "condom wearers". We also interviewed traditional healers, pharmacists, herbalists, and what we euphemistically referred to as "STI entrepreneurs" (untrained people who made "diagnoses" and sold drugs to STI patients at market places, bus stops and other local venues) to determine if they did condom promotion and counseling, or not, and if so, what the content and quality of their condom counseling was. They fared even worse than the clinic staff.
My point here is that it's hard to tell if intensive condom promotion would help to increase condom use and thus reduce the incidence of HIV and STI in Kenya. The health delivery system is in such bad shape, due to economic underdevelopment and years of bad national leadership and corruption, that it thus far has not seemed equipped to take it on. It wasn't that long ago that President Moi and other national religious leaders burned condoms and condom promotion literature on the steps of the Capitol in Nairobi. Recently, Moi put forth his own AIDS prevention plan: to wipe out AIDS, everyone in Kenya should abstain from sex for two years. This suggestion reflects the massive denial exhibited by the national leadership, an attitude that trickles down the bureaucratic chain all the way to the tiniest of clinics with catastrophic results. With a new administration in power, hopefully this attitude will change.
One last thing to mention and you can take it for what it's worth. I've traveled to Kenya frequently in the last 3 years and each time I go, inevitably someone (who is Kenyan) will tell me they are glad that international NGOs ( "beltway bandits"? ) are involved in the research and implementation of HIV/AIDS projects rather than handing the money to the Kenyan government, because some corrupt politicians would most likely siphon off a good portion of it. Are Westerners angels of mercy? Hell, no! Are we self serving? Hell, yes (ask me about the female condom)!
I think a lot of the emotions sparked by the articles about ABC come from deep frustration and grief over the continued horror of AIDS in sub-Saharan Africa, and a feeling of helplessness and impotence when the struggles to do something, anything, to stop the pandemic do not appear to work. But I firmly believe that the cumulative effect of condom promotion, HIV prevention education, voluntary HIV counseling and testing, and the increasing availability of ARVs, eventually will help to achieve a reduction in HIV/AIDS throughout the region.
Lorie L Broomhall, PhD
Senior Associate
Behavioral and Social Sciences
Family Health International
Hi, everyone, from Goroka, capital of Papua New Guinea's Eastern Highlands Province. Several of you have helped me join this list-serv discussion forum, and I just wanted to say "hello" to everyone and to thank everyone for their contributions this past week on the issue of, well, you know. Unlike Michael Jackson, I suppose that ABC ain't so easy as 123.
In my work as Senior Research Fellow here at the Institute of Medical Research, I'll be sort of a point-person helping to "shoe-horn" qualitative kinds of thinking and data-collecting and reportage. I'll be honest in saying that I am far more concerned about untreated STDs/STIs than I am about HIV, and that the clinical presentations of "AIDS" is taking a familiarly specific form here in P.N.G. (that is, in this case, T.B.- and pneumonia-heavy), but that's another story. Regardless of our views about disease(s) causation, I really appreciate all of the work you do, collectively and individually. Many of you whose comments I've been reading the past several days have had a big impact on how I think, etc., and no doubt lots of your works have influenced the way Papua New Guineans think about sex, condoms, disease, and so forth, especially insofar as I have used your works in my own publications (Brooke Schoepf, Ralph Bolton, Gil Herdt, and Edward Green deserve particularly special thanks).
Granted, I've been gone from P.N.G. for a long time (11 years) and have only been back here for three weeks, but I'm pleased to be able to report that in some ways things have really "progressed" (in terms of ability to speak freely in forms of public discourse), despite "numbers" apparently shooting through the roof. We're about to launch a nation-wide (sero)surveillance program, a goodly chunk of which is devoted precisely to those issues of sexual health and sexual citizenship that each of you have raised over the years, and I/we stand to benefit greatly.
I look forward to even more lively conversation (and more), now that Kepten Kondom is in the house.
Best wishes to you all.
Lawrence J. Hammar, Ph.D.
Senior Research Fellow
PNG Institute of Medical Research
Box #60, Goroka, E.H.P. 441
Papua New Guinea
(675) 732 2800
(675) 732 1998 (facsimile)
gorokadubu@daltron.com.pg
Ted,
One can see and hear what one would like to see and hear. There is good evidence that HIV rates are declining in many districts in Kenya. My opinion is that training in syndromic management of STIs has had much to do with that, and I largely disagree with Dr. Abdullah's, whom I know quite well, analysis. Beginning in 1995-96 a huge effort in Kenya was put into training of MDs, Clinical Officers, nurses, health educators, laboratory technologists, counselors, community health workers and even TBAs in syndromic management of STIs. (BTW, much of this training was done by FHI, AMREF and other USAID contractors.) This was coordinated with the World Bank loan for provision of free STI drugs, which were placed in virtually every clinic in Kenya - even the most remote rural clinics had STD drugs (and condoms and big posters). The training entailed workshops, workshops, workshops. When I now review 100s of applications for clinical officers, nurses, and counselors for our project in Kisumu, every application has multiple certificates documenting attendance at STI syndromic management seminars lasting between one day and one month. Since the early nineties, bacterial STIs have dropped precipitously in Kenya. Chancroid, which had a prevalence of about 15% in the 1980's, has virtually disappeared. Researchers who want to study chancroid can no longer do it because there are no cases, even among CSWs. Syphilis, gonorrhea, chlamydia have all dropped from double digits to low single digit prevalence. Why? In part because of syndromic management and widespread availability of drugs, but also, I would maintain, because all those training programs, workshops, distribution of drugs, distribution of condoms with the drugs, posters in every health clinic and every health workers office, and, yes, talk in the training about A and B - all this brought HIV prevention into the forebrains of health workers and many in the population and made it part of their everyday vocabulary. It also brought thousands of people to health care facilities that didn't come previously - because they could get free drugs and, coincidentally, some messages about safe sex behavior, including condoms and faithfulness. So, in the case of Kenya, I believe HIV rates are declining now in large part because of the huge push for STI diagnosis and treatment along with condom promotion. These efforts not only increased treatment of bacterial STIs, but, probably more importantly and effectively, increased awareness and attentiveness and discussion around STIs, HIV, condoms, risky sexual behavior. No doubt, Moi finally speaking out and getting others to talk has also had an effect (although I think this can be overemphasized in the Kenyam context), but I do not think we should underestimate the great(er) influence that all that training and all those drugs had, and are having on the general population's behavior and more rapid treatment.
Unless we have the foresight (and funds) to study these trends prospectively, I think we can each interpret history differently and find data to support our views. I don't think, despite yours and others cogent analyses, we really know what happened, or at least how it happened, in Uganda, and we never will. You and others have ably shown that reduction in number of partners really happened in Uganda, but we will never know what was or was not truly responsible for that. It is time to move on and figure out how we can get people to adhere to the behaviors that we know work: abstinence, faithfulness, condom use, rapid and effective STI treatment, HIV testing and counseling, and, as soon as possible, antiretroviral therapy and microbicides. And if the debate is about where do we put our money, we put it in all of these. Promoting condoms does not mean, and seldom ever meant, ignoring messages of faithfulness. Treating STIs does not mean, and seldom ever meant, ignoring faithfulness or condoms. Now that HIV testing is more widespread in Africa, counseling about faithfulness, condoms, STI treatment, as well as nutrition, self-respect, respect for others - these are all part of our prevention strategies and it would be difficult to know which is being emphasized to the exclusion of others.
Just one last point and then I'll shut up. There is no dichotomy between medical/technological interventions and behavioral interventions. Getting people tested and treated is as much, no, more BEHAVIORAL than medical. This is where we as anthropologists have so much to contribute. A magic pill or a vaccination or a surgical procedure, even if it is 100% effective, cannot work if people don't know it, want it, get access to it, believe in it, know how to take it, and adhere to taking it. Hell, the history of condom promotion and distribution has shown that, as many have been arguing. Medical interventions are behavioral interventions.
Bob
Robert C. Bailey, Ph.D., MPH
Division of Epidemiology
University of Illinois at Chicago
2121 W. Taylor Street
Chicago, IL 60612
Tel: 312-355-0440
Fax: 312-996-0064
e-mail: rcbailey@uic.edu
About the articles questioning sexual transmission as the major factor in Africa's HIV rates - WHO and UNAIDS has acted fairly quickly in shooting down the theory that healthcare practices are a significant factor in the spread of HIV in Africa. There still seems, however, to be more about this issue that needs to be investigated. Here are some links in case you are interested in reading more about the study and WHO/UNAIDS' response:
The articles (full text) are online in PDF format at:
Mounting anomalies in the epidemiology of HIV in Africa: cry the beloved paradigm http://www.rsm.ac.uk/new/std144intro.pdf
Heterosexual transmission of HIV in Africa: an empiric estimate http://www.rsm.ac.uk/new/std162stats.pdf
Let it be sexual: how health care transmission of AIDS in Africa was ignored http://www.rsm.ac.uk/new/std148main.pdf
AIDS in Africa: WHO & UNAIDS reaffirm unsafe sex as main mode of transmission
http://www.aidsmap.com/news/newsdisplay2.asp?newsId=1964
WHO/UNAIDS joint press release - Expert group stresses that unsafe sex is primary mode of HIV transmission in Africa.
http://www.who.int/mediacentre/statements/2003/statement5/en/
Georgette King
Georgette King, MPA
PhD Student
Department of Anthropology
University of South Florida
4202 E. Fowler Avenue, SOC 107
Tampa, FL 33620
gking005@tampabay.rr.com
Hi AARGers,
My apologies for repeated submissions of my e-mails over the weekend, but I understand that the filter was initially overzealous, and then all my attempts at e-mail transmission were sent at once. To reduce your e-mail burden, I am using this one e-mail to respond to several authors. Also, since I need to get back to working on a grant with a deadline coming up soon, this reluctantly will have to be my final word on the topic for awhile.
1. On the David Gisselquist absurd assertion (published in 3 papers in the March 2003 issue of the International J. of STD & AIDS) that unclean needles are more of a risk factor for HIV transmission than sexual practices in Africa, the WHO demolished this notion at a March 14th meeting, Maria Wawer attacked his points before a Congressional hearing a couple of weeks ago, amd I attacked his points at my talk at the SfAA meetings in Portland on March 19th. This is the same tired argument made by Randall and Epstein which I rebuked in a commentary following their article back in 1991 (Social Science & Med.). The most compelling of the several reasons why Gisselquist is wrong is that Africans over 50 and between 5-14 have very low rates of HIV (if it was poor medical practices instead of sexual practices, their HIV rates would be just as high as sexually active adults). By the way, Dr. Gisselquist introduces himself (to the media and Congress) as an anthropologist with a Ph.D. in anthropology. Can anyone out there confirm that?
2. While it is off topic, let me respond to Bill Weintraub's comments. The US government may have spent more than a dollar on AIDS for gay men between 1981-85, but not much. I am aware of Congressman Waxman's valiant efforts to fund AIDS in the early years, but if his $30 million request was actually allocated, I don't know what it was spent on. Randy Shilts' "And the Band Played On" details how little was spent (only $2 million out of CDC's budget of hundreds of millions of dollars, etc.) during those years. Lou Cannon's book on Ronald Reagan and Michael Melody's article in my "Global AIDS Policy" details how the triumvarate of Pat Buchannan, Bill Bennett, and Gary Bauer kept AIDS funding under wraps and Reagan in the dark until S.G. Koop blew the whistle. The small figures you cite are reported AIDS cases. We now know that a half million Americans were already infected with HIV by about 1985. As far as the definition of "frottage" goes, Anne Hooper (2003, "Sexopedia," New York: DK Publishing), and several other sources I found earlier today at a Border's bookstore here in Rochester, NY, define "frottage" as rubbing the genitalia against the other partner's body part (back, stomach, etc.). I guess you could call mutual genital rubbing "double-frottage!" Also, I think my wording in my previous e-mail may have been confusing: I consider frottage and other forms of non-penetrative sex to be safe sex; fellatio and other forms of "less risky sex" to be slightly riskier than safe sex. By the way, I agree with you that frot can be hot. But my research (not yet published) analyzing responses to personal ads by gay men reveals to me that for many gay men the act of receptive anal sex and/or insertive anal sex has both deep personal pleasure and significant personal symbolic meaning, and that calling for the universal abandonment of anal sex by all gay men is neither feasible nor desirable (providing condoms are worn routinely). You ask: What proportion of safer-sex monies would I be "willing to allocate" to non-anal alternatives? As far as HIV prevention campaigns targeting gay men in the US go (and this should be extended to Africa where there are newly emerging gay communities in several African cities), I would integrate non-penetrative sex (including "frot")messages and skills training, along with condom use for anal intercourse, in all programs.
3. On Janie Simmons (AARG Bulletin editor) generous offer to submit material to the next issue of the AARG Bulletin, I have already done so (it is a revision of the talk I just gave last Saturday at the excellent Yale University medical anthropology conference; my talk coincidentally was on the same topic). I encourage Ted Green do also submit to the AARG Bulletin.
4. While the paper presenters and discussant for my AAA session "Rethinking Global AIDS Policy" have been set, I think Doug G's (G for Great Current AARG Chair!) original suggestion of a Special Events panel on HIV Prevention Policy for Africa (AARG via SMA) is an excellent one. In the past, the AAA has been very open to including Special Events panels (where papers are not presented, but panelists are asked to comment freely on issues by a moderator/chair) well past the April 1st deadline. These are usually scheduled either during lunchtime or in the early evening time slots.
5. To Elizabeth Onjoro's hesitation to use the Human Relations Area Files, I agree that sexual behavior in Africa has certainly changed since the "ethnographic present." But HRAF is the best database on cross-cultural sexuality there is(along with Edgar Gregersen's absolutely superb "The World of Human Sexuality," NY: Irvington Publishers, 1996). Only the naive would want to throw "the baby out with the bath water" simply because much of the data was collected by early 20th century non-Africans with very obvious biases. If you want to understand sexual change in Africa, you need to know where the "ethnographic present" baseline was.
6. And Ted: What is clearly and urgently needed at this time is an ethnography (by an impartial anthropologist) of Uganda to find out what exactly did occur from 1986 on that caused the HIV seroprevalence to decline. I am hypothesizing that it was the breakdown of the wall of denial by the government and their national media followed by fear that led to short-term partner reduction in the face of condom scarcity. Such an ethnography should include interviews of Museveni and other top government officials and religious leaders at the time to find out why and how they did what they did, as well as interviews with those sexually active Ugandans who experienced this cultural shift when the AIDS crisis first hit. We also need to do several cultural audits in African nations, where they used an ABc Campaign (as Matt Steinglass so aptly points out for Togo and other countries) but the HIV seroprevalence continued to soar. In Zambia, for instance, in the early and mid-1990's, they basically ran an AB(and rarely c) campaign, and all it did was enhance AIDS stigma, religious bigotry, higher HIV rates, more AIDS orphans, and men who refused to use condoms even when they became available.
7. Ted: Part of the problem is that we define "partner reduction" differently. From what you have written you define it to include abstinence (partners = 0) and fidelity (partners = 1). I don't. "Partner reduction" as you define it (i.e.: rarely more than one partner) is central to your proposed policy; "partner reduction" as I define it (i.e.: many minus a few, but not less than 2), along with abstinence and fidelity, are options for some, but should not be the national HIV prevention policy for everyone in any nation. Indeed, if your insistence that 95% of Ugandans reported 0 or 1 sexual partners in 1995 is correct (and I don't believe you have adequately responded to Pieter Remes' brilliant challenge on that), then we are talking about a rather pathological condition in Uganda that should certainly not be used as a model anywhere else in Africa. Certainly, we can bring the HIV rate down even lower with quarantine camps, but at what price?!
8. Ted and Elizabeth: Whether we go with Elizabeth's 15% condom failure rate or Ted's 20% condom failure rate, the point of the matter is that if you don't use condoms at all the failure rate is 100%! The argument that many Africans don't know how to properly use condoms and this failure rate may go higher misses the point that we need to have better condom education programs throughout Africa so that condom use will be routine and reasonably safe. Thailand, I think, is an excellent model for a culture that has promoted the proper and routine use of condoms, with dramatic reductions in HIV rates there.
We need to really try condom use in Africa before we say it doesn't work.
9. Bravo to the excellent points made by Lorie Broomhall, Julie Eiserman, Ralph Bolton, and others.
Good night.
Oops! I need to make an important correction to my last posting: Merrill S is the Splendid Current AARG Chair, while Doug G is the Great Current AARG Chair-Elect. Also the original idea of the panel was Merrill's, while Doug G endorsed it. Apologies for any confusion. Now -- good night!
Doug
Douglas A. Feldman, Ph.D.
Professor
Department of Anthropology
SUNY Brockport
350 New Campus Drive
Brockport, NY 14420 USA
(585) 395-5709
dfeldman@brockport.edu
About the articles questioning sexual transmission as the major factor in Africa's HIV rates - WHO and UNAIDS has acted fairly quickly in shooting down the theory that healthcare practices are a significant factor in the spread of HIV in Africa. There still seems, however, to be more about this issue that needs to be investigated. Here are some links in case you are interested in reading more about the study and WHO/UNAIDS' response:
The articles (full text) are online in PDF format at:
Mounting anomalies in the epidemiology of HIV in Africa: cry the beloved paradigm http://www.rsm.ac.uk/new/std144intro.pdf
Heterosexual transmission of HIV in Africa: an empiric estimate http://www.rsm.ac.uk/new/std162stats.pdf
Let it be sexual: how health care transmission of AIDS in Africa was ignored http://www.rsm.ac.uk/new/std148main.pdf
AIDS in Africa: WHO & UNAIDS reaffirm unsafe sex as main mode of transmission
http://www.aidsmap.com/news/newsdisplay2.asp?newsId=1964
WHO/UNAIDS joint press release - Expert group stresses that unsafe sex is primary mode of HIV transmission in Africa.
http://www.who.int/mediacentre/statements/2003/statement5/en/
Georgette King
Georgette King, MPA
PhD Student
Department of Anthropology
University of South Florida
4202 E. Fowler Avenue, SOC 107
Tampa, FL 33620
gking005@tampabay.rr.com
Doug, you wrote:
"Ted and Elizabeth: Whether we go with Elizabeth's 15% condom failure rate or Ted's 20% condom failure rate, the point of the matter is that if you don't use condoms at all the failure rate is 100%! The argument that many Africans don't know how to properly use condoms and this failure rate may go higher misses the point that we need to have better condom education programs throughout Africa so that condom use will be routine and reasonably safe."
Doug, haven't we been trying just that for 15-20 years? I am not saying we give up, but just don't bet all your money on condoms. Or an African's life.
And Doug, its not Ted's or Elizabeth's failure rates, these are estimates from meta-analyses. I think you have heard of Susan Weller.
You ought to know all about condom effectiveness, since you are promoting the joys of polypartnerism--of course adding the stipulation that condoms be used consistently. I am saying we that should NOT be promoting polypartnerism--quite the reverse--given the 1 in 5 change of fatal infection even when use is consistent.
Have you read the widely-quoted Population Reports from Johns Hopkins on condoms, Closing the Condom Gap (Gardner, Blackburn, and Upadhyay 1999)? The authors summarize:
"Overall effectiveness for reducing sexual transmission of HIV through consistent use of condoms is approximately 80%. Estimates of condom effectiveness range widely from 94.2% (best case scenario) to 35.4% (worst case scenario)."
It is likely that failure rates are closer to the worst case than the ideal scenario in Africa. In real-world situations in Africa, where use may not be correct, condoms may be of poor or deteriorated quality, or made of non-latex, or the wrong size, protection may actually be well under than 80%, even when use is consistent, which is rare. This prospect is not very reassuring.
Meanwhile there is growing evidence that reducing the number of partners has worked in reducing HIV prevalence at the national level in Africa.
So, again, we should promote ABC and D. But that means really do it--don't put all our resources into C and D only. Don't exclude A and B inteventions as "missionary terrorism."
Cheers, Ted
Hi All,
thought you might be interested in this report. I am very uneasy when talk of condoms being ineffective start circulating for fear the message will be twisted and re-interpreted in harmful ways.
In a message dated 4/11/2003 11:05:22 AM Eastern Daylight Time, LBroomhall@fhi.org writes:
. I am very uneasy when talk of condoms being ineffective start circulating for fear the message will be twisted and re-interpreted in harmful ways.
Me too. So the best policy should be to always be as accurate and honest as possible, and therefore say that from the best current evidence, they appear to be 80% effective when used consistently.
Ted
Did anyone read about the situation late last year where a large shipment of defective condoms was sent to some African countries? How long or how many infections did it take before someone realized that demand is driving production, and hence higher quantities are now lowering the quality of condoms? This occurred after all the stories about the condoms that did not fit well etc. Those promoting condoms did not consider conducting research to see if the condoms would fit their Africa clients. And who is keeping tabs on condom producers' and their promoters' defectiveness rates to minimize wide-spread harm? I will not go into details about all the debate surrounding that issue. These are issues we as social scientists cannot ignore .
How any out there have data on how poverty is driving the spread of HIV. Should poverty reduction be a large part on HIV prevention alongside other strategies. Anyone has data to convince congress on this.
Thanks
Liz
From nonmember Bill Weintraub
Hi list,
I read with interest Lorie Broomhall's remark:
"Thought you might be interested in this report. I am very uneasy when talk of condoms being ineffective start circulating for fear the message will be twisted and re-interpreted in harmful ways."
I read the article Lorie's referring to, but:
First of all, in it Mr. Mumbuwa said nothing about condom failure rates -- he said he doesn't approve of sodomy.
So the article in question has nothing to do with information about failure rates being "twisted and re-interpreted in harmful ways."
There's simply no link, explicit or implicit, in that article between condom failure rates and Mr. Mumbuwa's dislike of sodomy -- the two have nothing to do with each other. And there's no reason to think that Mr. Mumbuwa has ever seen or was influenced by this or any other discussion of condom failure rates.
Furthermore, concern that facts might be "twisted" is no reason to hide the truth from Africans. That's an essentially colonialist attitude: Africans are children and if we tell them the facts about failure rates they'll become hopelessly muddled.
I think Africans are adults -- I think you can give them the facts and let them reach their own conclusions.
Also, just a because a "Christian" says something doesn't mean that he or she is wrong.
Mr. Mumbuwa said that condom distribution "could encourage sodomy" -- and that makes sense to me.
When you distribute condoms in an enforced all-male environment like prison, you're sending a message -- I know you guys need a sexual outlet, and the model I'm providing is anal.
The better way to go, in my view, is to say "I know you guys need a sexual outlet, but if you do it anally you're taking a significant risk -- condoms fail 1 time in 5 and the HIV infection rate among inmates in this prison is already xx%"
Also: Our prison system will not tolerate any prisoner pressuring or coercing another to do anal; be advised, coercion is rape, and if you rape someone you'll be punished.
But: If you need to masturbate, even with another guy, we won't care -- we'll turn a blind eye.
That's a reasonable policy -- it permits prisoners sexual release without giving them license to have anal sex, which is dangerous without or with a condom.
And it's enforceable if you instruct the guards to ignore masturbation, including mutual masturbation, and punish anal.
These are after all prisons, and people like Mr. Mumbawa are charged with keeping order within them, and keeping them reasonably safe for the prisoners -- and punishing them when they endanger others.
That's legitimate.
Now, obviously, I'd want to change Mr. Mumbawa's attitudes about homosex.
But I don't think forcing him to distribute condoms would help.
Whereas I think showing him MSMs leading faithful, committed, and healthy lives would.
Bill Weintraub
bill@man2manalliance.org
http://man2manalliance.org
Dear Ted,
I know you have said that "...you cannot control the political use of empirical findings", but I wonder if you have you responded to what may be the extreme and distorted use of ideas and findings that appear related to the ones that you have put forth by people on the political right such as Joseph R. Pitts whose Washington Times article (March 26, 2003), makes the claims, among others, that:
1. "Faith-based organizations encourage positive choices and have been the only consistently successful groups in the battles against AIDS..."
2. USAID and CARE funds support discredited ideas and programs that promote "safer sex" and funnel US money into the 'International HIV/AIDS alliance' (whoever they are) who support safer sex, legalized prostitution and needle exchange.
I know my remarks harken to an earlier point in the AARG dialogue. However, my point is that your ideas about A,B,C are worthwhile, of course, but few people only support condom distribution or safe sex messages only anymore. Yet, (and I am assuming here) that when the circulation of ideas similar to the ones that you are putting forth get generalized and distorted to condemn and suggest de-funding programs worldwide that provide preventive efforts that include situations of commercial sex work and social dislocation from economic depreviation and armed conflicts, where there is a need for the regular availability of condoms and safe sex messages, along with a host of other messages, policy considerations and support programs, they end up promoting a kind of "missonary prescription" (if not terrorism) and destructive ethnocentrism. This manipulation and mis-application of ideas seems to be just the kind of action you are arguing against.
I appreciate the need for a closer examination and dialogue on what works or has worked in particular settings, as all AARG members do, but I am concerned whether you have presented and clarified your reasonable and empirical views for the benefit of a wider, less informed, potentially more confused, yet powerful audience? I think your clarifications to such an audience could be effective, credible and reduce potentially harmful perspectives.
Yours truly,
Al Pach
Dear AARG
Its time for me to bow out of this debate, at least for now. Someone (Ray?) said early in the debate that we should keep this discussion going until we start repeating ourselves. I think we may be reaching that point. Or I have anyway.
For example, I want to say in response to Al Pach that just because an extremist might appropriate one of my comments, or some data I cite, that is no reason I should remain mute, no reason I should not state what I regard as a centrist position between the highly polarized, "abstinence versus condoms" partisans. But I have made this comment before, in a slightly different way.
For the record, I have also stated that my position is to achieve some sort of balance between ABCD. When I get attacked for giving A or B any credence, I have to repeat the empirical findings about the shortcomings of condoms alone IN AFRICA, as well as the evidence that A and B interventions and behavioral changes can make a big difference.
Let me re-state that my argument has centered on Africa, where I think the evidence is strongest that condoms have not (yet?) had an impact at the national level, while "primary behavior change" in some countries definitely has.
Bill Weintraub and Chuck Tarvar, whom I have never met, see parallels between the ABC experience in Uganda and the MSM epidemic in the USA. I have little experience in MSM AIDS or the situation in the US (I did evaluate a community-based African-American AIDS prevention program in New Orleans, for the DHHS Office of Minority Health). I find the ideas of Bill and Chuck fascinating, but know that they and I are not part of any conspiracy.
I know how many of you feel (judging by the postings, the great majority of you). When I worked with PROFAMILIA'S contraceptive social marketing project in the Dominican Republic (considered one of the best anywhere) in the 1980s, my counterpart Jorge would occasionally show me something in the local newspaper about the church criticizing our ads. We'd roll our eyes upward and make some comment about these uptight, sexually repressed missionary terrorists.
PROFAMILIA has a great FP program and I would work with them again.
My views about AIDS prevention (not FP) began to change somewhat when I first went to Uganda in 1993. I saw a different kind of AIDS prevention program underway there. Behavior was changing in ways we Western experts just didn't anticipate: Ugandans were "zero-grazing" (a term they came up with). And there was already evidence that STI and HIV rates had declined.
WHO epidemiologist Rand Stoneburner saw the evidence just as I and many Ugandans saw it. We thought the world would be happy to learn that simple, low-cost, community-based solutions developed by Ugandans themselves had proven effective. Not so. Rand later recounted,
"Everybody in the AIDS establishment attempted to come up with some explanation to dismiss the data, from blaming laboratory error to bringing up every imaginable bias. It seemed like the whole world had gone mad. When I was finally able to get people to talk about this, they would ask me, 'What are the implications for this with respect to funding?'"
I'll let you interpret what he meant by these comments.
The other reason I need to bow out for the time being is that this is taking up too much time.
The person I have argued the most with is Doug. F., partly because he kicked this whole thing off with his first posting, and partly because of his early posting about polypartnerism. I suspect a number of you who have been defending the way the major donors do AIDS prevention would not go so far as to recommend the joys of polypartnerism to youth in, say, Botswana these days. But I must say, Doug has been a good sport in this debate. He never resorted ad hominem comments (he just called anyone who disagreed with me brilliant! Hey, that's not so bad….).
So I ask you all to not address comments specifically to me for a while, because I need to get back to my regular work. Of course, its going to be hard for me to break the addictive cycle of point-counterpoint, so maybe I should not read anything from AARG during a cooling-off withdrawal period. (You can picture me at Betty Ford: "Doctor, I lie awake at night writing e-mails to Doug Feldman in my agitated mind ...")
But I hope the rest of you will continue what I think has been a highly productive discussion, and you will allow me to come back in at a later date.
Cheers,
Ted
Edward C Green
Harvard Center for Population
and Development Studies
9 Bow Street
Cambridge, MA 02138
Ralph Bolton has asked why non-AARGers are using the AARG listserv. The reason, of course, is cause it is a happening place. I made the decision when the ABC debate was taking off to allow folks who had "not yet joined" AARG to participate in the debate for two reasons: 1) because important issues were under discussion of considerable interest to many AARG members, and part of those involved in this did not "as yet" belong to AARG, but that we would all benefit from hearing the issues rather than toeing the line on use of the listserv; 2) having had the opportunity to see that the AARG listserv was developing as an important international site for the discussion of key issues in AIDS and the communication of AIDS-related information, additional individuals (who have been reminded to do so by various members in their posts) will join AARG.
Merrill
Dear AL Patch,
Thanks for the heads-up. The problem that anthropologists cannot control mis-use of their findings/statements is an old one. It surfaced in a debate over ethics during the Vietnam war, and I faced it in my own work in ghetto health centers in the late 1960s (I resigned.)
The upshot is that one try to avoid situations in which one's work can be mis-used and when misinterpretations surface, respond to them. In this case, following up on your heads-up is important. Green might write to the editor of the Washington Times with a clafification that stresses how important condoms are in stemming the core of STI epidemics at the outset AND ongoing, and how A & B are great, but do not work for all people, including many girls and women who have no choice. Or something.
My own inclination would be to add that condom supply, distribution and outreach campaigns need to be stepped up, not reduced. That more money needs to go into creative prevention campaigns. Taht A & B need to be addressed by other means than religious NGOs because they are a) counter-productive with some population sub-groups and b) violate the US Constitution which mandates separation of churches and the state.
Brooke G. Schoepf
Dear AARGers
Sorry to return from temporary retirement so soon, but Brooke Schoepf has written to AARG suggesting what Green ought to do, so I guess I must rise to the occasion.
Brooke suggests that I write to the Wash. Times and tell them how important condoms are. I don't know that that is really necessary. Of those who work in global AIDS in some way, there are about 10,000 already saying this, while there are only 5-6 dissidents who are saying anything else, something about fundamental sexual behavior. Besides, I said in this interview, " "It is not 'abstinence only' or 'condoms only.' Both are needed. There is a need for condoms, if A and B fail. Some people will never change their behavior." You can read this for yourself at:
http://www.washingtontimes.com/world/20030313-21315566.htm
I can tell from what Brooke has posted that she is interested in discrete high-risk groups. So am I. But I am even more interested in the majority or general populations of Africa. Why? Because this is where most HIV infections are. Condom user rates are low in the majority populations of Africa, and they are likely to remain too low, and too inconsistent (cf. Hearst and Chen 2003) to make a significant difference at the population level. Its time we faced this. (Again: lets keep on trying, as we have been doing for 20 years, but also do some other things as well.)
This is not to say that condom user rates cannot become quite high among FSWs and their clients. And this can avert many infections. That's great and we should strive to make condom user levels even higher among core transmitters.
But we need to think of workable solutions for the majority populations of Africa.
Brooke also said:
"A & B need to be addressed by other means than religious NGOs because they are a) counter-productive with some population sub-groups and b) violate the US Constitution which mandates separation of churches and the state."
Lets not ignore the majority of Africans in the interest of certain sub-groups. Africans are a religious people, whether the religion is Christian, Muslim or indigenous. Anyone who has spent time in Africa knows it is not uncommon for meetings to begin with a prayer or religious invocation of some sort. What should the participating-observing anthropologist do in such a situation? Disrupt the meeting and tell them they are violating the US constitution? Inform them that religion is the opium of the people? Or can we be restrained enough to put aside our own biases and practice a bit of cultural relativism?
Uganda, Senegal, and Zambia have all put some genuine emphasis on delay of first sex and partner reduction. This is not something Brooke or Ted or Doug thought up (perish the thought!). Ugandans thought it up. Yesterday I was reading a literature review of KAP studies in Uganda from the early 1990s. This was compiled by the then-new USAID-funded DISH (Delivery of Improved Services for Health) Project, in Dec. 1994. In the review, DISH found that "Most Ugandans associate monogamy and abstinence as prevention against HIV infection, rather than condom use." The only exception were those relatively few Ugandans who had been directly counseled by the USAID-funded AIC and TASO groups.
The direction Uganda took in AIDS prevention post-1995 makes an interesting story, and it is dealt with in my new book. But "monogamy and abstinence," to use the language of the 1994 lit review, is what was going on in the early days, up until the mid-1990s. Cross-sectional studies and qualitative research suggests that A and B behavior changes were the main behavioral changes 1986-1995. They were also the main behavior changes promoted by the Ugandan government. I am sorry if these are not behaviors many of us approve of because of American struggles with the religious right. But that's what happened. Maybe its time for a little cultural relativism and acceptance that something happened that we did not anticipate. Not only that, we said it was impossible: women have no power to negotiate sex; teens have raging hormones; monogamy among Africans is impossible; sexual behavior cannot be changed; sexual behavior SHOULD not be changed; etc, etc.
It seems we all believed this in the West. And there is some truth to all these premises except the last. But at least three countries in Africa have proven that behavior CAN change and prevalence can decline in spite of these truths we held self-evident.
Cheers, Ted
Dear AARG (from Ted)
Uganda is indeed a model for nations fighting AIDS, but it is not quite the model the religious right would like to believe.
True. These comments by Sophia Mukasa Monico (who testified in congress immediately before me) are not very different from my explanation of Uganda (she says "not QUITE the model..."). . But I myself would not give WHO the credit for the ABC model--it was implemented in Uganda in a distinctly Ugandan/African way, and that made it much, much stronger than a generic ABC model. That is, other countries in Africa paid lip service to an ABC approach, but then accepted western donor assistance and let donor priorities guide them into a condoms-mostly response to AIDS (with some treatment of STDs added)
But I certainly agree with Sophia that ABC was a comprehensive program in Uganda, and far from being "abstinence only." In fact, I wish the mutual fidelity or partner reduction ("B") part of ABC were brought out more, such as in the comments Tuesday by Pres. Bush and the clarifications by Ari Fleisher. Faithfulness/monogamy (measured as partner reduction) was probably the main thing that reduced prevalence in Uganda (consider: most people age 15-49 are sexually active), followed by abstinence in youth, and then condoms. Ever-use of condoms was in the single digits when HIV prevalence begun to fall in Uganda. By 1995, a crude measure of regular condom use (self-reported use, last intercourse with any partner) was up to 6%.
Sophia Mukasa Monico was interviewed in the recent Washington Times article (attached) that also interviewed me, where she brought out the women's empowerment dimension of Ugandan ABC, something I have also tried to tell people about.
Anyway, bottom line: Sophia and I are pretty close on what happened in Uganda
cheers, Ted
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