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AIDS in AFRICA

September 13, 2018

 

This paper on AIDS in Africa is several years old. Since then HAART – Highly Active Antiretroviral Therapy –has turned HIV from a death sentence to a chronic disease. At first, the cost of a year’s treatment of the HAART cocktail was too high ($15,000 per year) for the average infected person in Africa. Massive lobbying efforts have forced governments to override western patents and purchase or produce generic antiretroviral drugs at a more reasonable price.

Research has found that HAART taken consistently can render the HIV in a patient’s blood undetectable and prevent new infections in sexual partners. Rather than wait until the infected person shows symptoms, it is now recommended that the HAART treatment begin immediately upon diagnosis. There were concerns that Africans might not be able to follow the medication regime required to lower the burden of HIV in the blood. This concern has been shown to be false. Africans have better compliance rates than some western countries.

Since those infected are more likely to infect others relatively soon after they themselves have been infected, it is important to identify everyone who is infected as soon as possible. This can be accomplished through partner notification and contact tracing and mandatory testing of at-risk groups, such as persons with other STDs and prostitutes. These should be tested and immediately given HAART and their contacts traced and tested. It should be noted that in the U.S.A. men who have sex with men with a history of childhood sexual abuse are particularly high risk for contracting HIV and for failing to follow medication regime and progressing to AIDS. Aggressive programs to prevent the sexual abuse of boys and counseling for the abused could be prevent infections.

The funds currently used to fund failed condom programs could be redirected to fund HAART.

If, in combination with some of the risk avoidance strategies mentioned in the paper, the identification of the infected and the funding for universal HAART for all the infected is vigorously pursued, the HIV/AIDS epidemic in Africa could finally be over.

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AIDS PREVENTION IN AFRICA 

Pope Benedict XVI during his 2009 trip to Africa set off a firestorm of criticism when he said that the distribution of condoms only “increases the problem. The reaction demonstrates how the controversy over HIV/AIDS prevention strategies continues unabated. While many people continue to believe that condoms are the only “scientific” solution to the problem, the evidence points in a very different direction. Before positive programs are abandoned in favor of failed strategies, international funders and African leaders need to be reminded of the facts.

 

Edward Green’s new book Broken Promises: How the AIDS Establishment has Betrayed the Developing World (2011) brings the tragic story of the AIDS epidemic in Sub Saharan Africa up to date.

 

Introduction 

 

While it is impossible to overestimate the suffering caused by the HIV/AIDS pandemic, prevention is not an unsolvable mystery. The disease does not strike randomly. Effective treatment strategies have turned HIV infection from a death sentence into a chronic disease. There may not yet be a cure or a vaccine, but we have identified the virus which causes AIDS. We know the pathways the virus can take. The question facing the people of Africa is: Which prevention strategies should they choose?

Protection of public health in the face of deadly epidemics has always been a balance between respecting freedom and saving lives. Governments must choose between risk elimination, risk avoidance, and risk reduction strategies. Even the most devastating epidemics can be stopped if the government is willing to abridge its citizens’ freedom by employing Draconian risk elimination strategies such as mandatory testing, quarantine, and closing venues where transmission occurs. Such strategies are normally only employed for deadly fast moving epidemics. This is because it is more acceptable to restrict freedom on a short-term basis than it is to institute restrictive measures on a long term or permanent basis. Risk avoidance strategies prevent infection by motivating the public to avoid all possible sources of infection and enforcing public health regulations. Risk reduction strategies allow people to continue to engage in behaviors that could expose them to infection while reducing, but not eliminating, the risk of infection.

Early in the epidemic various non-African countries made different choices with differing results. When Cuban soldiers returned from fighting in Angola, the government realized that some were infected with HIV. The regime responded with mandatory testing and quarantine. This was condemned as a violation of human rights, but it prevented the spread of the disease.[1]

In the U.S., quarantine and mandatory testing were considered unacceptable. Standard public health (risk avoidance) measures used to control such sexually transmitted diseases (STDs) such as syphilis and gonorrhea were also rejected. Instead, prevention focused on risk reduction — educating people on the ways in which they could protect themselves by using condoms. The result: Thirty years after the threat was recognized, in spite of all the progress in treatment, in the U.S. over 50,000 persons per year are newly infected.[2]

The U.S. strategy with some modifications was exported to other countries as the preferred method for controlling the epidemic.[3] This strategy has received the lion’s share of prevention funding and has influenced the choice of prevention strategies in sub-Saharan Africa.

Africa leaders and those who fund AIDS prevention in Africa are confronted with critical decisions. They need to consider the full range of options available. No promising strategy should be arbitrarily removed from consideration. The following is a review of what is known about how HIV is transmitted, standard public health strategies, the prevention strategy presented to Africa as the “scientific consensus,” the agendas of those who created this consensus, the challenges to that consensus, alternative strategies, and the effect of the choice of prevention strategy on the culture.

 

I           Pathways from the Infected to Uninfected

 

Prevention strategies must take into account all the ways in which infection can spread. In the case of HIV, these are well known. HIV is not air borne, water born, or food borne. Humans do not catch it from animals or insects; they are infected by other humans. It is not transmitted by touch or sneezing. HIV is transmitted by body fluids, particularly blood and semen. HIV requires a pathway from the body of the infected person to the body of the uninfected person.

In order to become infected with HIV, an uninfected person must engage in a behavior that exposes him to an open pathway and at the beginning of that path, there must be an infected person. Different pathways carry different levels of risk.

 

Blood, blood products, and body parts

Blood transfusions, transplanted organs, drugs created to treat hemophilia made from blood, or semen used for artificial insemination provide a pathway for the virus to travel from one person to another. If the donor is infected, the probability is high that the recipient will become infected. Tests are available to assure that all blood products, transplants, and other human tissue destined to be used on another human being is HIV free.

Medical personnel are also at risk through inadvertent needle sticks. If medical personnel working with HIV positive patients are exposed to the patient’s blood prompt cleaning of the wound, plus treatment with antiretrovirals can prevent infection. In order to avoid unnecessary concern, medical personnel need to know which patients are HIV positive. A needle has been developed which prevents this kind of accidental needle sticks and health care workers have lobbied for the universal use of this style needle.[4]

 

Mother to Child Transmission (MTCT)

An HIV positive mother can transmit the virus to her unborn baby. Where prenatal testing and treatment of the mother and/or delivery by caesarian section are employed, this transmission pathway can be reduced to almost zero.[5]

 

Medical Contamination

The HIV virus can find a pathway from the infected person to the uninfected person through improperly sterilized medical equipment or multiuse vials of injected drugs or vaccines. In facilities where the procedures for sterilization are followed meticulously and/or disposable equipment is used, there is virtually no risk of infection. If a needle or syringe used on an HIV positive patient, it not properly sterilized, it can become contaminated with the HIV virus. If a vial of medicine is used for a number of patients, the virus from an infected person could be introduced into the bottle through an improperly sterilized needle and/or syringe. The entire bottle would be contaminated and everyone treated from that bottle subsequently would be exposed to the virus. Proper sterilization is essential in all facilities not only to prevent HIV but other blood and fluid born diseases. Today most health facilities rely on disposal products – particularly disposal needles and syringes — and single use bottles to avoid the risk of contamination.

 

Quasi-Medical Procedures

Not all injections and invasive procedures are done in medical settings. Traditional Africa healers frequently give their clients injections, often with improperly sterilized equipment.

 

Illegal Intravenous Drug Use (IDU)

Persons who inject illegal drugs often do not sterilize their equipment and often share equipment with other addicts. If one participant in such unsanitary sharing becomes HIV+, the risk is high that those with whom he shares equipment will become infected. A number of jurisdictions have chosen to dispense disposable needles to addicts in an attempt to eliminate this problem. Sexual partners of infected drug users are also at risk and by extension their unborn children.

 

Sexual Transmission

The HIV virus can be transmitted through sexual contact. While vaginal sex between a man and a woman can transmit the virus, the risk of a woman contracting HIV from a single act of vaginal intercourse is lower than for other STDs and the risk for man contracting it during vaginal intercourse is even lower.[6]

There is evidence that persons with open sores in the genital area are more susceptible to sexually transmitted HIV, since these sores provide an entry point for the virus into the blood stream.  Persons with sexually transmitted diseases (STDs) such as gonorrhea, which create open sores (genital ulcers), are at higher risk of being infected if they have sex with an infected person. Women suffering from Bacterial Vaginitis may also be more susceptible in infection.[7] Men who are not circumcised also appear to be at higher risk.[8]

Anal sex provides an efficient pathway for the virus, perhaps because the act causes small breaks in the tissue, perhaps because the intestinal track is more absorbent than the cervix and uterus. It is also possible to transmit the virus through oral sex, although this appears to be less common.

The more sexual partners a person has, the greater the risk that one of those partners will be infected with HIV. A person with multiple concurrent sexual partners in a social group where the virus is already present is at high risk. Prostitutes and their clients are, therefore, at high risk, as are men who have sex with men (MSM) because they often have many sexual partners.[9] A MSM who has only one partner can be at risk if his partner is not also monogamous. According to AIDS experts:

 

It seems obvious but there would be no global AIDS pandemic were it not for multiple sexual partnerships. The rate of change of sexual partners – especially concurrent partners – is a crucial determinant in the spread of sexually transmitted infections including HIV.[10]

 

There are other factors. The younger a person is, particularly the younger a woman is, when she begins to engage in sexual relations the greater the risk she will have multiple partners over her lifetime and therefore be at greater risk for exposure. There is also evidence that young women are physically more susceptible to the virus.[11] Women who use oral contraceptives or Depo-Provera appear to be at higher risk of contracting STDs and therefore could be at greater risk for HIV infections.[12]

There was hope that the spermicide Nonoxynol-9 might reduce HIV infection, but research found that “Women who used N-9 had been infected with HIV at about a 50% higher rate than women who used the placebo gel.”[13]

Condoms used consistently and correctly can reduce the risk infection during vaginal intercourse. A meta-analysis of condom effectiveness found that:

 

“Consistent use of condoms results in 80% reduction of HIV incidence. Consistent use is defined as using a condom for all acts of penetrative vaginal intercourse… Thus, condom effectiveness is similar to, although lower than, that for contraception.”[14]

 

Condoms have long been considered the least effective form of contraception. Of married women who rely on condoms for one year, 15% become pregnant. The failure rate for pregnancy prevention is higher for unmarried women. Even when people intend to use them correctly, condoms can leak, break, or slip off during use. This means that condom usage constitutes even under the best-case scenario a risk reduction strategy. While correct use decreases the probability that an individual sexual act will transmit the virus, massive condom distribution has not been effect against an established epidemic. According to an article in The Lancet: “Massive increases in condom use worldwide have not translated into demonstrably improved HIV control in the great majority of countries where they have occurred.”[15]

According to review of the literature on condom promotion:

 

“In many sub-Saharan African countries, high condom use has yet to produce demonstrable benefit. While HIV might have spread even faster without condoms, sad experience shows that high HIV transmission can coexist with high condom use.”[16]

 

In addition, consistent and correct condom use is the exception. A study done in Uganda found that an intervention that increased condom use actually increased HIV risk behavior. Those supplied with education and free condoms had more unprotected sex.[17] Even when people receive extensive education, know that they are at risk for infection, and begin to use condoms; few continue to use a condom every time. A study in Malawi reported that:

 

Consistent condom use peaked at 62% in the first 6 months, but declined to as low as 8% in the second year of follow-up.[18]

 

Several studies have found that inconsistent condom users have higher rates of STD and/or HIV infections than condom non-users.[19] While it might be assumed that condom use would be associated with lower rates of HIV infection, several studies of HIV infection among MSM found that those who did not use condoms were less likely to be infected, than those who did.[20] A study of HIV in Zimbabwe found that: “HIV risk was elevated among those who had used condoms consistently with their most recent partner.”[21] This may be because the non-users were less likely to have a number of different partners. On the other hand, condom users experience a false sense of security and go on to engage in sexual encounters with a number of partners, but fail to use a condom every time, either because they were high on drugs or alcohol or simply because they didn’t want to be bothered “this one time.”

A study of HIV incidence and sexually transmitted disease prevalence in Uganda found that:

 

“Irregular condom use was not protective against HIV or STD and was associated with increased gonorrhea/Chlamydia risk.”[22]

 

An article in The Lancet warned, “A vigorous condom-promotion policy could increase rather than decrease unprotected sexual exposure, if it has the unintended effect of encouraging greater sexual activity.”[23]

Female condoms have been recommended as a woman controlled form of protection. These have lower effectiveness rates than male condoms and are substantially more expensive. In poor countries, women are tempted to wash and reuse them.

 

While the potential pathways for the HIV virus to pass from an infected persons to an uninfected person are known, because the time between when the person is actually infected and when the first symptoms of the disease appear can be as long as 10 years, it is difficult to determine precisely how a particular individual was infected. However, because the virus can mutate slightly as it moves from person to person sophisticated tests can determine which form of the virus infected a particular person and link that form of the virus to another infected person. These tests are expensive and rarely done. In most cases, health care workers simply question HIV+ patients about their behaviors and make assumptions as to how they were infected. Because HIV/AIDS are classified as sexually transmitted disease (STD), those taking histories of the infected usually, consider sexual activity as the probable pathway. In some cases, patients who insisted that they had not engaged in sexual activity at all or at least not with an infected person have been dismissed as lying.[24] In one case early in the epidemic, a young woman insisted that she was a virgin and had not engaged in an activity that could have exposed her to the virus. After much investigation it was determined that she had probably been infected by her dentist, who had died of AIDS. When records were checked, several other patients of the dentist were also infected with the same variation of HIV, but because these patients were sexually active it had initially been assumed that they had been infected sexually.

Given all that is known, prevention is possible. A person who is chaste before marriage, who is faithful to their spouse, who marries a person who is HIV free and also committed to fidelity, who receives health care where sterilization, testing of any blood products, and all other proper procedures are followed, who doesn’t inject illegal drugs, who isn’t exposed to non-sterile non-medical invasive procedures, and who is not a health care worker exposed to HIV positive patients has a virtually zero risk of becoming infected with the HIV virus. This is true whether the person lives in the North America or Africa.  

            Prevention would seem therefore to be relatively straightforward. Warn people about the risks of various behaviors, discourage or restrict high-risk activities, and assure that all medical procedures are conducted in properly sterile conditions and all blood and body parts tested and HIV free before transfer.

 

Co-Infections

 

Those living in Sub-Saharan Africa do suffer from an additional risks. Malaria, genital herpes, and tuberculosis are more common and people are less likely to receive prompt effect medical care. These diseases may make a person more vulnerable to infection with HIV and HIV in turn makes the person more susceptible to these diseases.[25]

Diagnosis with TB may be the first sign that a person is HIV positive.

 

People infected with both MDR [multi-drug resistant] TB and HIV appear to have a more rapid and deadly disease course than do those with MDR TB only. If no medicines are available, as many as eight out of ten people with both infections may die, often within months of diagnosis.[26]

 

At one time spraying with DDT was controlling malaria, but international pressure against DDT eliminated widespread spraying and there was a resurgence of malaria – which is the biggest killer. New efforts to combat malaria with spraying of the inside of houses and bed nets are proving helpful.

Not only did the HIV/AIDS hit those already sick with one of these diseases harder and make them more likely to become infected, the epidemic also drained scarce resources away from general health care and into condom distribution, further undermining the health care system.

 

II         Standard Public Health Strategies

 

AIDS is not the first deadly epidemic with which public health officials have had to deal. Over the centuries they have developed a wide range of responses. When countries are faced with a deadly epidemic, public health officials frequently are given sweeping power to close down every pathway the infectious agent might take. Public health strategies have taken into consideration the social problems associated with STDs. Standard strategies for dealing with epidemics have included:

 

  • Educating the public and health care workers about the risks and measures required to prevent transmission.

 

  • Instituting stringent sterilization procedures and other preventive measures in all healthcare facilities, including when possible the use of disposable needles and syringes and other equipment.

 

  • Testing blood and blood products, screening blood donors, and when blood is found to infected notifying donors and tracing their contacts

 

  • Mandatory or routine testing of those thought to be exposed or at-risk groups including hospital patients, those diagnosed with other STDs, pregnant women, applicants for marriage licenses, prisoners, prostitutes. Routine testing means that people who present themselves for health care and who are considered at risk are tested unless they sign a paper opting out.

 

  • Contact tracing and partner notification. The standard procedure for dealing with STDs is to ask those inflected to provide the names and addresses of all their sexual partners, so that these persons can be warned about the risk, tested, and treated if infected.

 

  • Isolation and Quarantine – Patients in health care facilities infected with a contagious disease are often isolated in special wards, where extra precautions against infection of staff and other patients are employed. In some case people have been quarantined if it is determined they pose a risk to others. For example, HIV+ prisoners could be housed separately from the general prison population.

 

  • Closing Venues – During many epidemics public health officials prohibited public gatherings and closed locations where people were presumed to have been infected. For example, during the polio epidemic swimming pools and children’s camps were closed.

 

  • Personal protective measures – Hand washing, disposable gloves for food services workers, masks in the case of airborne viruses, condoms to prevent transmission during sexual relations. It should be noted that personal protective measures are generally not particularly effective methods of managing an epidemic and are usually not used as the first line of defense.

 

The response to the HIV/AIDS epidemic has focused on changing sexual behavior, but there has been substantial debate about the kind of change that should be encouraged. Prevention programs have moved in two different directions

 

1)         Condom Use – Educating every one to use a condom during every sexual act and seeing to it that condoms are easily available – a risk reduction strategy.

 

2)         Abstinence and fidelity (Positive Behavior Change) – Encouraging abstinence before marriage, delaying initiation of sexual activity, fidelity in marriage, and monogamy –  risk avoidance strategies.

 

III        THE AIDS Consensus

 

In the late 1980s a number of non-government organizations (NGOs), governmental agencies, and UN agencies began to work together to prevent, treat, and hoping find a cure for or vaccine against HIV/AIDS. These groups constitute the “AIDS Establishment.” They came to a consensus as to the proper strategy to deal rapidly spreading HIV/AIDS epidemic in sub-Saharan Africa. This consensus focused on condoms – condom education, condom provision, and social marketing of condoms — accompanied by other medical interventions. The AIDS Consensus was based on the following assumptions:

 

  • HIV in Africa is transmitted through heterosexual vaginal sexual relations. Other pathways such as homosexual relations, anal sex between men and women, IDU, non-sterile medical transmission, blood transfusion, and MTCT, constituted only a small fraction of cases.
  • The condom promotion campaign among MSM in the U.S had dramatically reduced new infections in that population and should be the model for controlling AIDS in Africa.
  • There was no need to employ standard public health measures such as routine testing, contact tracing, and partner notification. Instead, those are risk should be encouraged to accept voluntary counseling and testing (VCT) and the results kept secret.
  • Condoms are the only effective weapon in the battle to prevent infection.[27] Prevention programs should focus on condom education and distribution. Program success should be judged by how many condoms are supplied and the percentage of sexually active people using condoms.
  • The epidemic continues to spread because the African people do not have enough condoms and did not use condoms consistently.
  • Programs that emphasize abstinence and fidelity will not work in Africa because Africans are naturally promiscuous.
  • Condom education should focus on presenting condom use as modern and fun. Fear-based campaigns do not work.
  • Discrimination against AIDS victims and stigmatizing of persons who have multiple sexual partners endangers prevention campaigns. Faith-based organization should be involved in AIDS prevention only if did not moralize about sexual behavior and if agree to promoted condoms.
  • Women should be empowered by educating them on how to negotiate condom use and/or by supplying them with female condoms.
  • Treating other STDs can reduce sexual transmission.
  • Prostitutes should be supplied with condoms and encouraged to use a condom every time.
  • Poverty, marginalization, civil war, and gender inequality drive the AIDS epidemic.

 

The AIDS Establishment insisted that the “AIDS Consensus” was the only “scientific” approach to AIDS prevention and anyone who disputed this consensus was irresponsible, ignoring established scientific facts, and therefore causing the disease to spread and Africans to die.

Other experts challenged every assumption behind the AIDS Consensus. These experts questioned why HIV/AIDS was exempted from standard public health strategies, why non-sexual paths of transmission were not considered, why Africa was sold a risk reduction rather than a risk avoidance strategy, and why failed programs received funding and successful programs were ignored.

How did the AIDS Establishment react to these challenges?

 

  • They accused the critics of the AIDS Consensus of ignoring science, although each challenge was supported by carefully analyzed research.
  • They accused those who challenged the AIDS Consensus of being dangerous “fundamentalists” who were trying to impose “Victorian morality” on Africa, even though those challenging the consensus were respected scientists without particular religious affiliation.
  • They insisted that their condom programs had failed because they were under funded and what was needed was more money for more condoms, even though cartons of condoms sat unused.
  • They blamed the African people for being too ignorant or stubborn to use condoms or for engaging in bizarre cultural practices that contributed to the spread of the disease or uncontrollably promiscuous, even though research showed that Africans were far less likely to have multiple sexual partners than Europeans.
  • When all else failed, they tried to co-op the successful ABC programs, using the language of abstinence and fidelity, but directing all the funding to condoms. When the diluted programs failed, they blamed the A and B components.
  • They blocked the publication of studies which refuted their assumptions and sent out press releases accusing those who did not accept the AIDS consensus of “killing Africans.”

 

IV        The AIDS Establishment

 

In order to understand how the AIDS Establishment arrived at the AIDS Consensus and why they defend it so fiercely, one needs to understand the history of AIDS prevention and the various constituencies that make up the AIDS Establishment:

 

1)         Public Health Officials

 

Local, national and international public health officials are charged with controlling epidemics. In the U.S. states and municipalities respond to local outbreaks of disease, but the Centers for Disease Control (CDC) has primary oversight in this area. The World Health Organization (WHO) is a UN affiliated agency concerned with the international responses to epidemics.

The history of the U.S. response to AIDS was reported by Randy Shilts, in his book As the Band Played On: Politics, People, and the AIDS Epidemic. Shilts, who later died of AIDS, reported on the interplay between the politics of sexual liberation and the efforts to track the epidemic, identify the cause, develop treatment and produce a vaccine. Shilts documented how from the beginning public health officials were impeded in their efforts to contain the epidemic by militant gay activists who refused to sacrifice their sexual freedom to stop a deadly disease.

The public health officials had long been concerned that behavior patterns in gay communities constitutes a serious public health problem. Even before the HIV virus entered the blood stream of a man engaged in sex with other men, the gay male community was in the midst of an epidemic of sexually transmitted diseases. MSM frequented bars and bathhouses where they engaged in anal and oral sex and other practices with multiple partners. In 1980 Dr. Selma Dritz, the infectious disease specialist for the San Francisco Depart­ment of Public Health, warned that among MSM: “We’ve got all these diseases going un­checked. There are so many oppor­tunities for trans­mission that, if something new gets loose here, we’re go­ing to have hell to pay.”[28] Unfortunately, the warning was too late. The HIV virus had already begun to spread through the gay community. In June of 1981 the first cases of what would become known as AIDS were reported.

The public health officials put forward the standard measures for control a sexually transmitted infection: partner notification, contact tracing, closing venues where transmission was known to be occurring, warning people to avoid high-risk behavior (in this case anal sex), monogamy, and using condoms for all sexual activity. In 1983 the virus that causes AIDS was identified and public health officials recommended that MSM be tested so that their partners and sexual contacts could be notified that they were at risk. They further recommended that HIV+ men refrain from unprotected sex with HIV- men. Even though case histories revealed that many of the first victims had had 100s, some 1000s of sexual partners and many of these were strangers, the hope was to contact as many of those at risk as possible, encourage them to change their behavior, and stop the spread of the disease. As the nature of the epidemic among MSM became clear, the public health officials recommended closing the bathhouses since these were clearly venues where infection was being spread.

The gay community strenuously opposed virtually all standard public health practices for dealing with an STD epidemic. According to Ronald Bayer, “U. S. officials had no alternative but to negotiate the course of AIDS policy with representatives of a well-organized gay community and their allies in the medical and political establishments… In this process, many of the traditional practices of public health that might have been brought to bear were dismissed as inappropriate.” [29]

Routine testing and reporting was rejected as a strategy, even for those who were not part of the gay community. For example, tests were done to determine how many babies were infected, but the names were not reported to the government, nor were the mothers told of their babies and their own condition. Over time public health officials who did not accept the AIDS consensus left the field and were replaced by those who did.

On the other hand, public health officials were successful in dealing with other pathways of infection. Problems with the blood supply were addressed. Sterilization procedures were strictly enforced. As a result, the AIDS epidemic in the U.S. remained concentrated among men who have sex with men (MSM)

 

2)         The Gay AIDS Activists

 

From the beginning, in the West, MSM bore the brunt of the epidemic. A study conducted in the Baltimore STD clinic in 1984 found that HIV seroprevalence among MSM was 58%.[30] Similar findings were reported in other major metropolitan areas. The gay community responded by setting up a number of organizations, such as the National Gay Task Force and the Gay Men’s Health Crisis. Local and national groups came together to lobby for spending on research and treatment and to oppose public health initiatives they viewed as unacceptable.

Although in many epidemics people who are infected and engage in activity that would infect others are subjected to quarantine, such extreme measures were immediately taken off the table. The sincere hope was that given the death and disease all around them MSM would act prudently to protect themselves and others.

Gay activists insisted that none of the standard measures would work in their community. They were concerned about stigmatization and discrimination if test results were revealed and so opposed all mandatory or routine and at first even voluntary testing. They opposed all reporting by name of infected persons, even though this had been done for years with other STDs, and even after laws were passed protected patient confidentiality. They decried negative, fear-based condom promotion. Instead they insisted on “sex positive” condom campaigns. The Gay AIDS Activists felt it was their duty to their community to protect their recently won right to absolute sexual liberation. They opposed closing the bathhouses. Instead, they insisted that condom education would solve the problem and the prevention education must not focus on limiting partners or avoiding anal sex, but on using a condom every time. AIDS prevention strategies were tailored to fit their demands.

In the late 1980s the number of new infections among MSM dropped significantly. Gay AIDS Activists took this as proof their strategy had worked. They put themselves forward as experts on prevention and became influential in the formulation of prevention strategies in other areas of the world.

However, by 1990 it was clear that the strategy had failed and the number of young MSM infected with HIV increased and continued to increase. Those who studied the epidemic realized that, while initially there were changes in behavior, the dramatic decrease in new infections they had seen in the late 1980s were due at least in part to epidemic saturation. During that period those most at risk were already infected and so the number of uninfected MSM had decreased significantly and those not infected at that stage of the epidemic were more likely to have fewer sexual partners and therefore a lower risk of infection.[31] Given the effect of epidemic saturation, the number of new infections among MSM was bound to decrease. However, as young men entered the gay community, they were infected at a high rate. MSM now constitute the majority of those newly infected with HIV. MSM are 44 times more likely to become HIV positive than men who don’t.[32]

 

3)         Population Control Advocates

 

For several decades before the beginning of the AIDS epidemic, a number of Non-Governmental Organizations (NGOs) such as International Planned Parenthood Federation and the Pathfinder Fund had worked with governmental agencies and the United Nations Population Fund (UNFPA) on strategies to reduce population growth in the developing world. These organizations convinced many that high birth rates were a major cause of chronic economic problems in developing countries and that dramatically cutting the birth rate would improve conditions and speed development.

It should be noted that while Africa has a number of crowded urban centers, the continent as a whole is relatively under populated. Furthermore, many other experts dispute the theory that cutting the birth rate is the solution to underdevelopment.

The population control movement is well funded. In Africa, it focused on setting up clinics and dispensing IUDs, offering sterilization, condoms, and other contraceptive measures. Where abortion was illegal, they lobbied for legalization. When the AIDS epidemic hit Africa, these groups claimed to have expertise in providing sexual and reproductive health care services and took an active part in condom education and distribution. The condom campaign forwarded their interest in population control since condoms are a form of contraceptive.[33]

 

4)         Sexual and Reproductive Health and Rights Community (SRHR)

 

The Sexual and Reproductive Rights and Health Community (SRHR) is loose coalition of NGO’s and UN agencies, which has worked along side the Population Control Advocates, to promote contraception and abortion around the world.

While there is broad support for creating societies where women have equal protection under the law, equal education, equal rights to participate in the political process, and equal economic opportunity and where women are protected from violence and sexual exploitation, SRHR community focused on freeing women from religious, cultural, and social restrictions on their sexual freedom. Their aims include promoting an unlimited right to abortion, the sexual liberation of women, and lesbian rights. They are strongly influenced by the Radical Feminist ideology, which regards traditional marriage, family, and religion as oppressive to women. It should be noted that this attitude does not reflect the concerns of the majority of African women who, while they want their fundamental human rights protected, also value family, marriage, and faith.

The SRHR includes groups such as Women’s Environment and Development Organization (WEDO), Catholics for a Free Choice (CFFC), Center for Reproductive Rights (formerly the Center for Reproductive Law and Policy) and Center for Health and Gender Equity (CHANGE).

 

5)         Advocates for Western Technology

 

There are also a number of experts involved in AIDS prevention who are see Africa’s problem as primarily a lack western technology and expertise. These experts often fail to value local expertise and local low-tech solutions. In many cases, technological solutions that are effective in developed countries, fail in places where basic health care, clean water, electricity, communications, transportation, and financial resources are luxuries.

 

The AIDS Establishment is drawn from people in these five communities. They bring different concerns to the table, but they are united in the conviction that condoms are the best hope for AIDS prevention. Any approach that does not focus on condom use is viewed as denying science. They are willing to combine other technological approaches with condoms such as Voluntary Counseling and Testing (VCT), prevention of mother to child transmission (MTCT), treatment of STDs, circumcision, prophylactic treatment of those exposed to possible infection, antiretroviral treatment, and aggressive treatment of opportunistic infections, so long as these do not decrease the money and effort being directed to condom education, provision, and marketing.

Most of those in the AIDS establishment have been engaged in battles with various religious organizations on other issues. As a result, the AIDS Establishment as a group is generally hostile to religions they consider to be “fundamentalist.” By their definition any religion, which will not modify the fundamentals of its faith to conform to the agendas of the AIDS Establishment, is “fundamentalist.” They are particular hostile to Catholicism and frightened at the possible rise of the “Religious Right.”[34]

 

V         Challenging the AIDS Consensus

 

Before the AIDS Consensus had been firmly established the President Yoweri Museveni of Uganda recognized the threat the HIV/AIDS posed to his country – a country that had recently emerged from decades of oppression and strife. Under his and his wife’s leadership the ABC program was initiated: A for abstinence, Be Faithful (or in the Ugandan idiom Zero Grazing) and C for use condoms if one partner is infected and other not.

Dr. Edward Green, Senior Research Scientist at the Harvard Center for Population and Development Studies and a member of Presidential Advisory Council on HIV/AIDS had been actively involved in population control and AIDS prevention in Africa. In three books Rethinking AIDS Prevention: Learning from Successes in Developing Countries, Broken Promises: How the AIDS Establishment has betrayed the development world, and AIDS,  Green he recounts how he came to recognize the deficiencies inherent in the AIDS Consensus and the positive results of the ABC approach used in Uganda. Green had observed first hand the determination of the AIDS establishment to promote condoms as the prevention method of choice, even when it was clear that the strategy was not working. He had observed how faith-based organizations were able to achieve reductions in new infections with low cost intervention strategies and yet when these succeeded, the AIDS establishment interfered in ways that undermined these successes. Green goes out of his way to makes it clear that he is not a member of the “religious right,” but he was shocked to discover the undisguised hostility shown by members of the AIDS establishment toward faith-based organizations. Green’s book is essential reading for anyone who wishes to understand AIDS prevention in Africa. Green pointed out those countries, which have adopted the strategies recommended by the AIDS Establishment, have not seen a reduction in new infections.[35] His work, along with that of others, convinced the U.S. government to move funding to ABC strategies, thereby provoking a collective cry of outrage from the AIDS Establishment.

The AIDS Establishment insists that the AIDS Consensus has been scientifically proven to be the only way to prevent HIV infections. Each assumption behind the AIDS Consensus has, however, been challenged by other equally qualified experts:

 

Assumption #1 AIDS in Africa is transmitted through heterosexual relations.  Other pathways such as MSM, IDU, non-sterile medical transmission, mother-to child, constituted only a small fraction of cases.

 

In 2002, the WHO’s World Health Report stated, “current estimates suggest that more than 99% of HIV infections prevalent in Africa in 2001 are attributable to unsafe sex.”[36] A number of experts questioned how the WHO arrived at this estimate. Given the lack of disposable injection equipment and effective sterilization in many areas of Africa, it seemed reasonable to assume that transmission in health care settings was a major pathway for HIV infection.

In a three articles published in the International Journal of STD & AIDS in 2003, David Gisselquist, John Potterat, Devon Brewer, Stephen Minkin, and their associates presented evidence that this claim was not supported by the research. They suggested that medical transmission might be responsible for a significant percentage of HIV infections.

The titles of their articles explain the burden of their complaint: “Let it be sexual: how health care transmission of AIDS in Africa was Ignored” discusses how it was in the interests of certain groups in AIDS Establishment to ignore evidence of medical transmission.[37]

 

First it was in the interests of AIDS researchers in the developed countries – where HIV seemed stubbornly confined to MSMs, IDUs, and their partners – to present AIDS in Africa as a heterosexual epidemic; ‘nothing captured the attention of editors and news directors like the talk of widespread heterosexual transmission of AIDS.”[38]

 

Second, population control advocates saw condom promotion as “coinciding with pre-existing programmes and efforts to curb African’s rapid population growth.”[39]

Third, the WHO worried that discussion of health care risks might adversely affect immunization programs.

The second article “Heterosexual transmission of HIV in Africa: an empiric estimate” argues that the consensus view that 90 to 99% of adult HIV in Africa is from sexual transmission has not been derived from or tested against the evidence and doesn’t fit with what is known about STD epidemics.[40]

The third article, “Mounting anomalies in the epidemiology of HIV in Africa: cry of the beloved paradigm,” argues, “Africans deserve scientifically sound information on the epidemiologic determinants of the calamitous AIDS epidemic.”[41] Their concern is that the AIDS Consensus was reached without such research.

This was not the first time the issue had been raised. In 1991, Randall Packard and Paul Epstein challenged what they considered to be “a premature closure of African AIDS research.”[42] They pointed out that the explosive increases in HIV infections in some areas were not consistent with what is known about other STIs. For example, in Nairobi between 1981 and 1983 the HIV infection rate in a cohort of prostitutes rose from 4% to 61% and eventually reached 85%.[43] [44] Since prostitutes are routinely tested for STDs and the syringes for drawing blood in STD clinics are not always sterile, it is possible that the infection was spread in this manner, and then the infected prostitutes spread it sexually to their clients. Likewise, those seeking treatment for an STD at such a clinic could become infected with HIV through the testing or treatment procedures.

This challenge to the AIDS Consensus was not left unanswered. In an article answering Gisselquist et al, George Schmid and associates rejected the claim that unsafe injections caused 20 to 40% of HIV infections in Africa, but admitted that in Africa 18% of injections are given with non-sterilized equipment. In addition, that “unsafe injections are an unacceptable practice and that efforts should be increased to reduce exposure of patients to blood borne infections in health care settings.”[45]

In other areas of the world HIV infection through non-sterile medical procedures has been reported. Use of non-sterilized injection equipment among intravenous drug users is known to be major pathway for infection. It is reasonable to assume that use of non-sterile injection equipment in health care settings, STD clinics, and by traditional healers in Africa could also pose a significant risk.

Transmission of other diseases by non-sterile injections had long been a problem in Africa. In a poor area of Dakar, Senegal tetanus and infected abscesses from injections are the third leading cause of death among children under five.[46]

Preventing medical transmission in Africa is complicated by the fact that a substantial portion of the African population continues to rely on traditional healers – who may use injections or invasive procedures to treat a variety of aliments including AIDS and STDs. If these traditional healers are not using disposable needles and syringes and are not correctly sterilizing equipment, the chances are very high that they could spread HIV to their clients. The possibility that traditional healers are responsible for spreading infection has been acknowledged in the case of other diseases such as Marburg Hemorrhagic Fever. According to an article in the New England Journal of Medicine, “Home-based treatments involving the use of unsafe syringes have become an important route of transmission. Cases of Marburg disease have been confirmed in traditional healers.” [47]

The article on Marburg also points out “procedures for infection control at provincial hospital are not rigorously followed.” Many clinics lack disposal needles and syringes and sterilization equipment. In some areas electric power is unreliable rendering the sterilization equipment useless. There is also concern that clinics set up to provide sexual and reproductive health care in remote areas may not use proper sterilization methods during examinations, tests, insertion of IUDs, or injections.

In the US, stopping the medical transmission of HIV through sterilization and the testing of blood has proven extremely effective. There is no reason why with sufficient resources directed toward this effort and sufficient awareness of the risk this pathway of infection cannot eliminate in Africa. However, if all the money goes to condoms and basic healthcare is neglected, then healthcare transmission may be an ongoing concern.

This question has serious implications for the allocation of prevention resources in Africa. If sexual transmission were the only way that AIDS is transmitted in Africa, then it would be reasonable to devote the lion’s share of the prevention efforts to stopping sexual transmission, however if the virus is moving along multiple pathways then prevention funding should be used to shut down all pathways. Preventing medical transmission is straightforward; it does not involve changing sexual behavior. It is supported by medical ethics. It will prevent other infections. No health care provider — whether working a western style setting or with traditional African methods – wants to harm patients. Africans have a right to absolutely sterile procedures.

It should also be noted that focusing attention on the possibility that HIV was transmitted by non-sterile injections could reduce some of the stigma attached to the disease. An HIV+ wife with an HIV- husband could reasonable argue she had been infected by medical treatment not adultery.

 

Assumption # 2: The condom promotion campaign among MSM in the U.S dramatically reduced new infections in that population, and should be the model for controlling AIDS in Africa.

 

            Condom education was not, as had been thought, been responsible for the dramatic decline in new HIV infections among MSM in the US in the late 1980s. It is true that in the late 1980s the number of new infections among MSM in the U.S. decreased dramatically. This decrease was attributed to a massive condom education campaign, however it now appears that this was not the primary cause. Gabriel Rotello, a gay man, in his book Sexual Ecology and the Destiny of Gay Men presented convincing epidemiological evidence that the dramatic decrease was the result epidemic saturation.[48] By the late 1980’s the majority of sexually active MSM were infected with HIV. In San Francisco in one cohort, the infection rate reached 72% by 1988. The epidemic was burning itself out. It was a mathematical certainty that because the number of non-infected MSM had shrunk, the number of new infections had to decrease. In order to evaluate the effect of condom education program it is necessary to track new infections among young men entering the gay community. Study after study found that among MSM 17 to 22 years of age, the infection rate did not decrease. Thus what was believed to be a successful strategy was simply a statistical quirk.

By 2006 the CDC was reporting alarming increases in the number of young MSM newly infected with HIV. In the 13 to 24 age group, the number infected was going up  every year. In 2006 it increased 18% from the previous year, this in spite of massive condom education in the schools and a generally more tolerant attitude toward men who have sex with men.

Why hadn’t the intensive condom education campaign worked? Research on the behavior and HIV status of MSM in the US during this period found that no matter how intensive the initial educational process, how easy it was to obtain condoms, or how vigorous the follow-up, condom use remained inconsistent – falling off over time, with frequent lapses.

It is now clear that condom education has not worked among a well-educated-affluent group of MSM.[49]

 

The efficacy of health education interventions in reducing sexual risk for HIV infection [among MSM] has not been consistently demonstrated. More education, over long periods of time, cannot be assumed to be effective in inducing behavior changes among chronically high-risk men.[50]

 

Even if had, there is no reason to assume that a strategy designed for a high-risk group such as MSM in a developed country was appropriate for an epidemic among a general heterosexual population in a developing country.

Of even more concern is the fact that the virus is mutating and becoming resistant to the newer drugs and that men infected with HIV and on medication are engaging in unprotected sex and spreading resistant strains of the virus to uninfected men.[51]

 

Assumption #3: There was no need to employ standard public health measures such as routine testing, contact tracing, and partner notification. Condom education will solve the problem.

 

This approach is known as AIDS Exceptionalism. The gay AIDS activists argued that AIDS should be exempted from standard public health procedures because 1) condom education was working (although it actually wasn’t) and therefore there was no need to resort to more restrictive public health measures; 2) the stigma associated with the disease and the association of the disease with homosexuality would lead to discrimination, stigmatization, or even violence. Therefore, there should be no mandatory or routine testing, no revelation even to public health officials of the names of those infected and no notification of the partners or family members. This lead to situations where wives were not told their husbands had died of AIDS and mothers were not told their babies were HIV positive and they were therefore probably infected.

Not all in the gay community accepted AIDS Exceptionalism. In an article for The Atlantic Monthly, “The AIDS Exception: Privacy vs. Public Health” Chandler Burr, a gay man, wrote: “It’s time to stop granting “civil rights” to HIV – and to confront AIDS with more of the traditional tools of public health.” He pointed out that “an absence of routine testing, reporting, and notification” means that “a lot of undiscovered AIDS and HIV cases are festering in the larger society.”[52]

In 2003 Charles Karel Bouley, a San Francisco talk-show host who lost his partner to AIDS, asked, “What if HIV had been treated like SARS?” He pointed out that:

 

If someone who knew they had SARS decided to hop into a crowded bus or airplane and cough on everyone, wouldn’t they be dragged away in handcuffs and quarantined? Oh, but not HIV: Today we have parties in bigger cities where people actually go to have sex with HIV-positive people: bug chasing parties. It’s criminal.”[53]

 

AIDS Exceptionalism influenced the choice of prevention strategies in Africa. For example, although patients are tested for other diseases as part of ordinary health care at pre-natal clinics and STD clinics, routine testing for HIV was rejected as a strategy even though such testing would have identified infected persons and protected babies and sexual partners. Instead, voluntary counseling and testing (VCT) was recommended, although those most at risk frequently refused to present themselves for voluntary testing.

Kevin M. deCock and associates in an article in The Lancet  in 2003 argued for “A serostatus-based approach to HIV/AIDS prevention and care in Africa” under which  routine testing for HIV would be “done as an integral part of a preventive health service.[54] The article pointed out that clients at STD clinics are routinely tested for syphilis or other infections, and it is reasonable to include routine HIV testing, particularly since STD clinic patients are at high risk for HIV infection.

The deCock article was careful to acknowledge, “concerns about stigma and infringement of the rights of HIV-infected people. Central issues are autonomy and privacy, or clinically, informed consent and confidentiality.” There are, however, other concerns that could be taken into consideration, such as the rights of the uninfected to know their risk and the interests of the government in controlling a deadly and costly epidemic. Do people have the right to infect others by refusing to find out their HIV status? What should a government do to prevent new infections?

The public health community in Africa appears to be committed to VCT even though it appears to be ineffective. For example, in article on preventing the transmission of HIV to the babies of infected women, Jeffrey Stringer and associates point out that since 1994 medicine is available even in Africa to prevent Mother to Child Transmission.[55] Yet many mothers when offered refuse VCT. The results: babies born infected.

The authors suggest that rather than bother with testing just give all pregnant women Nevirapine to prevent possible HIV transmission. In other words since they can’t routinely test, routinely treat. The authors are concerned that treatment of at-risk children is currently being “held hostage to the inherent complexity of establishing testing services.” While routine treatment would prevent many infections, it would not provide treatment for the mother or the father or other possibly infected children, it is simply a way to cope with one of the problems created by AIDS Exceptionalism.

Routine testing, contract tracing, and partner notification had proven extremely effective in finding infected persons and in warning those who had been involved sexually with an HIV+ person of their risk, often prompting changes in behavior.[56]

 

Assumption #4: Condoms are the only effective weapon in the battle to prevent infection. Prevention programs should focus on condom education and distribution. They should be judged on how many condoms they supply and the percentage of sexually active people using condoms.

 

Country by country studies found that condom distribution and use was not associated with lower infection rates, and in some cases with higher infection rates.[57] Condom education did not work among MSM in the U.S. and there is mounting evidence that in spite of years of valiant effort and vast expenditures it will not work in Africa. In an article published in the Sept. 1, 2005 edition of the Journal of Acquired Immune Deficiency Syndromes by P. Kajubi and associates entitled “increasing condom use without reducing HIV risk: results of a controlled community trail in Uganda” found that more condom use resulted in more not less high risk behavior.[58]

The argument for condoms had been that if condoms were easily available and men were motivated to use them, then HIV infections would decrease. Kajubi and his associates found this conclusion was not supported by their experience:

 

“The authors note that whilst the uptake of condoms was much higher among the intervention group, proving that the intervention had overcome barriers to access, this improvement in uptake actually appeared to be associated with an increase in behavior that may paradoxically increase the rate of HIV transmission in sexual networks with high levels of partner change.”

 

It appears that, giving men condoms and encouraging them to use them, encouraged them to engage in high-risk activity with a greater number of partners:

 

“Men in the intervention group reported a significantly higher number of partners during the six month follow-up period when compared with the sex months prior to joining the study.”

 

On the other hand, encouraging positive behavior change has proven effective. According to a 2004 article in Science by Rand Stoneburner and Daniel Low-Beer.

 

Uganda provides the clearest example that human immunodeficiency virus (HIV) is preventable if populations are mobilized to avoid risk. Despite limited resources, Uganda has shown a 70% decline in HIV prevalence since the early 1990s, linked to a 60% reduction in casual sex. The response in Uganda appears to be distinctively associated with communication about acquired immunodeficiency syndrome (AIDS) through social networks. Despite substantial condom use and promotion of biomedical approaches, other African countries have shown neither similar behavioral responses nor HIV prevalence declines of the same scale. The Ugandan success is equivalent to a vaccine of 80% effectiveness. Its replication will require changes in global HIV/AIDS intervention policies and their evaluation[59]

 

Assumption #5 : The epidemic was spreading because the African people did not have enough condoms and did not use condoms consistently.

 

It is generally accepted that STD epidemics are driven by multipartner sexual activity.[60] Consistent condom use has been impossible to achieve among persons who engage in sexual activity with multiple partners. In addition, condom use, whether consistent or inconsistent has not proven effective in reducing infection rates. The AIDS Consensus blames the victims for the failure of their strategy. It assumes that Africans are unable or unwilling to act in their own best interests, locked into destructive traditions, and oversexed. The article by Packard and Epstein points out how such racist stereotypes about Africa have affected health care in the past and why they are negatively affecting it today. [61]

According to Green when the African people recognized they were faced with a new and deadly sexually transmitted disease, many spontaneously began to modify their sexual behavior – to limit the number of sexual partners or to delay sexual activity. They chose to act prudently in their own self-interest. Since the majority of Africans marry and marry young and want children, using a condom every time was not a reasonable strategy for most. However, the pervasive social marketing of condoms as “safe” convinced many young people that sexual restraint was unnecessary and they could engage in sexual relations with multiple partners. Where social marketing was prevalent, condom use increased, but infections did not decrease.

 

Assumption #6 : Programs that emphasize abstinence and fidelity will not work in Africa, because Africans are naturally promiscuous.

 

Unfortunately, stereotypes about African sexuality have influenced the prevention strategies offered in Sub Saharan Africa. Douglas Feldman, commenting on the Packard and Epstein article, defended those “African societies where multipartnering behavior and sex-positive attitudes are common” and argued, “the AIDS pandemic should not be used as a vehicle for imposing an ideology of sexual restrictiveness across Africa.”

Contrary to this assumption, many Africans have been willing to modify their sexual behavior to avoid infection. Even before organized educational campaigns began when people understood that AIDS could be transmitted sexually, they began to respond by choosing a form of behavior appropriate to their life situation. The success of the ABC campaign in Uganda, particularly abstinence and fidelity proves that when faced with a deadly epidemic and told the truth about the risk, Africans can make prudent decisions about how to protect themselves. Young women have come to see the advantages of continuing their education and waiting until marriage that African people are capable of controlling their sexual desires

Those promoting ABC also stressed how abstinence and fidelity are not simply positive personal strategies but also patriotic choices protecting the country’s economic future.

 

Assumption #7: Condom education should focus on presenting condom use as modern and fun. Fear based campaigns do not work.

 

Condom campaigns that emphasize fun and safety have not been shown to increase condom usage sufficiently to stem the spread on HIV. There is evidence that such campaigns may have the unintended effect of glamorizing risky multi-partner sex, giving young people a false sense of security and thereby increasing risk of HIV infections.[62] On the other hand, fear-based campaigns, which present condoms as an option for those who won’t change their behavior, but point out the risks of condom use have proven effective in increasing positive behavior change.

In Thailand, where brothels are common, the government instituted a campaign to force 100% condom use. A study of the intervention found that the percentage of men using a condom every time they visited a prostitute increased from 24% to 71%, however the percentage of Thai men visiting prostitutes dropped from 25% to 10%. While this is very dramatic and would at first glance appear to show a massive increase in condom use, if one considers the decrease in the percentage of Thai men going to prostitutes, the percentage of the total population of Thai men using a condom every time with a prostitute went from 6% to 7%. Any decrease in new infections would have to be attributed the decrease in prostitutes visits rather than increased condom use. It is clearly possible that the campaign to impress upon Thai men the importance of using a condom with a prostitute, impressed upon them the risk of having relations with a prostitute, thereby creating a fear of visiting prostitutes.

The AIDS Establishment is led by people with a pro-sexual freedom agenda. They regard the right to sexual pleasure without shame or stigma, with as many partners as one desires, regardless of one’s sex or marital status, as an absolute right. Those who have fought against traditional morality in the West are insistent that it not be reinforced in Africa. In a very real sense gay and sex-positive activists regard absolute sexual freedom as a right as worth dying for. For example, American anthropologist Douglas Feldman argues that “appealing to religious fundamentalism and sex-negative messages in Africa is not the answer.”[63]  Feldman opposes:

 

…utilizing an archaic Victorian standard of morality for Africa largely discarded in the West. For those African societies: where multiparatnering behavior and sex-positive attitudes are common, applying the pejorative label ‘promiscuous is an ethnocentric affront.”[64]

 

It is not clear whether the African governments understood the way in which these “sex-positive” attitudes shaped the AIDS Consensus.

 

Assumption #8: Discrimination against AIDS victims and stigmatizing of persons who have multiple sexual partners endangers prevention campaigns. Faith-based organizations should be involved in AIDS prevention only if did not moralize about sexual behavior and agree to promote condoms.

 

While discrimination against and stigmatization of persons with HIV was initially a problem, the threat has diminished. Faith-based organizations in Africa have demonstrated that it is possible to treat the victims compassionately while at the same time speaking forcefully against the behaviors that exposed them to infection.             Unfortunately, while faith-based organization provide a significant portion of health care in Africa, the AIDS Establishment has repeated excluded faith based organization from planning and funding for AIDS prevention.

One way to encourage people to change their behavior is to tell them that what they are doing is wrong, could kill them, injure the people they love, and damage their community and their nation. Religious groups can send a strong unambiguous message to the members of their congregations that certain behaviors are not only dangerous, but also contrary to God’s laws. These groups cannot compromise their fundamental beliefs and there is certainly no reason for them to do so in order to accommodate themselves to a strategy that at best promises only risk reduction. What makes faith-based organization effective is that they can preach behavior change as part of a consistent view of the human person and promise divine assistance as well as community support.

Many religious leaders have refused to endorse condoms for unmarried persons, instead stressing instead abstinence before marriage and fidelity in marriage. Encouraging religious leaders to speak frankly about HIV/AIDS has proven to be a low cost and very effective way of promoting positive behavior change without increasing discrimination against those living with AIDS.

 

Assumption #9: Women should be empowered by educating them on how to negotiate condom use and/or by supplying them with female condoms.

 

One of the frightening things uncovered in the research on sexual transmission of HIV in Africa is the high percentage of young African women who reported that their first sexual experience was not voluntary – in other words they were raped or in some way coerced into sexual activity.[65] Empowering women must begin with preventing sexual abuse, sexual harassment, statutory rape, and rape. These crimes against women have too often gone unpunished or worse the women have been punished for “losing their honor” and their rapists escaped punishment.

Protecting women from all forms of sexual exploitation is a key part of the abstinence strategy. While girls should be instructed on the importance to their health and future of waiting until marriage, they should also be protected from situations where they are vulnerable to seduction or rape. All girls’ schools, chaperoned social activities, parental supervision are well-established strategies for protecting young girls. The very modern idea that girls as young as 12 can protect themselves if left alone with sexually mature males has proven unworkable and should be replaced with a combination of abstinence education and prudent supervision.

Teaching a young woman how to negotiate condom use does not protect her from sexual exploitation and does expose her other STDs such as HPV.

Women also have the right to demand that their husband be faithful. Most African women marry and desire children. Using a condom – whether a male condom or a female condom  — is simply not a workable strategy.

 

Assumption #10: Treating other STDs can reduce sexual transmission.

 

            Several studies have linked STDs, which cause open sores with HIV infection and concluded that treating STDs will reduce HIV infections. STDs are epidemic in Africa. The treatment of STDs should be a normal public health priority not simply a means to preventing HIV infection. Several STDs cause infertility, which can have devastating social consequences in a society where the elderly are dependent on their children. Therefore aggressive treatment of STDs should be the rule and should include routine testing for HIV and the standard public health procedures of partner notification and contact tracing. Treating STDs have had limited success because those treated often continued high-risk activity. If treatment for STDs includes instruction on condom use and provision of condoms and not on limiting sexual activity, it will leave the clients vulnerable not only to exposure to HIV but also to a number of other STDs – including Chlamydia and HPV— diseases against which condoms  provide little or no protection.

 

Assumption #11Prostitutes should be supplied with condoms and encouraged to use a condom every time.

 

In countries where prostitution is legal or tolerated, the AIDS consensus recommends that prostitutes be carefully monitored and treated for STDs, supplied with condoms, and encouraged to use them every time.

There are two difficulties with this strategy. First, there is ample evidence that clients are willing to pay extra not to use a condom and that these are the very clients most likely to be infected. Prostitutes understand that they will suffer economically if they insist on condom use. The study of men in Thailand found that 29% did not use a condom when visiting a prostitute even though the government mandated 100% condom use. Senegal which has legalized prostitution claims that condom usage is universal, but 20 to 30% of prostitutes are HIV positive. At best, condoms and monitoring are harm reduction measures.

The second problem is with prostitution itself. It is difficult to imagine a more egregious abuse of women. In some countries women are sold into prostitution by families. Some women fall into prostitution because of poverty, sexual abuse, or drug addiction. Others are lured away from home with promises of an employment or kidnapped by those involved in the sex trade. Once a woman is caught up in prostitution it is difficult for her to escape. Prostitutes, even those monitored by the government, are at high risk of contracting a deadly or incurable diseases.

Many people feel that tolerating prostitution is condoning the exploitation of women and the proper response to the spread of STDs by prostitutes is to so far as possible to eliminate prostitution and rehabilitate the prostitutes. Others argue that this is impossible. However, there was a time not all that long ago when most people considered it foolish even to think about eliminating slavery. Prostitution is in many ways a form of slavery and like slavery should no longer be tolerated.

Campaigns to encourage prostitutes’ clients to use condoms may reduce the numbers of men frequenting prostitutes, but does not protect prostitutes over the long run. One study found that 30% of prostitutes who said they used condoms 100% were HIV+. Many people believed that legalized or legally tolerated prostitution exploits women and children and constitutes an ongoing threat to public health. The current pandemic of STI, including HIV/AIDS, creates a situation under which personal behavior which may have been tolerated in the past constitutes an unacceptable threat to public health

Given the health risks not only to the prostitutes and their clients, but also to wives and children of clients, from a purely public health point of view cracking down on prostitution by closing venues and arresting clients and detaining prostitutes is a reasonable strategy. Short of that, governments could consider an anti-prostitution campaign which portrayed men who frequent prostitutes as weak, unpatriotic, guilty of exploiting women, and endangering the lives of their wives and children.

It should be noted that boys are also lured into prostitution and are at high risk for HIV infection. Sex tourism, the business, which encourages men from wealthy countries travel to poor countries for the purpose of sex, is a growing industry. Sex tourists include men who are interested in sex with children and adolescent boys, as well adult women. There is growing outrage against such activities and against the governments that tolerate these abuses. Such activities pose significant threats to public health because in the jet age they spread disease from continent to continent.

 

Assumption #12: Poverty and marginalization drive the AIDS epidemic. 

 

While eliminating poverty and the oppression are worthy goals, prevention campaigns need to focus on what can be done today. AIDS prevention cannot wait until Africans solve all their myriad problems; indeed there is every reason to believe that the AIDS epidemic will prevent development and increase poverty and political instability. Prevention strategies must take into account the extreme poverty of some parts of Africa and the lack of development.

Furthermore, the assumption that the AIDS in Africa is driven by poverty is not borne out by the research. The well-educated, better off, and those living in urban areas are more likely to be HIV positive than those living in extreme poverty in isolated areas.

 

VI        Funding and Results

 

There is an old saying that beggars can’t be choosers. Africa has forced to accept programs that did not meet their needs because if they knew if they refused they would receive nothing. If all they could get was condoms, they accepted them, but many African leaders have been angered by the refusal of funding organizations to allow Africans to define their own needs and to choose strategies which respected their values and culture.

African leaders were particularly frustrated by the fact that during the 1990s all the funding was going to HIV/AIDS, while diseases, which could be successfully treated with a fraction of the funding were ignored. People who could be saved were dying. The Global Fund for AIDS, Malaria and Tuberculosis set up to respond to this concern. By lumping, these three killer diseases together, the hope was at least some money would be directed to projects that would actually save lives.

As the Bush administration became aware of the success of ABC in Uganda and other research on successful abstinence programs, it began to direct its funding away from failed condom programs, groups that promoted abortion, and groups that favor legalized prostitution and toward faith-based organizations, to programs that stressed positive behavior change, and to uncontroversial areas such as treatment.

The AIDS Establishment let out a collective howl. Bush was linked with the Vatican as a killer of Africans. The mainstream media repeated the charges. An article in The Guardian  Stephen Lewis the UN secretary general’s special envoy for HIV/AIDS in Africa accused President Bush of “doing damage to Africa by cutting funding for condoms.”

It would seem obvious that prevention strategies which have a proven record of success should be funded and those that have failed should be defunded. The argument that programs have failed because they did not receive enough money and the answer to failure is more money, may be a typical governmental reaction to failure, but given the limited resources, the immense need, and the existence of proven prevention strategies, the money should go to proven programs not failed ones.

International funding should be directed to interventions which are acceptable to the local population. Success should not be gauge by the number of condoms distributed or used, but by a significantly lower infection rate.

 

The Philippines A success story no one wants to talk about.

 

Given the nation’s poverty and other problems, the AIDS establishment has year after year predicted a massive wave of infections in the Philippines unless the nation adopts aggressive condom promotion. However, twenty-five years into the epidemic only 0.09% of the population is living with AIDS. Health care, a left over from the period of American control, employs high standards of sterilization. The influence of the Catholic Church is strong. Instead of seeing the Philippines as example of how to prevent an epidemic, the AIDS establish continues to push condoms.

 

VII      The Cultural Impact

 

It is clear that the debate over prevention strategies in Africa is not just about what will work. It is also about how implementing the various strategies will affect the culture. Some strategies, such as providing absolutely sterile conditions and HIV free blood, are culturally neutral. Other strategies require that substantial portion of the population change not only their behavior, but also their beliefs about right and wrong.

The AIDS Establishment supports prevention strategies that coincide with their beliefs about right and wrong. They believe that sexual pleasure is human right, which prevention strategies should promote.

The members of the AIDS Establishment, with few exceptions believe that AIDS prevention strategies must in no way inhibit sexual practices. The AIDS Establishment accepts multi-partnering (promiscuity), commercial sex work (prostitution), and the right to privacy (the right not to be tested and not inform sexual partners about HIV status) as fundamental to personal liberty. They not only want people to be free to engage in sexual activity, but to be able to do so without shame, discrimination, or embarrassment. Risks should be reduced as far as possible, but if it is a choice between avoiding risk and restricting sexual pleasure, the AIDS Establishment is willing to tolerate a certain amount of risk – meaning infections and deaths – is acceptable.

On the other hand, those promoting the ABC approach see sexual pleasure as the servant not the master. For them, waiting until marriage and being faithful in marriage not only have pragmatic benefits, they also strengthen the family and the family is the foundation of society. Strong families produce economic, social as well as emotional and spiritual benefits. In addition, abstinence and fidelity are in accord with traditional religious teachings.

It is this last part which particularly offends many in the AIDS Establishment. The AIDS Establishment rightly recognizes that traditional religions oppose the ideology of sexual liberation. Where ABC is successful, religious institutions will become more influential. Those who accept ABC for purely pragmatic reasons, they will come to reject sexual liberation for equally pragmatic reasons.

The sincere medical professionals like Green are caught between two warring camps. Common sense tells them that positive behavior change combined with standard public health strategies works. They see how the social marketing of condoms has been tried and failed. While as objective professionals they may feel uncomfortable preaching or judging, they recognized that in life or death situation sometimes someone has to preach; someone has to judge that certain behaviors are dangerous and some strategies don’t work.

 

VIII     Choices

 

Government leaders and the people have to choose between risk elimination, risk avoidance, and risk reduction prevention strategies.

 

Risk elimination – These are strategies which identify and isolate carriers before they can infect others, such as mandatory testing, quarantining those infected. While such measures have been employed in the past for diseases such as leprosy, today they are used only for deadly, fast moving epidemics such as SARS.

 

Risk avoidance – These are strategies which encourage and support behaviors which will allow people to avoid infection. These include: abstinence from sex before marriage; marriage to a person who has been tested and is HIV negative; fidelity in marriage; monogamy if in a non-marital sexual relationship with an HIV negative person; testing of blood and blood products; disposable needles; sterilization of all medical equipment; routine testing of STD patients, hospital admissions, prostitutes, and pregnant women; treating HIV positive pregnant women to prevent MTCT.  Eliminating the AIDS Exemption and treating HIV/AIDS like any other communicable disease, by reporting infections to a central authority, contact tracing and partner notification. This would protect innocent spouses and unborn children.

 

Risk reduction – This strategy involves educating people on how to reduce the chance of infection during sexual relations by using condoms correctly every time thus preserving the freedom to choose to be sexually active, to have multiple partners, to engage in anal sex, or to visit prostitutes. Risk reduction strategies assume that people will continue to engage in sex with potentially HIV positive partners and will therefore need to be treated STDs that cause genital ulcers. Treating the infected with antiretrovirals would lower their viral load is lowered so that they would be less likely to infect others during sex. Encouraging circumcision might reduce STDs and HIV infection through sexual relation. Condom promotion will encourage high-risk activity and result in more exposures to the virus and condoms use with multiple partners will spread other STDs such as cancer causing HPV. Supplying prostitutes with condoms assumes that prostitutes will continue to service multiple clients. The AIDS Exemption would be preserved. There would be no reporting of the names of those infected, no partner notification, no contact tracing. Everyone would assume that everyone else could be HIV positive and use a condom every time. However, even if 100% condom usage was achieved– and this has never happened — condom failures would lead to new infections. The epidemic would continue.

 

Western nations may have the economic resources to deal with the pandemic of sexually transmitted disease, out-of-wedlock pregnancies, and disintegrating families, but that Africa cannot afford sexual liberation. The Africa people have a duty to consider all the facts, all the possible strategies, and the predictable consequences of each strategy, and to decide what is in their best interests.

[1] http://www.cybercuba.com/os.htm

[2] Lawrence Altman (2008) “HIV study finds rate 40% higher than estimated,” New York Times, Aug. 3

[3] Edward Green, (2003) Rethinking AIDS Prevention: Learning from Successes in Developing Countries, Westport CT: Praeger.

[4] http://www.premierinc.com/quality-safety/tools-services/safety/topics/needlestick/index.jsp

[5] Marc Santora (2005) “U.S. is close to eliminating AIDS in infants, officials say,” New York Times, Jan. 30.

[6] Robert Biggar (1986) “The AIDS problem in Africa,” Lancet, Jan. 11, 1986, p. 79-82.

[7] http://www.urologychannel.com/std/gardnerella.shtml

[8] B. Williams B et al. (2006) “The potential impact of male circumcision on HIV in Sub-Saharan Africa<” PLoS Medicine, 3, 7, p. 262.

[9] C. H. Mercer, et al. (2009) “Behaviourally bisexual men as a bridge population for HIV and sexually transmitted infections? Evidence from a national probability survey,” International Journal of STD & AIDS, 20, p. 87-94.

[10] James Shelton et al. (2004) “Education and debate: Partner reduction is crucial for a balance ‘ABC’ approach to HIV prevention,” British Medical Journal,  April 10, p. 891-893.

[11] http://www.globalhealthreporting.org/diseaseinfo.asp?id=254

[12] J. M Baeten, et al. (2001) “Hormonal contraception and the risk of sexually transmitted disease acquisition: results from a prospective study,” American Journal of Obstetrics and Gynecology, 185, 2, p. 380-85: A prospective cohort study involving 948 Kenyan sex workers found that the use of oral or injectable hormonal contraception was associated with susceptibility to STIs: Users of OCs were at greater risk of acquiring chlamydial infection and vaginal candidiasis than women not using hormonal contraception, while women using DMPA had a significantly increased risk of chlamydial infection.

[13] Helene Gayle (2000) “Nonoxynol-9 Trial- The implications” Department of Health and Human Services, August 2000. www.cdc.gove/HIV/ppubs/mmwr11aug00.htm.

[14] S. Weller, K. Davis (2002) “Condom effectiveness in reducing heterosexual HIV transmission,” http://www.update-software.com/abstracts/ab003255.htm.

[15] John Richens, John Imrie, Andrew Copas, (2000) “Condoms and seat belts: the parallels and lessons,” Lancet,  355, p. 400.

[16] Norman Hearst, S. Chen (2003) “Condom Promotion for AIDS Prevention in the Developing World: Is it Working?” Geneva: UNAIDS, p. 7.

[17] P. Kajubi, M. Kamya, S. Kamya, S. Chen, W. McFarland, N. Heart, “Increasing condom use without reducting HIV risk: Results of a controlled community trial in Uganda,”  Journal of Acquired Immune Deficiency Syndromes,  (2005) 40, (1): pp 77-82

[18] T. E. Taha et al. (1996)  “Lack of association between reported condom use and rates of sexually transmitted diseases in Malawi,”  AIDS, 10, p. 207-212.

[19] W. W. Darrow et al. (1989) “ Condom use effectiveness in high–risk populations,” Sexually Transmitted Diseases, 16, p. 157-160; Hearst  op. cit.

[20] Green, p. 108, referencing J. M. Zenilman et al. (1995) “Condom use to prevent incident STIs: The validity of self reported condom use,” Sexually Transmitted Disease, 22, p. 15-21: “A prospective study of condom use in Baltimore found no differences in STI infection rates among those who reported using condoms 100 percent of the time versus 0 percent of the time.”

[21] S. Ahmed et al (2001) “HIV Incidence and sexually transmitted disease prevalence associated with condom use: A Population study in Rakai, Uganda.”  AIDS, 15, p. 2171-2179.

[22] Ibid.

[23] Richens, op. cit.

[24] Randall Packard , Paul Epstein (1991)”Epidemiologists, Social Scientists, and the structure of Medical Research on AIDS in Africa,” Social Science Medicine, 7,  p. 221.

[25] Laith J. Abu-Raddad, Padmaja Patnaik, James G. Kublin (2006) “Dual Infection with HIV and Malaria Fuels the Spread of Both Diseases in Sub-Saharan Africa,”  Science, 314, p. 1603-1626.

[26] National Institutes of Health,  http://www3.niaid.nih.gov/topics/tuberculosis/Understanding/tbHIV.htm

[27] Green, p. 74.

[28] Randy  Shilts, (1987) And the Band Played On,  NY: St. Martins Press, p.40

[29] quoted by Chandler Burr (1997)  “The AIDS Exception: Privacy vs. Public Health,” The Atlantic Monthly,  June, p. 59.

[30] A. Rompalo (1990) “Sexually Transmitted Causes of Gastrointestinal Symptoms in Homosexual Men” Medi­cal Clinics of North America, 74, 6, p. 1633 – 1645.

[31] Gabriel Rotello, Sexual Ecology (NY: Dutton, 1997)

[32] CDC

[33] David Gisselquist et al (2003) “Let it be sexual: how health care transmission of AIDS in Africa was ignore,” International  Journal of STD & AIDS, 14, p. 148-161.

[34] Green Broken Promises

[35] Edward Green (2003) Rethinking AIDS Prevention: Learning from Successes in Developing Countries, Westport CT: Praeger.

[36] World Health Organization, (2002) The World Health report 2002: Reducing risks, promoting healthy life, Geneva: WHO.

[37] Gisselquist, “Let it be sexual.”

[38] Ibid.

[39] Ibid.

[40] David Gisselquist and John Potterat (2003)  Heterosexual transmission of HIV in Africa: an empiric estimate” International Journal of STD & AIDS,  14, p. 162-175.

[41] Brewer “Mounting anomalies in the epidemiology of HIV in Africa: cry of the beloved paradigm,” International Journal of STD & AIDS,  14, p. 144-147.

[42] Packard, p. 782

[43] J. Pepin, et al. (1989( “The interaction of HIV infection and other sexually transmitted disease : and opportunity for intervention. 3, p. 3-9.

[44] Packard, p. 787.

[45] George Schmid et al. (2004) “Transmission of HIV-1 infection in sub-Saharan Africa and effect of elimination of unsafe injections,” Lancet, 363, p. 482-88

[46] Packard, p. 789;  O. Lontaine et al. (1984)  La diarrhea infantile au Senegal. Medicine. Troicale, 44, 1, p. 27-31.

[47] Nestor Ndayimirije, MaryKay Kindhauser (2005) “Marburg hemorrhagic fever in Angola – Fighting fear and a lethal pathogen,” New England Journal of Medicine, May 26, 21.

[48] Gabriel Rotello (1997) Sexual Ecology: AIDS and the Destiny of Gay Men, NY: Dutton.

[49] K. Sack (1999) “For Gay Men, HIV Peril and Rising Drug Use,” New York Times. Jan. 29.

[50] R. Stall, T. Coates, C. Hoff (1988) “Behavioral Risk Reduction for HIV Infection among Gay and Bisexual Men,” American Psychologis, 43, 11, p. 878 – 885.

[51] T. Maugh (1998) Transmission of drug resistant HIV Reported. Los Angeles Times.  July 1.

[52] Chandler Burr (1997) “The AIDS Exception: Privacy vs. Public Health” The Atlantic Monthly, June, p. 57- 67.

[53] Charles Karel Bourly, (2003) “Who’s Sar-ry Now?” posted on Advocate.com, April 23.

[54] Kevin deCock et al. (2003) “A serostatus-based approach to HIV/AIDS prevention and care in Africa,” Lancet, 362, p.1847-1849.

[55] Jeffrey Stringer, et al. (    ) “Nevirapine to prevent mother-to-child transmission of HIV-1 among women with unknown serostatus. Lancet, 362, p. 1850  – 1853.

[56] Chandler Burr, p. 57.

[57] Green, op. cit.

[58] P. Kajubi  et al. (2005) “Increasing condom use without reducing HIV risk: results of a controlled community trail in Uganda,” Journal of Acquired Immune Deficiency Syndromes Sept. 1.

[59] Rand L. Stoneburner, Daniel Low-Beer (2004) “Population-Level HIV Declines and Behavioral Risk Avoidance in Uganda,” Science, April, 304, 5671, p. 714-718.

[60] Green, p. 75

[61] Packard , p. 221.

[62] Richens, op cit.

[63] Douglas A Feldman, (2003) “Problems with the Uganda Model for HIV/AIDS Prevention,” Anthropology News, Oct. p. 6.

[64] Douglas Feldman (1991) “Comments on Packard and Epstein,” Social Science Medicine,  35, 7, p. 784.

[65] Hygean/ FHI (2001) Enquete de Surveillance du Comportement ESC , Senegal Ministry of Health and Prevention. quoted in Green, p. 231: “85% of women who reported a sexual debut said that the debut was involuntary against their will and wishes.”

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