May
08
2008

AIDS on the decline in parts of Africa

Fighting AIDS in Africa: Many people are at risk, but officials disagree over the best approach.
Fighting AIDS in Africa: Many people are at risk, but officials disagree over the best approach.Courtesy Stig Nygaard

Two years ago, an article in the journal Science noted that rates of AIDS infection were falling in Zimbabwe, south east Africa, thanks to the “ABC” program. “ABC” stands for “Abstinence, Be faithful, use Condoms” – three things that help prevent the spread of sexually-transmitted diseases. Other countries using the ABC approach, including Uganda and Kenya, also report success in stemming the tide of AIDS.

The report was in the news again lately as Congress debates funding for the President's Emergency Plan for AIDS Relief (PEPFAR). Rep. Chris Smith of NJ cited this and other studies as evidence of the program effectiveness. (An argument for continuing the funding can be found here. )

The program is controversial, however, because it adds a moral dimension to medical treatment. Many aid workers don’t want to be in the position of telling people how to live, or imposing a particular view of right and wrong behavior on another culture. They would rather just treat the disease. OTOH, this particular disease spreads through a particular behavior. Programs that rely exclusively on condoms without any behavioral component have had little success against the AIDS epidemic.

Some people see this controversy as playing politics with a world health crisis. But others take it very seriously. In 2005, Brazil refused to accept US funds for their AIDS program because it came with the requirement that workers try to discourage prostitution. Many aid groups argue that such a provision hurts their ability to reach the people who need help the most. The government argues that discouraging prostitution and sex trafficking makes all kinds of sense when combating an STD.

It would be good to get this sorted out soon, since there is no vaccine against AIDS, and some scientists believe it may be impossible to ever make one.

What do you think? Should aid workers try to combat disease by changing people’s behavior? Or should they just stick to medicine? And should government funding come with such restrictions? Leave us a comment.

Your Comments, Thoughts, Questions, Ideas

Liza's picture
Liza says:

I don't have any empirical evidence to back my opinion up, but it seems to me that this program works because it provides options. Changing behavior may be the most effective way to curb the spread of a disease, but at what cost? If people are non-compliant, for whatever reason, I don't want the price to be debilitating illness and death. I want there to be a backup option.

Encouraging abstinence or fidelity is probably the single best way to prevent the spread of AIDS. But since we can't presume to understand all the circumstances and complexities of people's lives, emphasizing condom use when abstinence isn't an option is a good thing.

The oversimplified story of the spread of AIDS in Africa goes something like this:

  • A lack of economic opportunities has caused many men to leave their home villages for work in cities or along major trade routes.
  • During their extended absences from home, some men have relationships with other women, including prostitutes, and pick up the virus.
  • When the men return to their home villages, they have an expectation of intimacy with their wives, and cultural norms do not allow the women to refuse or to request condom use.
  • Women become infected, sometimes passing the illness on to children. Economic opportunities in the villages become even less available, and the cycle continues.

What I like about this message is that it preaches to both sides: people of both sexes should be faithful, and barring that, people should ALWAYS use condoms.

As for the part about government restrictions, I'm always going to come down on the side of wanting to provide more information. Sure, prostitution is degrading and harmful (in the vast majority of cases, anyway, if not all), and I'm happy to stand in opposition of it. But I also understand that many women have few options, and if they're able to organize and protect themselves (which incidentally protects their customers, and their customers' families), then I'm all for that. I feel the same way about family planning: there's no one solution that's right for everyone, and health care providers should be free to talk about options. Information never hurt anyone. It's what you do with it that matters.

posted on Thu, 05/08/2008 - 4:09pm
Anonymous's picture
Anonymous says:

Hi this is Eiman and Asgad from Rochester, MN Upward Bound and we believe that this article is very powerful and interesting. People all over the world are suffering from aids and HIV and we as a nation must help those in need. I have a dream that someday we as people will discover a cure for AIDS and HIV. Thank you for reading our opinion, we are extremely passionate about this issue. Thank You again!

posted on Thu, 07/03/2008 - 11:50am
andyshadexx's picture
andyshadexx says:

oh wow that is so great!! If this ABC program keep going then it would help Africa big Time!!

posted on Thu, 05/08/2008 - 9:24pm
Liza's picture
Liza says:

A new article in Science sort of agrees with the findings in the post that began this thread, but goes a step further: according to some scientists from Harvard University, the best way to combat AIDS in Africa is to reduce people's numbers of sex partners, and to encourage male circumcision.

What do folks think about that? If we're uncomfortable trying to change people's behavior to stop the spread of a disease, where will we come down on encouraging surgery?

posted on Fri, 05/09/2008 - 10:46am
JGordon's picture
JGordon says:

I read about the circumcision thing a while back.

Male circumcision isn't that weird to most people in this country, but as an idea for fighting AIDS... It really creeps me out. Obviously you have to weigh it against the benefits of combating an epidemic, but it just smacks of, I don't know, neutering stray cats.

At the risk of sounding shrill, the fact that the idea is primarily coming from another country (and a former colonizer of Africa) feels pretty weird. Like, we don't think you can change your behavior, so we are going to physically alter your bodies to get the same effect. It seems like it eliminates some human agency, which is an awful thing to do. There are strong arguments for the justification of this, but that doesn't necessarily make me really comfortable with it.

I can't imagine that this sort of thing would be mandatory, but still... Plus, it seems like a culture, or cultures, that have had a difficult time accepting condom use are going to be a lot more thrilled about cutting off parts of their penises.

posted on Fri, 05/09/2008 - 11:09am
Gene's picture
Gene says:

If it's not mandatory, then I don't see the problem. It's elective surgery.

The suggestion is coming from Harvard. Harvard is in the United States. The United States never had a colony in Africa.

And, not to get too far off-topic, but what's wrong with neutering stray cats? Strays lead short, miserable lives, so reducing their number is good. Also reduces predation on birds and small mammals, which is a major environmental problem.

Unless you feel the program is treating humans like stray animals. Which, I agree, would be disturbing and wrong. But as long as it's a choice, no problem.

And circumcision is a LOT different from neutering, as I'm sure you know.

posted on Sat, 05/10/2008 - 7:02pm
JGordon's picture
JGordon says:

Whoops--Harvard, right. For some reason, I was thinking Oxford. Oh, wait, I know the reason: I'm an idiot.

But the same sort of idea applies: it's a Western culture telling a Non-western culture what's best for them. And, of course, just because someone is from a different culture doesn't mean that their suggestions are bad. It's just that the West hasn't got the best track record in Africa, to where suggestions on how Africans should live their lives might best be made with particular sensitivity. (Then again, maybe AIDS isn't worth being delicate about, if being delicate means that more people will die from the disease.) I wonder if I'd feel different were it an African institution making the suggestion.

Yeah, I mean treating humans like animals. (Neutering stray cats is great.) And, as you say, if it's a choice, not letting someone do it would be much more problematic. So I suppose it's not that big of a deal.

Still, there's part of the idea that doesn't sit well with me (and maybe it's not a big enough part to matter). I mean, it looks like Spain and Italy have the highest HIV rates in Western Europe--would this suggestion be made to the Spanish and the Italians? I'm not sure that it would; it seems to imply that these people are unable to change their own behavior, and so a physical change should be made to render their behavior choices irrelevant. That's kind of a dangerous move, you know? Then again, perhaps if infection rates were as high in Western Europe as they are in many parts of Africa, the suggestion would be made. I don't know.

I'm not trying to imply that the people at Harvard (somewhere deep in England, right?) have anything but the best intentions. It's just a little bit weird. A surgical solution to a (partially) social issue seems creepy. I think I've been thinking too much about the Deadly Medicine exhibit lately, or something.

But, yeah, if it's elective, people should do whatever the hell they want, especially if it's good for them. Again, though, if people don't like condoms, is this really going to be a hit?

Pff. Harvard. I knew that.

posted on Sun, 05/11/2008 - 11:56am
Gene's picture
Gene says:

I hear ya' -- cultural sensitivity, Western imperialism, all that PC crap. But scientific fact is not subject to cultural context. If something has been shown to be objectively true, then it is -- regardless of who says it or whom they are saying it to. The cultural context might require more or less sensitivity, but it doesn't change the facts.

All cultures -- not just Western -- have done wonderful things. All cultures -- not just Western -- have done some pretty awful things (female circumcision, anybody?) Africa, Italy, Spain -- I don't care whose tender ears we may offend: if a procedure can help stop AIDS, I say we tell them about it, give them the option.

posted on Sun, 05/11/2008 - 7:34pm
JGordon's picture
JGordon says:

Well, I'm not just concerned about offending people, but, yeah, that mostly makes sense.

posted on Mon, 05/12/2008 - 9:25am
ursula's picture
ursula says:

we hope the scientist continue the research for a cure for aids.

posted on Fri, 05/09/2008 - 1:50pm
Anonymous's picture
Anonymous says:

Abstinence only doesn't work. I don't know where you got that idea. ESPECIALLY in regions where some people survive off of prostitution and rape is rampant.

posted on Fri, 05/09/2008 - 4:05pm
Gene's picture
Gene says:

No one has said "abstinence only." Abstinence is only one-third of the ABC program.

posted on Sat, 05/10/2008 - 6:57pm
Anonymous's picture
Anonymous says:

i think that we need to do someting quick about that.
it is horrible.
i want to help!

posted on Thu, 05/15/2008 - 9:59am
FSX's picture
FSX says:

Medicine should be used only. You should allow people to continue to live however they want to, and probably do, live. Everything else should be like, "you can do this, and it'd be a pretty good idea to for other reasons, but you don't need to."

posted on Sun, 05/18/2008 - 2:11pm
tiffany_88's picture
tiffany_88 says:

It's great because a lot people die for AIDS and the most important sometimes are childrens. The used of condoms is really important to take the control in the situation.

posted on Thu, 05/22/2008 - 10:20am
hawa's picture
hawa says:

I think that these are really suffering from the HIV so the should help to save these people lives

posted on Thu, 05/22/2008 - 10:27am
Anonymous's picture
Anonymous says:

oh im sorry

posted on Sun, 06/01/2008 - 2:30pm
Karissa and Jasmine's picture
Karissa and Jasmine says:

OMG!!! This is really sad... I wish there was a way to help...

posted on Thu, 06/05/2008 - 11:10am
mariah and Sammi's picture
mariah and Sammi says:

i think aids are horrible . they should go away

posted on Wed, 06/11/2008 - 3:27pm
Emma's picture
Emma says:

I think that in order to change a situation like HIV/AIDS infection worldwide there needs to be a comprehensive approach. Merely emmphasising fidelity often leads to women being blamed for the infections while men take little credit for their own actions. In Africa, education and knowledge tend to be the key to lowering disease rates. Additionally, it is valuable to emphasis fidelity, not as a moral issue, but as essential to the health and safety of others. If people want fidelity to be moral they can get that through their church or belief system not through foreign aid. Fidelity is about being responsible for your actions and fulfilling your promises to others. Also, mother to child transmission needs to be a key stone of any HIV/AIDS treatment program.

posted on Sat, 06/21/2008 - 4:08pm
Gene's picture
Gene says:

The ABC program is comprehensive in this regard. Fidelity is only one-third of the program (the "Be faithful" part). Abstinence and condom use get equal billing. It is the combination of these three efforts that seems to be having the greatest effect.

posted on Mon, 06/23/2008 - 11:47am
Gene's picture
Gene says:

Former President Bill Clinton has also come out in support of monogamy as a means of stopping the spread of AIDS. And while some people may snicker that Clinton is not exactly the best poster boy for fidelity, The Wall Street Journal points out that:

"...[H]is failure to practice what he preaches has no bearing on the hygienic merits of his statement. Even if he had put his argument in moral terms, it would be equally valid regardless of his own behavior."

posted on Thu, 08/21/2008 - 10:04pm

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