Ruth Institute Blog

Sigh. Why doesn’t anyone pay attention to this stuff?

by Matthew Hanley

The predominant Western approach to preventing the spread of AIDS in Africa has failed. Though in theory the risk reduction strategies favored by Western governments and aid agencies—handing out condoms, promoting counseling and testing, and treating other sexually transmitted infections (STIs) to block HIV transmission—can “work” in theory, they have not done so in practice. In Africa, despite years of promised improvements, they have not brought any downturn at all.

But a handful of African countries have actually forced down the AIDS rates, each of them by changing behavior—particularly reducing sexual partnerships—not through the heavily promoted risk reduction measures.

Well before western donors and condoms arrived on the scene, Uganda had cut its level of casual sex by two-thirds and subsequently its HIV rate by two-thirds. Several years later, Kenya replicated this success. A few other countries have also done so, with partner reduction always the most important factor.

In sharp contrast, South Africa has maintained high rates of multiple (and concurrent) partnerships and, despite its vigorous promotion of condoms, still suffers from persistently high rates of HIV infection. The same can be said of many of its neighboring countries, which lead the world in the prevalence of HIV, with some 15 to 35 percent of all adults infected.

These successes and failures are, tellingly, too often treated in a manner inversely proportional to their merits. Behavior change, though responsible for success, remains the least emphasized approach, while risk reduction invariably receives the benefit of the doubt despite its failure to deliver as promised. Its disappointing results always mean that efforts—along with funding—must simply be doubled.

Many in the AIDS Establishment will only unreservedly applaud success if it comes through the technical means promoted by Western governments and activist groups. In a 2005 PBS documentary, UNAIDS’ executive director Dr. Piot refused to concede that behavior change played the paramount role in Uganda’s unparalleled success. “But we also know,” he added, “that no country has been successful in bringing down the number of new infections of HIV without strong condom promotion.”

To viewers who have never had reason to think twice about the issue, this might sound like a sober assessment. Human sexual behavior, we tend to assume, is hard to change and so the most effective way to reduce the number of people getting sexually transmitted diseases must therefore be to reduce the risk of sexual activity. That appears to many people just common sense.

But Uganda clearly refutes Piot’s claim, as does the fact that the countries with the most robust condom promotion programs have some of the most severe AIDS epidemics in the world. The evidence suggests that common sense may be wrong.

For starters, people tend to take greater risks when they feel protected by technical innovation. In a state of the art program in Uganda, for example, those explicitly encouraged to use condoms ended up at greater risk than the control group not exposed to the sophisticated intervention, because they had more sexual partners than those not told to use condoms. People have also been seen to take greater risks when antiretroviral therapy for HIV/AIDS became available.

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