Introduction Catherine Campbell is a professor of Social Psychology at the London School of Economics and an adjunct professor and Fellow of the Center for HIV/AIDS networking at the University of Natal, South Africa. She has written widely on the topic of HIV/AIDS prevention and care and is widely respected in her field. The concluding remarks of one of her recent papers on the effectiveness of youth HIV prevention included the following:
“In the HIV/AIDS field there is now general recognition that HIV prevention efforts need to go hand in hand with parallel efforts to promote social environments that are supportive of safer sexual behaviour (Beeker et al., 1998; Tawil et al., 1995; Waldo & Coates, 2000). Details of the social changes that are needed nearly always refer to the need to mitigate the more general impacts of poverty and gender inequalities, in the interests of providing contexts that increase people’s power to protect their sexual health….
Our findings have shown how young people in Ekuthuleni are excluded from access to education and work; political representation; respect and recognition; and participation in informal and formal community networks. We have highlighted how these forms of exclusion undermine the likelihood of effective HIV prevention on the assumption that sexual behaviour change is facilitated not only by knowledge about HIV/AIDS, but also by youth solidarity, empowerment, critical thinking and the presence of bonding and bridging social capital. There is much scope for youth HIV prevention initiatives to work hand in hand with community development programmes that promote young people’s social and political participation, increase opportunities for their economic empowerment, challenge negative social representations of young people, and work towards greater recognition of their sexuality and their right to protect their sexual health.” (Campbell et. al., 2005)
While Dr. Campbell and her colleagues have chosen to specifically target youth in this particular study, the excerpt is informative because it is representative of a number of key points in current HIV/AIDS prevention research. First, there is a growing recognition within the international AIDS community that, as stated above, AIDS programs cannot ignore the context in which they are to be implemented. ‘Context’, in this instance, can be defined broadly: politics, cultural norms, poverty, societal institutions and their stability (or lack thereof), gender relations, religious practices and beliefs, civil and international conflict, etc. Again and again, researchers have found that even the best funded and most careful conceived and implemented AIDS programs fail if local realities are not taken into consideration (a number of examples will follow below). Development issues, such as poverty, the lack of infrastructure and the dearth of education, are often mentioned as fundamental barriers to effective HIV/AIDS preventions.
The reason that HIV/AIDS prevention and care in sub-Saharan Africa is such an intractable problem, and the second reason that Campbell’s excerpt bears mentioning, is because it seems to be a place-holder for everything else that is wrong in the African nations that have been the hardest hit by the epidemic. Campbell’s analysis of the shortcomings of HIV/AIDS programs, in this instance and elsewhere, is, to be sure, well informed. But is it helpful? Initially, the answer is ‘yes’. Dr. Campbell’s research is certainly informative, and there is a desperate need for more and better information in this fight against AIDS. Understanding the details of what has contributed to the explosion of HIV and AIDS in sub-Saharan African can only be a boon to those who work to halt the epidemic.
And yet, there is the very real risk that the information that AIDS researchers provide will have a paralyzing effect on HIV/AIDS prevention work. What is the activist writing a proposal for doing work in, say, a mining community in South Africa supposed to do when he comes to the conviction that the paramount factor contributing to the spread of AIDS in the community is endemic poverty? Or, perhaps, the lack of political will to adequately address the issue? These are the very concerns that the entire development community in Africa has been trying to address for a generation – and with seemingly little positive gain. Realistically, what does the AIDS care worker, a relative newcomer to the African development scene, hope to contribute?
This paper will begin with a brief description of the scope of the problem of AIDS in sub-Saharan Africa in general, and will then provide a general epidemiology of the disease. A number of specific examples will be addressed, and the paper will conclude with a discussion of the various responses to the epidemic.
AIDS in Africa: an Informed Response According to the joint United Nations program on HIV/AIDS (UNAIDS), 40.3 million people in the world are currently HIV-positive. Although it is home to only 10% of the world’s total population, sub-Saharan Africa has 25.8 million AIDS victims, representing two thirds of the global epidemic. Worldwide, nearly 5 million people were newly infected with HIV in 2005, but over three million of them were from sub-Saharan Africa alone. (UNAIDS, 2005)
The bright spots in the battle against AIDS in sub-Saharan Africa are few and far between. A decline in national adult HIV prevalence seems to be taking place in 3 African1 countries: Kenya, Uganda and Zimbabwe. Studies in Zimbabwe have indicated a drop in HIV prevalence among pregnant women from 26% in 2002 to 21% in 20042. This and other studies seem to suggest that the rate of new HIV infections in the country is slowing. Kenya has also witnessed a drop in an overall HIV prevalence, with the epidemic standing at a 10% adult prevalence in the late 1990s, and dropping to 7% by 2003. Uganda, long hailed as one of Africa’s few AIDS success stories, had an HIV prevalence that peaked in the mid 1990s at around 15% and steadily declined thereafter. Recent studies suggest that prevalence now holds at about 7% of the adult (aged 15-44) population. (UNAIDS, 2005)
If those three countries represent positive trends in HIV prevalence, what of the rest of the continent? Mozambique, Swaziland, Botswana, and South Africa, represent some of the hardest hit nations. National adult HIV prevalence in South Africa was less then 1% in 1990, but it quickly rose to 25% by the end of the decade. HIV prevalence among pregnant women has currently reached its highest level to date, with nearly 30% reporting HIV infection. South Africa leads the world in terms of the raw number of HIV-positive people living in a single nation. Mozambique, whose AIDS problem lagged behind that of other southern African nations in the 1990s, rose to a 16% adult prevalence in 2004, up 2% from 2002. The HIV/AIDS issue in Swaziland is nothing short of catastrophic: HIV prevalence among pregnant women rocketed to 43% in 2004 (up from 34% in 2000), and the infection rate among pregnant women, ages 25-29 years old, was 56% in 2004. Botswana’s HIV prevalence rate among pregnant women is not far behind, at roughly 37%. (UNAIDS, 2005)
To make any use of the many statistics about AIDS in Africa, one must first understand the general epidemiology of the disease. There are four ways that HIV/AIDS is spread: sexual intercourse (both homosexual and heterosexual), mother-to-child, transfer of infected blood, and between intravenous drug users. The epidemiology of HIV in different parts of the world is not necessarily homogenous, however, and the spread of HIV/AIDS generally depends on one or more of these specific modes of transmission. While all of them are predominately found in urban areas, researchers have discovered three general categories of HIV/AIDS spread: first, transmission via homosexual sex (men who have sex with men) and intravenous drug users. This pattern is found in wealthy, Western nations, particularly the United States, Europe and Australia. In these cases, the overall HIV prevalence is very low and the disease is generally contained within these high-risk groups. Second, HIV can be spread among small populations of prostitutes, a pattern seen in a country like Thailand. In this case, once again, overall prevalence is low, and the disease is fairly well contained. The final category of AIDS transmission is through heterosexual sex within the general population. This category stands in contrast to the other two in that HIV/AIDS is not contained within a ‘high-risk’ group, but has spread into the general population. AIDS in Africa falls within this last category. (Webb, 1997)
While there can indeed be a great deal of overlap within these broad categories, the distinctions are very important. Although Thailand, widely considered as another AIDS success story, has been able to significantly lower its HIV prevalence within the last ten years, it must be noted that its national HIV prevalence never rose much above 2% of the adult population. (Caldwell, 2004) Uganda’s adult HIV prevalence, however, peaked at around 15%, and a number of other African countries currently have HIV prevalence rates much higher than that. Consequently, although it may be useful to compare how the two countries ran their anti-AIDS campaigns, it must be understood that the situation in the two countries was radically different. AIDS activists and policy-makers must take these profound differences into account, particularly if their current work is focused on Africa.
If HIV and AIDS exist in other parts of the world, why has Africa been so hard hit? Why are many African nations losing the battle against HIV/AIDS so completely? It is tempting to provide simplistic answers to these questions. After all, if it is true that the spread of AIDS is a human behavioral issue, why don’t more people simply change their behavior? Unfortunately, the problem is not that simple. A complete understanding of the nature of the epidemic on the African continent must have a balanced view of culture, politics, economics, and personal agency.
While traditional African cultural practice places great emphasis on stable, cohesive family structures, modernity has brought with it quite a number of challenges to this pattern. African colonialism and its legacy, for example, has had a profound impact on family life in Africa. It was often the policy of colonizers to force African men to live and work in areas far removed from their families. The highly lucrative mines in southern and central Africa, for example, were often mined with migrant labor. European colonizers encouraged, but often forced, men to live in work camps near the mines, apart from their families. In many cases, women and children were not allowed in or near these camps. (Vellut, 1983) Some colonizers enforced the same kind of labor migrancy policy in large cities whereby men would travel from the villages to find work in urban areas. Again, women and children were not allowed to accompany them. (Gondola, 1996) Although the pattern whereby men live and work in areas that are geographically distant from their families is no longer officially enforced today, it continues to persist, adversely affecting the stability of familial relations.
Indeed, rapid urbanization, colonialism, and endemic poverty have all contributed to the destabilization of many social institutions within African societies, including family life. Without the benefits that these institutions provide – acceptance, material provision for children and young people, education, direction and instruction, etc. – the young men and women who flock to the cities are forced to fend for themselves. Women often suffer the most in these circumstances because they do not have the same access to education and wealth that most men do. Many use sex as a means of survival. In Africa, prostitution, although widespread, often does not go by that name. It is common practice in many settings for a man to give small gifts to the woman with whom he has sex, regardless of the longevity or stability of the relationship, and there is a large grey area between unmarried women in long-standing relationships and actual prostitutes. Depending on the economic situation of the woman involved, the gifts that a man, or men, give to her can be an important source of income. (National Research Council, 1996)
Gender roles are an important component of the pattern of sexual behavior in Africa. In many areas, men cannot marry until they have attained a certain amount of wealth and status in the society. Often, men use the promise of marriage, which would mean economic security for the woman, as leverage to entice a woman to give into their demands for sex. It is also accepted in some areas for men to have more than one sexual partner, even if these men are married or are in the midst of a long-standing relationship. Older men, those who have achieved the needed level of wealth and status, frequently marry women and girls far younger than themselves. This means that young girls that are raised within the context of endemic poverty are enticed from a very early age, fifteen or sixteen years old, to become sexually active, especially with older men who provide the greatest possibility of economic security. It is also not uncommon for professors, school teachers, and bosses to use their role and authority to entice young girls to perform sexual favors. Abuse and rape in these contexts are simply accepted as a part of life. (Mgalla et. al, 1997)
Governments in Africa have often contributed to the problems surrounding AIDS, and the government of South Africa has been one of the worst offenders. Thabo Mbeki’s government did not have a national AIDS plan until as late as 2003, and the government’s position before then had long been one of denial. Following their government’s lead, the citizens of South Africa have long been allowed to deny the scope of the AIDS pandemic in their country. Other, more visible problems in South Africa are given attention, while the problem of AIDS has, in the past, been ignored. (Webb, 1997)
Poverty, war, the marginalization of women, a lack of adequate health care, corruption and bad governance – all of these factors contribute to the problem of AIDS in Africa. While there is no doubt that prevention is ultimately a behavioral issue that must be addressed at the level of individuals, researchers are increasingly aware of these contextual issues that pose problems for HIV prevention programs. Furthermore, although many program-developers in the early 1990s were optimistic about the role of education in effecting behavioral change, it has been demonstrated over and over again that education does not necessarily, or even very often, translate into behavioral change. As Campbell and Cornish point out, “this is because health related behaviors are determined not only by conscious rational choice by skilled and knowledgeable individuals, but also by the extent to which community and societal contexts enable and support the performance of such behaviors (see also: d’Cruz-Grote, 1996; Sumartojo, 2000).” (2003) And while certain “high-risk groups” – prostitutes, truck drivers, miners, military - have been targeted for HIV prevention campaigns in the past, there is an increasing awareness of the need to address “high-risk situations.” (Webb, 1997) Some researchers have even suggested that as the disease spreads into the general population, like it has it has in many African nations, the goal of targeting “high-risk” groups becomes increasingly irrelevant. (Schoepf, 1992)
These observations, which highlight the complexity and inter-connectedness of the many issues surrounding the problem of AIDS in Africa, threaten to engender a sense of hopelessness. After all, if the AIDS epidemic is the fault of “society”, or “the government”, then there is little that an individual, or even an NGO, can do to combat it. And yet, hope should not be forsaken, if for no other reason than the fact that we do have an example of a nation that has had the experience of lowering its HIV prevalence rate significantly: Uganda. A comparison of this country with Botswana should help us in our thinking about HIV prevention efforts in the future.
Uganda was formally granted its independence from Britain in 1962, and in 1966 Prime Minister Milton Obote suspended the constitution, assumed all government powers, and removed the ceremonial president and vice president. The fight for power in Uganda had only begun. The next twenty years of Uganda’s history were characterized by instability, warfare, and military dictatorships. It was not until 1986 that a national resistance army, led by general Yoweri Museveni, was able to take power and assert a semblance of order. Using his military followers as a support base, Museveni organized the National Resistance Movement as the nation’s major political party. The NRM has generally ended the human rights abuses of former governments, and, under Museveni’s leadership, has implemented important and beneficial economic policies. Most importantly for this paper, Museveni met the challenge of HIV/AIDS head-on when he first encountered it among his soldiers in the mid-1980s.
The NRA in the mid-1980s was a classic guerrilla resistance movement that relied on mobilizing the peasantry against the genocidal dictatorship of prime minister Obote. Although composed mainly of young men and boys, it was characterized by a high level of discipline. Furthermore, there existed close, often intimate, relationships between the older commanders and their troops. Museveni, for his part, was energetic and charismatic, and he took great care to instruct his soldiers and to form strong bonds of trust. Once in power, Museveni began to send troops to Cuba for training. At the time, Cuba regularly tested its soldiers for HIV, and the practice was extended to the Ugandan troops. The initial results were staggering, and, importantly, “the imminent loss of much of his officer corps struck directly at Museveni’s power base.” (De Waal, 2003) Museveni immediately educated himself about the disease, and began a vigorous anti-AIDS campaign among his troops. He spoke openly and frankly about the disease, and he demanded that his ministers do the same. This all occurred by 1986, well before the problem had even been recognized in many parts of the continent.
Admittedly, Uganda’s AIDS epidemic is older than that of southern Africa. People in Uganda had been dying of a disease called “slim” even before the first AIDS cases were diagnosed in 1982 and 1983. (Allen, 2005) Early experience with the disease was an important motivating factor for local communities to address the issue. By the time Museveni had taken power in 1986, his National Resistance Movement, with its emphasis on mobilizing the peasantry, had completely transformed the structure of local government from one based on chiefs and descent to one based on resistance and elections. There was a profound feeling of empowerment, even on the local level. Local councils were supported by the army, given authority directly from the president, and had the freedom to operate as they saw fit. They were involved in setting policy and settling disputes in their area. They were also free to promote, and even enforce, behavior change within their communities. In fact, the work that individuals and communities contributed to the effort to prevent the spread of AIDS was critical to its overall effectiveness. While government ministers and public health workers made speeches, musicians, local and international NGOs, chiefs, Christian and Muslim groups, and local councils also got involved. This local participation in the campaign was often the most important reason for behavioral change on the part of community members. (Allen, 2005)
The behavioral change messages pronounced by Museveni and his ministers included slogans like “love faithfully” and “zero grazing,”3 and these campaigns proved to be effective. Significantly, the use of condoms was rarely mentioned. When he did speak of them, Museveni denounced condoms as un-African and raised doubts about their effectiveness. Indeed, it is understood that condoms played a very small, if not insignificant role in the decline of HIV/AIDS prevalence among young people in Uganda. (Hogle, 2002) Instead, the key was a decline in casual sex, partner reduction and a postponement of first sexual intercourse for girls. The widely touted ABC campaign (Abstinence, Be faithful, Condoms), with its equal emphasis on all three prevention methods, was not actually implemented in Uganda until the later 1990s. Overall, it became a patriotic duty to fight AIDS in Uganda. (Hogle, 2002)
The importance of Museveni’s leadership, and his close relationship with his followers, cannot be overestimated. His government was new and energetic, and his motivation to lead the anti-AIDS campaign was entirely homegrown. The high-level political commitment to this issue created a positive atmosphere that motivated and empowered local groups. The rights of women and the issue of discrimination was addressed, and support groups for those living with HIV/AIDS were formed all over the country. (Hogle, 2002)
Sadly, Botswana’s AIDS story is very different. While Uganda’s incidence of AIDS steadily declined in the 1990s to less than ten percent, Botswana’s has risen to roughly 40% of the adult population. This is cruelly ironic, considering the facts of the nation: with a population of less than two million, Botswana is one of the most ethnically and linguistically homogenous nations in sub-Saharan Africa. Since its independence, Botswana has had the fastest growth in per capita income in the world, driven largely by wisely spent revenue accrued from oil and diamond resources. It has a stable, multiparty constitutional democracy, and the government is deeply committed to social welfare programs. Health care services are excellent by African standards, and are essentially free. Education is inexpensive and widespread, and the adult literacy rate in 2003 was 81%. (Boulanger, 2005) Furthermore, Botswana has not struggled with poverty, war and civil unrest like many other African nations, including Uganda. (US Department of State, 2005)
At about the same time that Museveni was starting his anti-AIDS campaign in Uganda, Botswana began working with the WHO, USAID, and various western NGO’s to develop its anti-AIDS programs. The first national campaigns appeared in 1988, and they used radio messages, car bumper stickers and t-shirts to spread their message. Posters could be seen around the city that read “Avoiding AIDS is as easy as ABC- Abstain, Be faithful, Condomise.” (Allen, 2005)
The early AIDS messages, and their open talk about sexuality, were seen as brash and offensive to the general population. There were very few in Botswana who understood what was going on, since there had been very little experience with the disease by the time that the campaigns began. People remained skeptical that the disease actually existed, and HIV/AIDS remained secret and stigmatized. Billboards and t-shirts were in English, encouraging the population to think that the campaign was simply a ploy of western governments to control African sexuality.
The heavy promotion of condoms proved to be disastrous. Their tireless promotion on the part of western NGOs not only added fuel to the conspiracy theories about western governments controlling African sexuality and reproduction, they also were seen as a rejection of African morality and culture and a forceful promotion of Western values. Church leaders and African elders, for their part, believed that condoms encouraged immorality and sexual promiscuity. Such a view was not necessarily misinformed, moreover: a survey in 1992 reported an increase in condom use among its urban young respondents, but it also reported an increased rate of partner change. (Botswana, 1994)
Another important problem regarding the western-led AIDS campaigns in Botswana and their promotion of condoms was the often bitter relationship between the western medical establishment and traditional healers. Whereas Uganda had no medical establishment to speak of, Botswana’s medical facilities were quite good. Uganda therefore relied heavily on traditional healers to promote its behavioral change campaign, while Botswana’s medical establishment, including western medical professionals, eschewed any attempt to cooperate with local, traditional healers. With this wedge driven between the country’s two forms of medical establishment, two parallel beliefs about AIDS and condoms developed. On the one hand, there was the western message that was played on the radio and plastered on billboards. The other set of beliefs, based on Tswana culture, suggested that there was no new AIDS epidemic, only old diseases that were now mixing and strengthening. This was later corroborated by personal experience, as AIDS does, indeed, manifest itself as a mass of familiar afflictions. The promotion of condoms was further undermined by the Tswana belief regarding the proper flow of blood: blood flow is important, including the flow of blood between people during sex. Sexual intercourse, then, is seen not only as procreative, but health-giving. Stopping this flow of blood, specifically by using a condom, was widely accepted as the very reason for the AIDS pandemic at all.
Disregarding these local beliefs, the government of Botswana continued to promote an exclusively western model of HIV/AIDS prevention. In doing so, it alienated the very religious and community groups that were necessary for the program’s success. The community’s complete lack of support for the government’s campaign was also due in part to the stable, centralized government that existed. While Uganda’s local communities were empowered to make decisions and implement them, leaders at the local level in Botswana were entirely dependent upon higher approval before they were given permission to act. There was very little motivation on the local level to get involved in the political process. Even if they had wanted to, however, local communities weren’t buying the governments message: by the late 1990s, AIDS was still considered an outside disease, and chiefs didn’t believe that there was anything that they could do to alter the younger generations’ sexual behavior.
There is also an important economic consideration regarding AIDS campaigns in Botswana and Uganda. Botswana provides roughly 70% of the cost of its anti-AIDS campaigns, while Uganda has never had to pay more than 10% of its programs. (Allen, 2005) This is due, in part, to the differences between the nation’s economies, but it also has a lot to do with Yoweri Museveni’s ability to procure international assistance. The money that is received is widely spread over the entire country to local councils and groups, providing a profound economic incentive for anti-AIDS campaigns. Furthermore, whereas Botswana’s economy, based on tourism, cattle, and diamonds, does not depend on a large workforce, Uganda’s exports require a large number of agricultural laborers. Botswana’s economy will continue to grow if those three important industries are protected, but the AIDS pandemic in Uganda, on the other hand, poses a clear threat to the nation’s economy as a whole.
While the current administration in Botswana under Festus Mogae is trying once again to tackle the burgeoning AIDS crisis, silence about the disease persists. Because so few people are willing to come forward and be tested, the president has instituted universal testing for HIV. Individuals must choose to opt out of the program if they do not want to be tested. The country is also trying to become the continent’s leading provider of antiretroviral treatment, but the large number of AIDS cases will put a massive strain on the nation’s health infrastructure.
The two examples given above are useful on a number of levels. Not only do they give us background and a context in which to frame further thinking about HIV/AIDS work in Africa, they also help shed light on the ideological underpinnings of both the programs that have worked and those programs that have failed. Summing up many of the salient points about the troubles of AIDS prevention in Africa, Heald writes, “the ‘safe/r sex’ model of prevention was initially developed in the West and used successfully among a particular group of Westerners, that of homosexual men. Barrier methods were evidently appropriate for a group that valued sexual freedom and non-procreative forms of sexuality.” (2003) Indeed, while passionate debates over HIV/AIDS policy occur in Washington, D.C., the campaigns themselves are carried out in the far-away capital cities on the continent of Africa. If context is king, then that fact must rule in the minds of policy-makers in the West.
Arguments over how to mitigate the threat of HIV/AIDS can become vitriolic at times, but opposing sides tend to agree on quite a lot. The clear consensus is that behavioral change is at the center of the answer to the AIDS epidemic. Implementing behavioral change on a large enough scale, however, is the challenge that is before governments and AIDS activists. This leads to another important point of agreement: behavioral change can only take place at the level of the individual living within a particular context. As Webb points out, “an individual must know about the disease, want to change his or her behavior, and be in a position that allows for behavioral change.” (1997) An attempt to encourage individual behavior change without appropriately dealing with contextual issues will be ineffective. Campbell, writing as a psychologist who has witnessed failed HIV/AIDS prevention programs, attempts to bridge the space between context and the individual: “Behavior change needs to be conceptualized as a community-level phenomenon, involving changes in participants’ social identities, their collective empowerment and their access to various forms of health-enhancing social capital.” (Campbell, 2003)
Critiquing the current state of HIV/AIDS prevention and care, de Waal writes, “There is an un-theorized consensus on what an HIV/AIDS program should look like: it should be founded on voluntary counseling and testing, education (preferably by peers), provision of condoms, efforts to overcome denial, stigma and discrimination, and care and treatment for people living with HIV and AIDS. Prevention of mother-to-child transmission and treatment of STIs are also prominent. It is, overwhelmingly, a model of voluntarism and community participation.” Later in the same article, de Waal goes on to claim that, “The two basic preconditions for successful measures against HIV/AIDS are that they should be founded on rigorous public health science and that they should be framed by the real potentialities of African governance.” (de Waal, 2003) The importance of de Waal’s comments is his emphasis on the ability - rather, the necessity - of national governments to help shape and define local contexts, as well as the HIV/AIDS programs themselves, in such a way that programs have a real chance for success. It is accepted that HIV/AIDS programs need to be “scaled up” from the local level in order to have a widespread impact, and it is de Waal’s contention that NGO’s simply do not have the capacity to do so.
Do African governments have the capacity to “scale up” HIV/AIDS campaigns, and are they effective? The answer is not entirely straightforward. An important innovation of Yoweri Museveni’s in the mid-1980s was to establish an AIDS committee within the president’s office. Significantly, he was able to focus the entire government’s attention on the AIDS epidemic without creating overlapping and conflicting levels of bureaucracy. The issue was not allowed to become wholly political, and it is crucial that most of the resources and the organization of a systematic campaign against the virus in Uganda remained within the Ministry of Health. (Putzel, 2004) The template proved to be very effective for Uganda in the late 1980s and early 1990s.
Sensing the growing threat posed by HIV/AIDS, the United Nations created the Joint United Nations program on HIV/AIDS (UNAIDS) in 1996. Bringing together ten different UN agencies, including the World Health Organization and the World Bank, UNAIDS was created to engender a unified, concerted response to the global AIDS epidemic. The World Bank also recognized the centrality of the AIDS issue to its many development projects across the continent of Africa, and it established the Multi-Country AIDS Program (MAP). Wanting to streamline the process of program development and fund allocation even further, the United Nations General Assembly voted in 2001 to create the Global Fund To Fight AIDS, Tuberculosis and Malaria. Its purpose is not to implement any programs on its own, but instead to raise funds, finance programs and manage resources efficiently. The common desire of each of these organizations is to scale up prevention and treatment efforts.
Poor African nations, including Uganda, do not have the resources to mount adequate anti-HIV campaigns on their own, and they rely on three broad sources of outside funds: bilateral donors (especially the US and the UK), private foundations, and multilateral donors including the World Bank and the Global Fund. These last two organizations, in particular, looked to Uganda’s successful program to determine the template of the AIDS efforts they would encourage and fund. According to the United Nations, Museveni’s leadership and ability to attract a wide variety of non-governmental groups to confront the epidemic were paramount to Uganda’s success. The organizational template agreed upon by these bodies can be summed up by the “Three Ones”: one agreed framework of action against AIDS that unifies all partners; one national AIDS coordinating authority, with a broad-based, multi-sector mandate; one agreed country-level monitoring and evaluation system. The goal of the national AIDS commissions was to ensure that all sections of government are involved in confronting the AIDS epidemic on the one hand, and encouraging non-state action to address HIV/AIDS on the other. The AIDS programs in the African countries interested in receiving funds from the Global Fund or from the World Bank are required to be built on this template. (UNAIDS, 2004; World Bank, 2005; Global Fund, 2005)
The template sounds very effective, but it has proven to be problematic in practice. Nations with existing programs were asked to formalize them and ensure compliance with the United Nations model. For Uganda, this meant the establishment of the Uganda AIDS Commission, a stand-alone body within the government. Unlike the president’s former program, the Ugandan Ministry of Health was not the central organizing and support entity, but was to be a co-equal member along with other sectors of the government. This marginalized the central work of the Ministry of Health, and engendered confusion and rivalry between departments. If a separate AIDS coordinating body within the government was frustrating for countries with existing AIDS programs, it was disastrous for countries that had to form them from scratch. In some countries, resources and funds were diverted away from national ministries of health and to the national AIDS commissions. When a national AIDS commission was established, other sectors of government tended to assume that the AIDS program was no longer their concern. In short, an emphasis on implementing the correct organizational structure without active leadership in all the ministries was detrimental to national AIDS programs. (Putzel, 2004) Replicating Yoweri Museveni’s leadership has proven to be very difficult.
It should surprise exactly no one that HIV/AIDS programs are defined in large part by the wishes of their financial supporters. The Global Fund and the World Bank often make recommendations before dispersing funds, and African governments are generally quick to accommodate. In 2003 the United States president announced the fifteen billion dollar President’s Emergency Program for AIDS Relief (PEPFAR), touted as “the largest international health initiative in history initiated by one nation to address a single disease”. (United States, 2005) While the US program shares much in common with the multilateral programs, including a commitment to “the three ones”, there are profound ideological differences that under gird their respective approaches to AIDS work. Indeed, the differences between the American approach to HIV/AIDS prevention efforts and that of the various UN-affiliated organizations is representative of the disagreements that occur about AIDS work generally.
On September 17, 2002, the U.S. Agency for International Development (USAID) hosted a technical meeting in Washington, D.C. to consider behavior change approaches to HIV/AIDS prevention. Over 130 HIV/AIDS experts attended. The meeting ended with researchers agreeing on four important aspects of HIV/AIDS prevention: first, that there is a need to balance A, B and C interventions (Abstinence/delay of sexual debut, Being faithful/partner reduction, and Condom use, respectively). Second, that interventions need to be targeted in order to respond to differences among target groups. It was noted that condoms, in particular, needed to be targeted towards specifically high-risk groups. Third, that political leadership and community involvement are crucially important. Finally, that partner reduction is very likely the key to successful HIV prevention. (USAID, 2003; 2004)
Edward Green is a long-time AIDS activist who is currently a member of President Bush’s Advisory Committee on HIV/AIDS. His importance is that his 2003 book, entitled Rethinking AIDS Prevention, provides much of the intellectual meat behind PEPFAR. In the book, Green elaborates on the results of the 2002 USAID technical meeting, singling out personal behavior change as the primary tool for AIDS prevention. For him, this basically means two things: partner reduction and delay of sexual debut among the youth. Green argues that personal behavior change is the natural, spontaneous response of Africans to fear of infection, and he points to the example of Uganda for his support. He emphasizes that AIDS prevention efforts must be simple and cost-efficient, and that personal behavior change campaigns fulfill both of those requirements. Green admits that contextual issues, particularly poverty and the marginalization of women, can make personal behavior change difficult. He responds to the criticism by pointing to Uganda once again: according to Green, Uganda not only mounted a successful AIDS prevention campaign as a poverty-stricken nation, but it also made great strides towards empowering women. Perhaps more controversially, Green argues that religious groups and schools are the best at effectively promoting personal behavior change, and so governments and NGOs should specifically target them for support. Whereas many secular prevention programs fail because they lack the political will in the form of full commitment from the stakeholders, this would not be the case with faith-based organizations. (Green, 2003; Caldwell, 2004)
To American observers, this sounds eerily familiar to the debates over sex education that occur in our own nation. It sounds even more familiar when the most contentious issue is mentioned: the role of condoms in prevention efforts, and their relationship vis-à-vis abstinence messages targeted towards the youth. While not advocating abstinence per se, Green favors programs that encourage the youth to delay their sexual debut, citing studies that suggest that an early sexual debut is associated with a higher lifetime number of partners. (White, 2000) While he does maintain that condoms can be useful in specific high-risk groups, Green stridently opposes their widespread promotion among the general population. There are three reasons for his opposition to condoms: first, he points out that an individual in a non-casual relationship will be very unlikely to use a condom, due to the lack of commitment and trust that its use would communicate. Second, he cites a 2001 study that argues that “inconsistent condom use may actually be an ‘enabling’ process allowing individuals to persist in high risk behaviors with the false sense of security,” (Ahmed, 2001) and studies in Botswana seem to corroborate these findings. (Botswana, 1994) Finally, Green asserts that, despite the massive promotion of condoms all over Africa, there simply is no “condom success story” on the continent. (Green, 2003)
Green’s frustration with the western-led AIDS campaigns centers on what he refers to as “the Washington-Geneva consensus that AIDS programs should not interfere with peoples’ sexual behavior.” (Green, 2003) He contends that the western model is based on prevention among homosexual men in the United States, a specific high-risk group that placed a premium its sexual freedoms, and that such a model simply is not applicable to the African context in which the disease is widespread in the general population. Green condemns the United Nations for its lack of support for behavioral change interventions, and he even goes so far as to say that UN interventions are tailored to avoid behavior altogether. Instead, according to Green, UN programs require high levels of sustained funding, technology, and oversight from western nations.
Are Green’s critiques of the UN well founded? The UNAIDS AIDS Epidemic Update, released in December of 2005, is useful in answering this question. According to page fourteen of the UNAIDS document, “In June 2005, the UNAIDS governing Board comprising member states, cosponsoring UN agencies and civil society endorsed a policy position paper for intensifying HIV prevention with the ultimate aim of achieving universal access to HIV prevention, treatment and care. This policy position paper included a compendium of proven programmes and actions that could be used to close the prevention gap…” (UNAIDS, 2005) The list of policy actions on the same page includes such issues as the promotion of human rights and gender equality, the need to have targeted, community-specific programs that address cultural norms and involve those living with AIDS, and the importance of continued HIV/AIDS education. On a national level, the list underlines the importance of building leadership from all sections of society, and expresses the need to address legal frameworks that challenge effective prevention campaigns. Finally, the last point on the list mentions the need to ensure proper investment and research into new prevention technologies. Nowhere is behavior change specifically mentioned. The following two pages, however, provide a number of examples of “new prevention methods” that deserve attention: female condoms, microbicides (offering “the best promise of a prevention tool women can control”), pre-exposure prophylaxis and vaccines. Apparently, the United Nations believe that adequate HIV/AIDS prevention is a commodity that they must provide to benighted African nations.
Concluding Remarks In a fit of honesty, the World Bank listed the United Nations millennium development goals, and their progress, in its 2005, Global HIV/AIDS Program of Action. Of the eight goals mentioned, the World Bank admitted that its progress towards universal primary education and gender equality were “lagging”, that the situation regarding child and infant mortality, maternal health, and the spread of AIDS and other diseases was “worsening”, and that its work toward reducing poverty and hunger were “stagnant, at best.” (World Bank, 2005) Context is certainly important when facing the threat of HIV/AIDS, but it is the opinion of this author that we cannot wait for the World Bank’s structural adjustment policies to take effect and stem the epidemic. We must face the issue now, with the tools that we currently have at our disposal.
Nor can we run the risk of commodifing prevention efforts in such a way as to force African nations to continually rely on the West for funding and technical expertise. Campbell’s 2005 journal article, mentioned in the introduction to this paper, suggested that the youth in her study seem to be unable to participate in “informal and formal community networks,” and it goes on to suggest the implementation of “programmes that promote young people’s social and political participation.” But is it not hubris that allows us to think that such social networking and social capital can be injected into the society by Western AIDS activists? While well meaning, AIDS prevention and care programs are often generated with the assumption that they need to rely primarily on Western resources and knowledge.
Instead, if the example of Uganda has taught us anything, it is that AIDS prevention in Africa will not work without sustained, energetic leadership on the part of Africans themselves. The most effective way to address the AIDS crisis is not to ensure that the proper structures are in place, in the form of national commission, but it is instead to build leadership in Africa. Uganda has also taught us that the time for running HIV/AIDS programs with an emphasis on voluntarism, confidentiality and gentle persuasion is over. The AIDS crisis is only accelerating, and we must be willing to implement tough policies if we hope to see a brighter future for the continent of Africa.
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1 Unless otherwise noted, ‘Africa’ will refer to sub-Saharan Africa.
2 Blood samples from pregnant women who attend antenatal clinics are commonly used to gather information on HIV prevalence. While it is not an exact science, information gathered in this way can yield reasonable estimates of national HIV prevalence. (UNAIDS, 2005)
3 “zero grazing” refers to the technique of tethering a cow or a goat to a post, so that it would eat grass in a circle.