Should have been posted 3 September 2010
40
The Sibebe Challenge bike race, a 40km adventure along paths around this area, took place on Saturday, Aug. 28. David, Terry, and Solomon Litty, who live just a couple kilometers from the starting point, graciously put me up on Friday night. I got to the starting point about 6AM; no other cyclists were there yet. A few minutes after my arrival, a number of grade-school age kids appeared. For a brief moment, my hopes of winning this race were kindled. I may be 42 years old, I thought, but surely I can outpace these little guys! Inevitably, however, the heavy hitters gradually arrived, and I knew I was back to cycling for pleasure.

We got off about 20 minutes late, but it was a real blast. We started out the road to the school taken by Shining Star bus; I could only think again and again to myself "Man this is MY neighborhood; I know just how long and steep this hill is, and I know where it bends, etc. At least for this part, I'm gonna do ok." I did pass a few people on that initial stretch, and got passed by one guy whom I never saw again. But that was okay.

The course left the road and took a turnoff I have never travelled, looking down into the Mbuluzi river valley. I've been in that valley many times, but had never seen it from this perspective. Small knots of homestead children stood at their gates and cheered us as we came by. There were only about 20-25 racers by the way; I was by myself most of the trip. This was good, as it removed the competitive edge from the experience; I really wanted to enjoy this, and not get wound up about winning.

The course rejoined some old roads I know from walking to town, and I got the "home field advantage" rush again. I called Ruth (you can see I wasn't so concerned about time) and told her where I was, but that I wasn't sure how close we'd come to the school.

The course then went down to the river and crossed it. This marked (I think) the halfway point in the race. I was having a great time. Thing was, just after crossing the river, the course went up a bunch of steep hills. This meant a lot of getting off and pushing the bike. Also, as I have been riding about 4-5km three times a week and I had now covered about 20, my legs began to complain about the uphill pedaling. The mode of complaint was cramps. More later.

I went along some paths I had been on but rarely; boy, they are lots steeper when you have a bike than when you are just walking! I got passed by a guy at least 10 years older than me. Humbling, and a reminder that age (for better or worse) isn't everything. Coasting down a hill I thought this would be a good time for one of the candy bars I bought in town. Suprising what an appetite for sugar/carbohydrates biking can give you! I did not think I could eat a 200 gram (7 oz.) chocolate bar in less than 2 minutes. Ruth sent me a text message about 3km before a water point right next to the school (I forget how she figured out the course came so close, but I was glad). I told her I was getting close, and the legs were cramping nearly to the point of refusing to work at all. We met up, took some photos, I drank a bunch of water, the girls unwrapped chewy candies and pressed them into my hands (and I crammed them into my mouth), then I charged off again.

The course went up another steep hill; a bystander (a former student, actually) said the course went to the water source. I knew that way was steep. A little fear of my ability to finish crept into my mind. But I decided to just keep putting one foot in front of the other.

Another racer and I went along for a while. During the next uphill, the legs really did cramp and refuse to go. I jumped off the bike, screaming and stretching them. The other competitor gave me what she called "tissue tablets"; she said they had calcium and something else (I forget what now). If she had said they had nitroglycerine, arsenic, and battery acid, I wouldn't have cared: as long as they promised to relieve the cramps I would take them. Whether they had any effect or not, the cramps did not return (though they did threaten to; the rest of the trip was walking a tightrope between pedaling to make faster progress but not pedaling so hard that the muscles cramped again).

That racer soon left me behind. The path went through some areas I had never seen, and that was great; it's always fun to see new areas. Some of the areas had been recently burned, though, and those stretches looked like the land of Mordor from "The Lord of the Rings". There were times I felt like Sam or Frodo, travelling through scorched desolation with fading strength and no water and precious few signs of other bikers. Some of you may know the U2 song "40"; it includes lines like "I waited patiently for the Lord; he turned to me and heard my cry". "He set my feet upon a rock, made my footsteps firm". I learned a few years ago that those are lines from Psalm 40 in the Bible (hence the song title). Those few verses went around and around in my mind, as only song lyrics can when you are doing semi-monotonous work or need inspiration. The song also includes a line "How long, to sing this song". That verse passed through my mind too, with a twist: "How long, will this course go on". Still, I could not think of a place I would rather have been at that moment. I mean, how often do you get to have adventures like this?

Eventually I ended up on top of Sibebe, and the tracks were clearer. I knew where the path down to the Sibebe gatehouse (which was where the starting point was), and found the way down. What a relief to see those parked cars at the bottom of the hill! I crossed the finish line, they cut my number plate off my bike and took it (I could understand that, though it would have been fun to keep it), got off the bike and took a rest. One of the kids who arrived early wanted to talk, so he asked questions about Ruth and the kids, where we live, where the children were born, etc. When it came time to stand up, I told him "Now you stay close to me when I stand up, because I don't know how steady I'll be". Sure enough, the blackout/headrush thing came on me, and I grabbed that kid for dear life. Thankfully I didn't fall down. I called Ruth and told her I'd finished, then I called David Litty and threw myself on his mercy, asking for a ride back to the school. He was in a time crunch but he graciously took me, piling the bike in the back of his car and me into the front seat. 30 minutes later I was soaking my feet in a basin in the living room while Ruth and the girls and I enjoyed popcorn. What a good day.

Leonard Dlamini, a former (1990s) student who was pretty involved in organizing the race, called on Monday. He said they were looking for input for next year, as 30% of the trail this year was pushing the bike uphills. On Sunday Ruth and I had indeed talked about alternate paths out here, and this morning (Thursday) I took a longer than usual ride, looking for options. I think I'll do it again next year, and might even have a finger in the course layout. It was fun.

SIGNS OF THE TIMES
I (Ruth) was reading a story to my girls. One of the lines went:
"Grandma said, 'Your Grandpa would have been SO proud...' Grandma had a tear in her eye."

I asked the girls what this line meant. No response. I asked, "Where is Grandpa? Why isn't he here?"
Gracie piped up, "Grandma and Grandpa split up."

I was stunned. My first reaction was--these are GRANDPARENTS for goodness sake! Grandparents can't be divorced. Then I started thinking of the divorced Grandparents I know. I finally got out a response,"Well Gracie, that is a very MODERN answer."

Late that night I was pondering how different the world is. I didn't know any divorced grandparents and I couldn't have imagined a divorced grandparent when I was a child. I still have trouble imagining such a thing--the two categories don't fit together in my head. Slowly the irony of the situation surfaced. My own Grandfather, who died before I was born, had been divorced before he married my Grandmother. While divorced Grandparents were unimaginable in my world, they were not nonexistent.

OPINIONS ON AIDS
AIDS is a recurrent theme in these newsletters, as it is a major dynamic in the life of Swaziland right now. Posted at poglitshphotos.blogspot.com are two newspaper articles from the Times of Swaziland. One is an interview with a man of significant cultural rank. Without giving too much away, the responses to his interview were overwhelmingly strong and negative-which is a good thing. The other is by a medical person, who seems to miss the point that an ounce of waiting until marriage is worth a metric ton of technological interventions. A line like "Male circumcision and early HIV treatment are the strongest interventions in our armament and we should avail ourselves of these opportunities" would be laughable were it not so lethally false. That approach makes sense if we enjoy some universal right to consequence-free sex, which we do not, and which we never have, and which zillions of dollars and the brightest minds in the world have not been able to bring to fruition. A HIV rate hovering in the mid-30% range for pregnant women would indicate that boatloads of condoms, free circumcisions, etc. are not doing the job.

On the other hand, a longtime friend of ours relayed a hopeful story to us this week. She called an office trying to contact someone. The man who answered the phone asked her name. She gave her last name, and he said (pseudonym) "FRANCINE Johnsen?" Our friend said yes. The man said "I read your book about staying a virgin until marriage. When I was in college my classmates laughed at me and said 'You don't know how to have fun'. I did indeed wait for sex until marriage, when I married a fine Christian girl. As for my classmates, I have attended their funerals, and have visited them when they are sick in the hospital. Who is having the fun now?"

Reality inexorably grinds out its consequences. I sincerely hope more and more Swazis take this young man's approach to life, and ditch the approaches advocated by the other two men. It is a matter of life and death.

PHOTOS OF CUBBY WALK
Last week I could not access our blog; it may be that the company running the internet shop is trying to filter out junk sites (good for them), but it seems the program they used is a little overenthusiastic! The site is available again, and photos of Cubby's 5-hour ascent of Sibebe from the backside are now available. Enjoy.

Have a good day,
Rudy for the gang

Originally posted 9 December 2010
BREAKFAST OF CHAMPIONS
School closed Friday, 3 December. The original closing date was 10 December, but Swaziland is hosting a large multi-event sports competition, and so the closing date was moved. This change was made after our plane tickets were purchased, so that's why Ruth, Grace and Jabulile are already in the US while Rudy and the other two girls are still in Swaziland. I (Rudy) do not mind too much, though of course it would be fun to have another week with Ruth and friends and family stateside. But this gives the three of us "left behinds" some unique "down time" in Swaziland.

Though not entirely down time. On Saturday morning we discovered that the water was out. Again. Yet again. And I did not know why. And Mamba was gone. Silver lining: on Friday the 10th, my "team" will travel to Mbabane and the next day to Joburg. From 10 December to 22 January, I do not expect to repair any water outages.

So, what to do. I could wait around and hope Mamba came back and fixed it, or I could go out and do something myself. I decided to go out, carting the girls in the wheelbarrow (worked well with Kit last time). But first, something to eat. The previous night saw an eruption of tinhlwa, the flying ants the girls like to eat. They captured and drowned about a dozen, and we pan-fried them for breakfast (visit the poglitshphotos website and visit the "breakfast of champions" post for a photo). A long-time expatriate friend said it well: they taste just like bacon, and I don't think it's just all the oil and salt.

Off we went at about 8:30AM. I took the girls in the wheelbarrow on the flat portions, and they got out and walked on the steep parts. We made pretty good time, arriving all the way to the big tanks at about 10:30. Someone had turned off the inflow pipe (reason unknown; information flows like molasses in an Anchorage January); 5 or 6 turns with my fancy new crescent wrench ("adjustable spanner" in British English) reinstated the flow. We're feeling pretty accomplished.

Unfortunately, I had also opened a valve a little ways down the hill on our way to the big tanks, and this caused an overflow at a later portion. So I closed the valve to the tank where the overflow was taking place (and from which the school gets most of its water), went back up the hill, and redirected the water (using another valve) to the folks on the other side of the road. Then it was back to the valve I had opened too far to turn it down a bit, then back to the tank from which the school gets its water, in order to fine tune it. But, with so much water backed up behind this valve, the valve would not turn. It does not help that the handle which should be on the valve stem is long gone (if it was ever there in the first place), and that one simply has to apply vise grips to adjust the valve. I made some terrific contact on the stem, but could not get it to turn. Now I was starting to worry; It was after 2PM, the girls are getting tired, and I was afraid I had ruined this valve. Mamba is out of reach (phone calls and text messages are not being answered, and he's off at his home in another part of the country anyway). I could see the headlines: "Wanna-be nice guy expat destroys part of community water system; Thanks a lot, Yankee".

Fortunately, the valve was allowing a little water to pass, and a faucet just above this valve was also letting water out. Eventually the force of water on the valve went down enough that I could open the valve. What a relief! I opened it all the way (the way it usually is), then went back to the point where water is directed either to the folks across the way or the folks on this side. I adjusted it to my satisfaction (hoping it would be adequate for both parts of the community), then returned to the troublesome valve and got the water going to Nsukumbili. As we went home along the road, I saw a pipe leaking; this was a very welcome sign, indicating that water was indeed on its way to the school. The school tanks were overflowing when we got there (and that is okay). Whew!

After fixing the water but before going home, we stopped by Entfubeni Primary school. A pastor friend of ours from the US was visiting the church he works for here, and we had been told by Mr. Shandu (a colleague at Nsukumbili and a member of the church) that Pastor Hawkins would be around Friday and Saturday. We had planned to go on Friday, but time and weather were against us. I really did not want to show up muddy, sweaty, smelly, and poorly dressed, but I thought I would not have time to go home and change and then come back; and I suspected that once we were in the house, we would not want to leave again. So we took a chance and just arrived as we were. We snuck in a back door while someone was preaching, hoping to sit quietly at the back and speak to Pastor Hawkins afterward. We were immediately ushered to the front table and asked to sit there. Oh man; in our condition? Everyone else was clean and nicely-dressed, and I had a torn shirt (I had put it on the valve stem and then clamped the vise grip over it, hoping to get it to turn) and torn sneakers, and I cannot imagine how nasty I smelled. During the trips up and down the hill, the girls (naturally) did not want to be left behind. So I had spent considerable effort pushing them up and down the hills in the wheelbarrow. That exertion extracted its due in sweat. Man was I feeling out of place. But no one stared at us (that I could notice), so I did my best to understand the preaching. Kit fell asleep on my lap in about 5 minutes. Cub looked zoned out, but stayed awake. I let her eat the raisins and macadamia nuts we had brought with us. She generously offered to let me have some.

The preacher ended, and Pastor Hawkins asked me to stand up and give a testimony to the goodness of God. I have never been asked to do that, but I did not mind and I just backed up what the preacher had been saying (he had a good message). I delivered it in what must be to the folks around here my laughably amateur broken SiSwati. Still, I felt good about what I had tried to say, and it had enough SiSwati in it that Mr. Shandu was translating it to Pastor Hawkins. After that I told Mr. Shandu and the pastor that the kids were wiped out and we needed to get home. So the girls piled back into the wheelbarrow (they got pretty good at getting in and out in a hurry), and we went down the road.

LAST STOP BEFORE HOME
We stopped at the Mamba shop, because our food was spent and we were thirsty. I had an E100 bill in my pocket, I told Cub, and I had every intention of breaking it. We shattered that thing on a 1 liter of Sprite, two packages of chocolate cookies (one of which I ate on my own), and two bags of popcorn. Cookies and soda never tasted so good (Tromans, I am reminded of your comment about biking across Canada-"Your body is screaming for carbohydrates". Now I understand). After that we were in better spirits. One of the Mamba children, without being asked, pushed the wheelbarrow (with the girls inside) about a quarter of the way home. That was a bigger relief to me than I can describe. Along the road we passed a group of former male students. Two of them whipped out their cell phones and wanted to take pictures of us. I got down next to the girls and we all smiled. Writing this, it strikes me how the tables had turned; isn't it usually the foreigners who pull out the cameras to take pictures of the locals doing their day-to-day things? We all had some laughs. After explaining what we had been doing, one of the students said I should go into Parliament. That was a thoughtful comment, but there's no way I could, and I wouldn't want to anyway.

We snapped on the water heater as soon as we got in the front door, at 5:30PM. The girls had been out for about 9 hours! A couple hours later, after dinner, we all took baths. The girls, now washed, fed, and in clean jammies, slept right away. In my turn, so did I.

I was thinking this is not the way I hoped to spend the Saturday; but then again, we had an adventure together that they won't soon forget (at least Cubby will remember it; I don't think memories are registering quite yet for Kit). I certainly don't want to do this everyday, but we did have a good bonding time, and I did learn some more about how (and how NOT to) get the water going again when it goes out. So, all in all, I think it was a day well spent.

ABNER DLAMINI
This is our homestead father, the head of the homestead in which Rudy spent 10 days during his Peace Corps training. We mentioned that he suffered a stroke in mid-2008. Recently he was in a hospital in Manzini, and has suffered another setback. During physical therapy there he fell. He is now unable to walk, and has to move around in a wheelchair. He has to be lifted from his wheelchair to his bed. We visited him twice last week, and before helping his wife move him into his bed, I was given a pair of examination gloves to put on. He is very weak and looks thin. On Sunday 5 December the homestead asked for a loan to hire a local someone to take him to town, because his cough was getting worse. I do not know how long he will live. When he dies, there will be no resident adult male in that homestead; the other adult men live and work elsewhere. Abner's other homestead (he has two wives) does have an adult man there, named Bernard.

It is common that expatriates come and go in Swaziland rapidly; more than a few years is remarkable. We have been here 8 years, and I guess I assumed that we would come and go before anything significant changed at the homestead. Boy was I wrong. This is a tough time. If you pray, please pray for his homestead. His wife (the one he married after our "original" homestead mother, Make Malinga, died) is a very good caregiver, but I can only imagine the stress on her is very large.

EXCHANGE
A friend of ours had something to say in response to a recent newsletter. We wrote back to him, and our response is below. We could not secure permission to reprint his response. In summary, he explained that he was frustrated that some groups will not allow some morally-objectionable HIV interventions (namely, condoms) when those interventions could save lives. You will find lots of information about AIDS prevention after our note. It is a lot of material, but it is easy to read, and may give you a perspective on AIDS prevention you have never had before. We have had the privilege of corresponding with and meeting Edward Green, researcher and author of the extra material. Enjoy.

Here is what we wrote, from which our friend launched his response:
On 11/13/2010 1:26 AM, Ruth & Rudy Poglitsh wrote:
> Another reaction I'm finding more frequently is anger. It is no mystery
> in Swaziland what is killing these folks (namely, having sex before and
> outside marriage) yet many Swazis keep doing the same thing. Is not one
> definition of insanity to "keep doing the same thing while expecting
> different results"? HIV/AIDS is, at its root, a self-inflicted wound.

Our response:

I appreciate your concern about the deaths in Swaziland; living here in HIV/AIDS central, your sympathy is welcomed.

You said the anger at all the deaths is why all potential interventions to save lives should be used, including condoms. If I could restate your summary, it would look like this:

It is immoral if, for ideological reasons, people refuse to promote something that works and will save someone's life.

It is actually because we agree on this fundamental point that I get so angry. The big point of disagreement is on what works to save lives. Your assumption that condom promotion saves lives seems quite reasonable. Unfortunately, in Africa, research has shown that it is not true.

Condoms have been aggressively promoted here since I left the Peace Corps in 1993. In Swaziland, where condoms have been vigorously promoted, HIV rates among pregnant women went from 3.9% in 1992 to 42.6% in 2004. (a 10-fold increase in HIV rates is not usually considered success.) In Uganda during this same time period, the emphasis was on abstinence and faithfulness; the HIV rates dropped two thirds. After twenty years of condom promotion in Africa, there is not a single country where a drop in HIV rates is attributable to increased condom use.

Please find below a few articles by Edward Green, written while he worked at Harvard, studying the relationship between various HIV interventions and HIV rates. Dr. Green will teach a course at the University of Florida in the new year. The end of this e-mail has its title and textbooks.


So let us return to my summary of your argument:

It is immoral if, for ideological reasons, people refuse to promote something that works and will save someone's life.

If you are around the international aid community, you rapidly find that encouraging abstinence and faithfulness instead of technological fixes to prevent new infections is very offensive. Ruth and I think it has to do with a commonly-held (but never directly articulated) assumption of a universal human right to consequence-free sex. 15 years ago that offense might have been excusable, given the common sense of the position that you expressed. Two decades into the African debacle and with empirical data in hand, the best explanation for the continuing aversion to abstinence and faithfulness is that for ideological reasons some people will refuse to promote something that has been proven to work and save people's lives. And that is why I get angry.

I would like to know who advocates letting people die rather than promoting condoms; can you send me a link to back up your statement?

No one gets hurt following orthodox Jewish or orthodox Catholic teachings on sexual issues. If people are ignoring those teachings about sexuality within marriage, they aren't likely to agonize about ignoring those teachings about condom use. It sounds like you are objecting to what should be a Saturday Night Live skit:

"I'm a faithful Catholic, so when I have sex with a prostitute, I don't use a condom. If only the Pope would let me use a condom, I would not be in danger of contracting HIV. But because I am Catholic, I will probably die of AIDS."

Catholics and Jews (and many others) present to the world a comprehensive teaching about sexuality. This teaching denies that consequence-free sex is possible. Sex is powerful. Used correctly, it builds up people, families, and cultures. Used carelessly it destroys. We are surrounded here by the destruction caused by careless sex. Certainly it shows up in HIV statistics, but that is just the tip of the iceberg. You would not believe the things that are common here. My students and friends live lives that sound like soap opera plots, with all of the interpersonal viciousness seen in those stories plus a lot more physical suffering and quite a few murders and suicides. Even if condom promotion did protect people from HIV, it would not protect them from this suffering that has already marked many of their families. Like you, I want to see people prosper. I want them to know the joys of family life that I experience. I see no conflict between proposing the beauty of the Catholic teachings on sexuality and saving lives.

If my students don't choose to pursue that beauty, there is no lack of condoms. It is easier to find free condoms in Mbabane (the nearest town) than it is to find free toilets. In fact, one can get free condoms from the shop across the street from the school. But fulfillment in life is not found in using sex to get access to the ever-popular 3 C's (cash, a car, and a cell phone). Nor is it found in the arms of a prostitute. Nor in learning to use others and get used by others. And that is what too many of my students pursue. Until about 2 years ago, the HIV prevention efforts here were not willing to address these issues. "Use a condom every time!" was their only message and the trail of death and destruction has been unspeakable. Expats are quietly wondering if Swazis will continue to exist as a people, as are the writers of the report on the most recent census.

To me it seems that my choices are clear: parrot the "condom gospel" and get more of the same results we have seen in the last 17 years, or clearly point people to a different way--a way to fulfilling life. "I have set before you life and death, blessing and curse; therefore choose life, that you and your descendants may live." I want life--for me and my children. I am not willing to encourage my students to settle for anything less than what I want for myself.

Perhaps this comes across strong. Two weeks ago I was at the burial of four young men. I dug the grave for one of my co-workers last weekend. Sunday (yesterday) we learned that the baby of a young girl who we know died suddenly. Monday morning I learned that a student who graduated in 2007 was found dead, hanging by her neck. Later in the day I found out about a suicide attempt by a friend's brother. I am tired of unnecessary deaths. Please read the articles below. Maybe then you can understand why I don't see emphasizing abstinence and faithfulness far ahead of condoms (as Uganda did with success early on) as heartless and lethal ideology.

Sincerely,
Rudy Poglitsh





http://www.washingtonpost.com/wp-dyn/content/article/2009/03/27/AR2009032702825.html
The Pope May Be Right

By Edward C. Green
Sunday, March 29, 2009; Page A15

When Pope Benedict XVI commented this month that condom distribution isn't helping, and may be worsening, the spread of HIV/AIDS in Africa, he set off a firestorm of protest. Most non-Catholic commentary has been highly critical of the pope. A cartoon in the Philadelphia Inquirer, reprinted in The Post, showed the pope somewhat ghoulishly praising a throng of sick and dying Africans: "Blessed are the sick, for they have not used condoms."

Yet, in truth, current empirical evidence supports him.

We liberals who work in the fields of global HIV/AIDS and family planning take terrible professional risks if we side with the pope on a divisive topic such as this. The condom has become a symbol of freedom and -- along with contraception -- female emancipation, so those who question condom orthodoxy are accused of being against these causes. My comments are only about the question of condoms working to stem the spread of AIDS in Africa's generalized epidemics -- nowhere else.

In 2003, Norman Hearst and Sanny Chen of the University of California conducted a condom effectiveness study for the United Nations' AIDS program and found no evidence of condoms working as a primary HIV-prevention measure in Africa. UNAIDS quietly disowned the study. (The authors eventually managed to publish their findings in the quarterly Studies in Family Planning.) Since then, major articles in other peer-reviewed journals such as the Lancet, Science and BMJ have confirmed that condoms have not worked as a primary intervention in the population-wide epidemics of Africa. In a 2008 article in Science called "Reassessing HIV Prevention" 10 AIDS experts concluded that "consistent condom use has not reached a sufficiently high level, even after many years of widespread and often aggressive promotion, to produce a measurable slowing of new infections in the generalized epidemics of Sub-Saharan Africa."

Let me quickly add that condom promotion has worked in countries such as Thailand and Cambodia, where most HIV is transmitted through commercial sex and where it has been possible to enforce a 100 percent condom use policy in brothels (but not outside of them). In theory, condom promotions ought to work everywhere. And intuitively, some condom use ought to be better than no use. But that's not what the research in Africa shows.

Why not?

One reason is "risk compensation." That is, when people think they're made safe by using condoms at least some of the time, they actually engage in riskier sex.

Another factor is that people seldom use condoms in steady relationships because doing so would imply a lack of trust. (And if condom use rates go up, it's possible we are seeing an increase of casual or commercial sex.) However, it's those ongoing relationships that drive Africa's worst epidemics. In these, most HIV infections are found in general populations, not in high-risk groups such as sex workers, gay men or persons who inject drugs. And in significant proportions of African populations, people have two or more regular sex partners who overlap in time. In Botswana, which has one of the world's highest HIV rates, 43 percent of men and 17 percent of women surveyed had two or more regular sex partners in the previous year.

These ongoing multiple concurrent sex partnerships resemble a giant, invisible web of relationships through which HIV/AIDS spreads. A study in Malawi showed that even though the average number of sexual partners was only slightly over two, fully two-thirds of this population was interconnected through such networks of overlapping, ongoing relationships.

So what has worked in Africa? Strategies that break up these multiple and concurrent sexual networks -- or, in plain language, faithful mutual monogamy or at least reduction in numbers of partners, especially concurrent ones. "Closed" or faithful polygamy can work as well.

In Uganda's early, largely home-grown AIDS program, which began in 1986, the focus was on "Sticking to One Partner" or "Zero Grazing" (which meant remaining faithful within a polygamous marriage) and "Loving Faithfully." These simple messages worked. More recently, the two countries with the highest HIV infection rates, Swaziland and Botswana, have both launched campaigns that discourage people from having multiple and concurrent sexual partners.

Don't misunderstand me; I am not anti-condom. All people should have full access to condoms, and condoms should always be a backup strategy for those who will not or cannot remain in a mutually faithful relationship. This was a key point in a 2004 "consensus statement" published and endorsed by some 150 global AIDS experts, including representatives the United Nations, World Health Organization and World Bank. These experts also affirmed that for sexually active adults, the first priority should be to promote mutual fidelity. Moreover, liberals and conservatives agree that condoms cannot address challenges that remain critical in Africa such as cross-generational sex, gender inequality and an end to domestic violence, rape and sexual coercion.

Surely it's time to start providing more evidence-based AIDS prevention in Africa.

The writer is a senior research scientist at the Harvard School of Public Health.

This is from a question posed to Edward Green by the Templeton Foundation (or something like that; I forget the complete title) about western aid.

http://www.templeton.org/questions/africa/essay_green.html
By now we should have learned. Donor nations have spent billions of dollars for development schemes in post-colonial Africa, yet there is little to show for this beyond dependency and corruption. Yet current policy and sentiment seem to advocate more of the same. Pop music and movie stars join celebrity academics in trying to shame wealthy nations into committing ever-expanding funds to address African poverty and ill health. This grand scheme mentality has remained immune from the feedback that failed programs ought to have provided. As for the intended beneficiaries, we find a psychological colonialism that has brainwashed the poor into believing the solutions to their problems are to be found in the technical know-how and largesse of wealthy countries. A recent book, The White Man’s Burden, by William Easterly, challenges "utopian social engineering" by international development experts he calls planners, for whom poverty is an engineering problem with technical solutions only they can concoct. Needed instead are searchers, who go to Africa with humility, open minds, and ability, to learn and discern what works and what doesn’t in different cultural settings.

Public health is one of the few areas of development that has achieved some genuine, sustained results. Yet we need only examine the Western response to AIDS, one of Africa’s worst problems, to see replication of every mistake made by planners over the past half-century. Evidence is mounting that the Western biomedical model of AIDS prevention – condoms, antibiotics for sexually transmitted infections, and testing people for HIV infection – has been largely ineffective in Africa. More recently, billions of dollars has gone into treating AIDS with expensive antiretroviral drugs, an unprecedented public health intervention with as-yet unknown effects on the future of the pandemic. Availability of these drugs has not reduced the rate of new HIV infections in the U.S.

African AIDS is driven primarily by those men and women who have multiple, concurrent sexual partners. The global prevention model focuses on medical devices and does not actively promote partner reduction, or even address multipartner sex – dismissing this inaccurately as an abstinence-only scheme. Yet, largely before Western technical advisors showed up, Uganda developed its own response to AIDS based on common sense, sound public health principles, and cultural/religious compatibility. Its emphasis on partner reduction (zero grazing) was appropriate to the type of generalized epidemic Uganda faced. HIV prevalence fell by an unprecedented two-thirds between 1992–2004. The cost? During the early years of major behavior change, $0.23 per person, per year. Meanwhile, the AIDS prevention investment per capita in South Africa and Botswana, where Western-favored approaches are funded, is hundreds of times higher. Yet these countries have among the highest HIV prevalence anywhere and it has been difficult to demonstrate the impact of these expensive programs on HIV infection rates, where it counts. Alas, most Western donors seem to have learned nothing from all this. Until the reasons for this are examined openly and objectively, the wealthy nations are likely to continue repeating the mistakes of the past.

Edward Green is the director of the AIDS Prevention Research Project at Harvard’s Center for Population and Development Studies.


Here is an article by Green from First Things magazine. It was free on their website at that time. It is where I first heard of his work.

http://www.firstthings.com/article.php3?id_article=6172
AIDS and the Churches: Getting the Story Right
by Edward C. Green and Allison Herling Ruark

Copyright (c) 2008 First Things (April 2008).

Responses to the global HIV/AIDS epidemic are often driven not by evidence but by ideology, stereotypes, and false assumptions. Referring to the hyperepidemics of Africa, an article in The Lancet this fall named “ten myths” that impede prevention efforts—including “Poverty and discrimination are the problem,” “Condoms are the answer,” and “Sexual behavior will not change.” Yet such myths are held as self-evident truths by many in the AIDS establishment. And they result in efforts that are at best ineffective and at worst harmful, while the AIDS epidemic continues to spread and exact a devastating toll in human lives.

Consider this fact: In every African country in which HIV infections have declined, this decline has been associated with a decrease in the proportion of men and women reporting more than one sex partner over the course of a year—which is exactly what fidelity programs promote. The same association with HIV decline cannot be said for condom use, coverage of HIV testing, treatment for curable sexually transmitted infections, provision of antiretroviral drugs, or any other intervention or behavior. The other behavior that has often been associated with a decline in HIV prevalence is a decrease in premarital sex among young people.

If AIDS prevention is to be based on evidence rather than ideology or bias, then fidelity and abstinence programs need to be at the center of programs for general populations. Outside Uganda, we have few good models of how to promote fidelity, since attempts to advocate deep changes in behavior have been almost entirely absent from programs supported by the major Western donors and by AIDS celebrities. Yet Christian churches—indeed, most faith communities—have a comparative advantage in promoting the needed types of behavior change, since these behaviors conform to their moral, ethical, and scriptural teachings. What the churches are inclined to do anyway turns out to be what works best in AIDS prevention.

This good news is often lost on organizations that purport to represent churches and the faith-based response to AIDS. The Berkley Center at Georgetown University, for instance, issued a report late last year called Faith Communities Engage the HIV/AIDS Crisis. The report is worth taking seriously, as it reflects the thinking of many international organizations, including many of the faith-based organizations that respond to AIDS. This thinking is often drastically out of sync with the culture and values of the beneficiaries. The Georgetown report claims to explore “development issues from the perspective of faith institutions,” but in fact the report betrays a deep ambivalence about whether faith communities, particularly Christian churches, are part of the problem or part of the solution to AIDS.

Katherine Marshall and Lucy Keough, lead authors of the report, are clearly uncomfortable with approaches to HIV prevention that emphasize sexual responsibility, behavior change, and morally based messages. They praise the work and compassion of faith communities in treating and caring for people ­living with AIDS and their families, yet harshly ­criticize the messages of faith communities for increasing the stigma of AIDS. Their discomfort with attempts to change sexual behavior is evident early in the report, when, for example, they muse: “Should the focus be on changing the behaviors that contribute to HIV/AIDS? (Is that possible? Desirable? How? With what assurance?)”

If Marshall and Keough are undecided as to whether changing sexual behavior is even desirable in the context of an epidemic driven by people who have more than one sex partner, they then need to become educated in the basic epidemiology of HIV transmission. One must ask whether they are more concerned with upholding a Western notion of sexual freedom or with saving lives. Their concern over any prevention approach that might be “moralistic” causes them to miss entirely the evidence for the remarkable success of sexual-behavior change in reducing HIV infections. They miss, as well, the crucial contribution of faith communities to HIV prevention, even while they are producing a report on the role of faith communities in the HIV crisis.

Marshall and Keough reflect conventional wisdom when they blame poverty, gender inequality, powerlessness, and social instability for the spread of AIDS. Yet epidemiological evidence is increasingly challenging this wisdom. In Africa, for instance, the wealthy are more likely to be HIV-infected (as a 2007 study in AIDS and a 2005 report in The Lancet have both noted). The countries of southern Africa are both the wealthiest on the continent and the worst affected. Meanwhile, within many countries, the wealthy are most likely to be HIV-infected—and, surprisingly, it is often among women that the greatest difference in HIV prevalence between poor and wealthy is seen. For instance, in Tanzania, women in the wealthiest quintile of the population are more than four times more likely to be infected than women in the poorest quintile. Poverty may make some individuals prone to risky sexual behaviors that can spread HIV; yet wealth can facilitate lifestyle choices that increase HIV risk, such as living in an urban area, abusing alcohol, and having the mobility and opportunity to acquire extramarital sexual partners.

While gender inequality may severely circumscribe a woman’s right to choose or refuse sex, and while faithful women can be and are infected by their husbands, new data are showing that women also bring HIV into marriage, putting husbands at risk. Last year the researcher Damien de Walque showed that, for 30 to 40 percent of infected couples in five African countries, the woman alone was infected. Vinod Mishra similarly reported that in some African countries, among couples in which one partner was infected and the other was not, the woman, not the man, was infected in more than half of couples. Both studies conclude that women’s extramarital sex must be the predominant factor behind these surprisingly high rates of female-­discordant couples—and thus “be faithful” messages must be targeted to women as well as to men.

Although turmoil and instability may make people more vulnerable to HIV, it does not follow that an HIV-prevention strategy aimed at changing sexual behavior is doomed in circumstances of turmoil and instability. Many of the greatest successes in HIV prevention have been in situations of social, political, and economic turmoil, such as Uganda in the late 1980s and Zimbabwe in the early 2000s. Experts predicted that the HIV epidemic would explode in Rwanda, but it did not, in spite of extreme violence and instability and tremendous numbers of rapes. Sexual behavior in Rwanda has remained conservative, and, at 3 percent, HIV prevalence is low for the region.

Of course, many other reports—and more alarmingly, peer-reviewed articles—make the same mistake of repeating conventional wisdom that does not stand up to scientific scrutiny. But the report from Georgetown is guilty not only of poor epidemiology but also of ignoring the perspectives of faith institutions that it claims to put forth. Fortunately, faith communities seem to be going forward with what they can address—influencing sexual behaviors and norms in their own parishes and communities—and not heeding the warnings of experts that such efforts are doomed as long as poverty, gender inequality, and less-than-ideal political and economic conditions persist. But the blessing and backing of the AIDS establishment would surely energize this work.

Uganda provides an illustrative example of the central role of faith communities (among others) in bringing about behavior change. In a sidebar in Faith Communities Engage the HIV/AIDS Crisis, Marshall and Keough give credit to the work of faith communities in Uganda, but they get most of the story wrong. Their account emphasizes the role of increased condom use in bringing down Uganda’s HIV rates and downplays the dramatic increases in the number of people reporting abstinence and faithfulness behaviors. In making their case, Marshall and Keough cite a little-known (and non-peer-reviewed) World Bank report written by Keough herself, and they ignore the wealth of peer-reviewed literature showing that the critical factor in Uganda was not increased condom use but reductions in the number of sexual partners.

The list of countries that have seen both changes in sexual behaviors and declining HIV prevalence is growing and now includes Uganda, Kenya, Haiti, Zimbabwe, Thailand, and Cambodia, as well as urban areas of Ivory Coast, Ethiopia, Zambia, and Malawi. Many countries that have not seen declines in HIV have seen increases in condom use, but in every country worldwide in which HIV has declined there have been increases in levels of faithfulness and usually abstinence as well.

Arguably, every community and institution has been guilty of some fear, stigma, discrimination, and marginalization of those living with HIV. No faith community, including the Catholic Church, should claim to be immune, and, where stigma and fear exist, they should be openly admitted and confronted. Yet the Georgetown report treats faith communities particularly harshly, claiming that churches impose “retribution for ‘sinful behavior’” and that “religion has been used to foster stigma, exclusion, and marginalization related to HIV/AIDS.” Indeed, the report continues, “faith hierarchies, leaders, and communities have in the past often been promoters of stigma associated with HIV and AIDS, partly because of their difficulty in confronting aspects of human sexuality and partly because they often assume a link between AIDS and what they regard as sinful activities.”

Faith communities are, in fact, facing the challenge of upholding orthodox beliefs about sexuality without contributing to stigma. Rather than accurately reporting this, however, Marshall and Keough offer only their own perspective, insisting that religious beliefs about sexuality are “values structures” that “have tended to perpetuate stigmatization.”

This language is reminiscent of the campaign that appeared immediately after the Fourteenth International AIDS Conference in Barcelona in 2002. Such comments as “Religion kills” and “The only good priest is the priest who distributes condoms” flooded many of the more ideologically driven HIV/AIDS email listservs and online discussion groups. Within the international community, a religious group’s willingness to promote condoms was the unsubtle litmus test for funding in AIDS prevention until the United States Congress changed the discriminatory practice by law in 2003.

In Faith Communities Engage the HIV/AIDS ­Crisis, Marshall and Keough make a particular effort to discredit the ABC approach for preventing the sexual transmission of HIV ( Abstain, Be faithful, or use Condoms). They write, “Many faith-based groups, like many governments, have been attracted to an approach to HIV/AIDS prevention, first articulated in Uganda, that has come to be known as the ABC model. . . . While aspects of this approach are incontrovertibly effective in reducing the spread of HIV/AIDS, the current consensus is that it does not go far enough.”

Whose consensus, one must ask? Are the authors truly representing the consensus of the world’s faith communities, or rather the consensus of a public-health community that is deeply uncomfortable with an approach that calls, in a simple and straightforward manner, for sexual responsibility? A more cynical view is that simple behavior changes such as mutual fidelity do little to contribute to a robust and ever-expanding multibillion-dollar “risk-reduction” AIDS industry focused on medical services, drugs, and devices such as condoms while leaving the true driver of the pandemic, sexual behavior, alone.

Since the beginning of the global epidemic, most AIDS programs have been designed solely with high-risk groups in mind. Risk reduction seems to have had some success among high-risk groups. (Although, in certain groups, such as American gay men, HIV is once again rising.) But a risk-reduction approach ignores a central epidemiological fact: The great majority of people worldwide are not at much risk for HIV infection, which in fact does not occur easily. Thus, encouraging the majority to maintain low-risk behaviors is the great missing piece of AIDS prevention.

The criticisms that Faith Communities Engage the HIV/AIDS Crisis levies against the ABC approach are hardly original and do not face up to the evidence that this approach has proved effective in various settings—so much so that it was endorsed by a landmark 2004 statement in The Lancet signed by more than 150 public health experts and leaders from around the world. Marshall and Keough claim that an ABC approach is insufficient because it does not ­recognize the role of voluntary counseling and testing (a measure that has been shown to have no effect in preventing new HIV infections, however important it is as a gateway to treatment); does not address prevention of mother-to-child transmission (a matter that the ABC approach, which targets sexual transmission, makes no claims to address); does not address the care of orphans and vulnerable children (clearly also beyond the scope of a prevention approach); and does not address women’s risk of becoming infected even if they do practice faithfulness. This is akin to criticizing smoking-cessation programs because they do not ­provide chemotherapy for those suffering from lung cancer or do not impose regulations on secondhand smoke and air pollution.

The Georgetown report clearly gets it wrong when it states that, for the ABC approach “to be effective, abstinence and fidelity must be practiced by both partners.” In fact, abstinence is always 100 percent effective in preventing sexual transmission when practiced by an individual. As for fidelity, it is certainly true that sexually faithful people may be infected by unfaithful partners—but this is true for men as well as for women. Proponents of the ABC approach do not claim that it confers total protection—for one thing, even consistent condom use reduces risk by, at best, 80 to 90 percent. Yet people (even women whose husbands are unfaithful) can reduce their own risk by choosing to practice faithfulness. More important, when ABC behaviors are promoted at a population level, risky ­sexual behaviors (particularly multipartner sex) are reduced, and a population-level decline in HIV infections is seen.

Marshall and Keough promote the SAVE approach, developed by ANERELA+, a network of African clergy led by Gideon Byamugisha. ( SAVE stands for Safe sexual practices, Access to treatment, Voluntary counseling and testing, and Empowerment.) “The objective in developing such a new approach,” the authors explain, “is to move away from judgmental, moralizing stigma, and towards a more positive approach.” The problem with SAVE, however, is that three of the four components have already been demonstrated to have no effect on reducing new HIV infections. Only the S, safe sexual practices, truly addresses prevention—and in a sufficiently vague way that it provides no clear call for changes in sexual behavior that will actually reduce transmission. Moreover, in the AIDS world, “safe sex” is understood to mean condom use. Criticizing the ABC approach has evidently been something of a crusade for Byamugisha, an Anglican priest, as he has made clear in multiple public statements. Byamugisha does not represent the views of most Ugandan or African clergy, and the SAVE approach is more a political statement than a guide to AIDS prevention.

The Georgetown report tells us: “While the ‘mainstream’ HIV/AIDS program and global communities accept that widespread availability of condoms and promotion of condom use are major elements in successful HIV/AIDS prevention strategies, a focus on condoms is contentious for some religious communities because it contradicts the core recommended strategy of abstinence before marriage and faithfulness within marriage.”

In fact, the mainstream HIV/AIDS community has continued to champion condom use as critical in all types of HIV epidemics, in spite of the evidence. While high rates of condom use have contributed to fewer infections in some high-risk populations (prostitutes in concentrated epidemics, for instance), the situation among Africa’s general populations remains much different. It has been clearly established that few people outside a handful of high-risk groups use condoms consistently, no matter how vigorously condoms are promoted. Inconsistent condom usage is ineffective—and actually associated with higher HIV infection rates due to “risk compensation,” the tendency to take more sexual risks out of a false sense of personal safety that comes with using condoms some of the time. A UNAIDS-commissioned 2004 review of evidence for condom use concluded, “There are no definite examples yet of generalized epidemics that have been turned back by prevention programs based primarily on ­condom promotion.” A 2000 article in The Lancet similarly stated, “Massive increases in condom use world-wide have not translated into demonstrably improved HIV control in the great majority of countries where they have occurred.”

Faith communities are not shutting their eyes to evidence when they choose to emphasize the “core recommended strategy of abstinence before marriage and faithfulness within marriage.” These behaviors have, in fact, proved far more effective than condom use in curbing HIV transmission for the vast majority of any population. A 2001 study of condom use in rural Uganda found that only 4.4 percent of the population reported consistent usage in the previous year, a rate that is probably typical of much of Africa. In contrast to the estimated 95 percent or more of Africans who did not practice consistent condom use in the past year, studies from all over Africa show a solid majority of men and women reporting fidelity over the past year, with a majority of unmarried young men and women reporting abstinence.

The Georgetown report devotes several paragraphs to the position of the Catholic Church on condom usage and the apparent “nuance” within Catholic communities on the issue. The report seems to imply that the Church’s teaching on condom usage is detrimental to the fight against AIDS, while recognizing the Church’s contribution to prevention through promotion of abstinence and faithfulness. (For instance, the authors note that Pope John Paul II chose to emphasize abstinence and faithfulness rather than directly criticizing condom use.)

The report also erroneously claims that Protestant evangelicals are “among the staunchest supporters of the U.S. Government PEPFAR (President’s Emergency Plan for AIDS Relief) earmark for ‘abstinence only’ prevention programs.” This is mistaken. There is no such “abstinence only” earmark within PEPFAR, nor are the great majority of Protestant groups who receive PEPFAR funds implementing abstinence-only programs. Current PEPFAR guidance recommends that two-thirds of funds for the prevention of sexual transmission of HIV be allocated to abstinence-until-marriage and faithfulness or partner-reduction programs. This amounts to less than 7 percent of PEPFAR funds. Among recipients of these funds, faith-based organizations such as World Vision, World Relief, and Samaritan’s Purse implement programs that emphasize abstinence and faithfulness but also include accurate information on condoms—in other words, a comprehensive ABC approach, the approach known to work best.

Marshall and Keough are right to call faith communities to action in defending the rights of women and protecting women and girls from violence, coercion, and exploitation. Yet the presence of gender inequality does not negate the need for, and effectiveness of, approaches that focus on sexual responsibility and behavior change. On the contrary, central to faithfulness interventions—as stated clearly in the PEPFAR Guidance document for implementing “B” programs within a context of ABC—is the focus on changing male behavior in particular.

If protecting highly vulnerable women and girls in patriarchal societies is a genuine goal rather than a political posture, then there must be explicit strategies for discouraging men from sexual abuse, rape, infidelity, and seduction of minor females. Furthermore, women must be empowered to refuse unwanted sex (as one of us, Edward Green, has been arguing in publications since 1988), not simply to “negotiate condom use.”

Thus far, research has produced no evidence that condom promotion—or indeed any of the range of risk-reduction interventions popular with donors—has had the desired impact on HIV-infection rates at a population level in high-prevalence generalized epidemics. This is true for treatment of sexually ­transmitted infections, voluntary counseling and ­testing, diaphragm use, use of experimental vaginal microbicides, safer-sex counseling, and even income-­generation projects. The interventions relying on these measures have failed to decrease HIV-infection rates, whether implemented singly or as a package. One recent randomized, controlled trial in Zimbabwe found that even possible synergies that might be achieved through “integrated implementation” of “control strategies” had no impact in slowing new infections at the population level. In fact, in this trial there was a somewhat higher rate of new infections in the intervention group compared to the control group.

The one medical intervention that has now been proven effective according to the highest standards of scientific research is male circumcision, which reduces a man’s risk of HIV transmission by more than half. Lack of male circumcision, along with high rates of long-term concurrent sexual partnerships, likely accounts for the hyperepidemics of southern Africa. But even many advocates of male circumcision believe that it needs to be promoted along with partner ­reduction.

Meanwhile, the other interventions that have generally been called “best practices” simply do not seem to work in generalized epidemics, even though they are still applauded loudly at global AIDS conferences, while mention of fidelity and abstinence is received by booing, as Bill Gates discovered at the International AIDS Conference in Toronto in 2006. If we are to progress beyond science-by-popular-acclaim, we must accept that the evidence is much stronger for fidelity or partner reduction than for any of the standard-package HIV-prevention measures—in Africa at least—and so we need to rethink and reprogram AIDS-prevention interventions.

Admittedly, changing direction is hard when there has been massive investment in these “best practices.” It is not in the interest of a multibillion-dollar global AIDS industry to endorse interventions that are low-cost and homegrown and that rely on simple behavior change rather than medical products or services provided by outside experts. And so the major donors of AIDS programs continue to do the same things, expecting different results. The authors of the Georgetown report reflect this popular but misguided opinion, despite mounting evidence to the contrary.

That’s a shame, for a report like Faith Communities Engage the HIV/AIDS Crisis offered an opportunity to rethink the failing group consensus and to point toward the central fact that has emerged from all the recent studies of the HIV epidemic: What the churches are called to do by their theology turns out to be what works best in AIDS prevention.

Edward C. Green is the director of the AIDS Prevention Research Project at the Harvard Center for Population and Development Studies, where Allison Herling Ruark is a research fellow.

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1544373
AIDS Behav. 2006 July; 10(4): 335–346.
Published online 2006 May 11. doi: 10.1007/s10461-006-9073-y.

PMCID: PMC1544373
Copyright © Springer Science+Business Media, Inc. 2006
Uganda's HIV Prevention Success: The Role of Sexual Behavior Change and the National Response
Edward C. Green,1 Daniel T. Halperin,corresponding author2,5 Vinand Nantulya,3 and Janice A. Hogle4
1Harvard University School of Public Health, Boston, Massachusetts USA
2AIDS Research Institute, University of California, San Francisco, California USA
3Global Fund for AIDS, Tuberculosis and Malaria, Geneva, Switzerland
4Family Health International, Arlington, Virginia USA
5NERCHA, Mbabane, Swaziland, South Africa
Daniel T. Halperin, Email: dhalp@worldwidedialup.net.
corresponding authorCorresponding author.
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>Abstract
INTRODUCTION
HIV PREVALENCE DECLINE IN UGANDA
TRENDS IN DECLINING CASUAL/MULTIPLE SEXUAL PARTNERSHIPS
KEY ELEMENTS OF THE NATIONAL RESPONSE
LOWER LEVELS OF MULTIPLE PARTNERSHIPS AND REDUCED SEXUAL NETWORKS IN UGANDA COMPARED TO MANY OTHER AFRICAN COUNTRIES
CONCLUSION: A “SOCIAL VACCINE” FOR AFRICA?
AUTHOR'S CONTRIBUTIONS
References

Abstract
There has been considerable interest in understanding what may have led to Uganda's dramatic decline in HIV prevalence, one of the world's earliest and most compelling AIDS prevention successes. Survey and other data suggest that a decline in multi-partner sexual behavior is the behavioral change most likely associated with HIV decline. It appears that behavior change programs, particularly involving extensive promotion of “zero grazing” (faithfulness and partner reduction), largely developed by the Ugandan government and local NGOs including faith-based, women’s, people-living-with-AIDS and other community-based groups, contributed to the early declines in casual/multiple sexual partnerships and HIV incidence and, along with other factors including condom use, to the subsequent sharp decline in HIV prevalence. Yet the debate over “what happened in Uganda” continues, often involving divisive abstinence-versus-condoms rhetoric, which appears more related to the culture wars in the USA than to African social reality.

KEY WORDS: HIV-AIDS prevention, Africa, behavior change, ABC, partner reduction, multi-sectoral response.


INTRODUCTION
Much debate over HIV prevention has arisen in recent years. While both international and locally-based AIDS organizations continue to seek funds to scale up prevention efforts, researchers and policymakers have debated the meaning of Uganda's unprecedented HIV prevalence decline. One school of thought, including Stoneburner and Low-Beer (2004), Shelton et al.(2004), Hearst and Chen (2004), Green (2003), Wilson (2004), Epstein (2004, 2005b), and Cohen (2004), conclude that a
decrease in casual/multiple sexual partner behavior, rather than mainly condom use or increases in mortality, was primarily responsible for Uganda's success. Others have argued in favor of the more prevailing prevention approach that has centered on condom promotion and HIV testing as well as an array of broader structural factors, such as poverty, gender violence and conflict (Fenton, 2004; Halperin and Allen, 2000; Singh et al., 2003; Wawer et al., 2005; Shelton et al., 2005).
It is important to note that the behavior change-based analysis of the Uganda prevention success, much of it now published in leading scientific journals, has not argued that such broader factors, as well as condom use, were unimportant; rather, the argument has focused more on the relative impact of the different “ABC” factors (Abstinence, Being faithful and Condom use), especially in more generalized epidemics driven mainly by heterosexual transmission. Moreover, it is worth noting that most of the critics of the partner reduction-focused analysis likewise do not take extreme positions (i.e., condoms only, with no role for partner reduction), although it appears that some of these critics have, perhaps inadvertently, helped to re-polarize what has come to be called the ABC debate – a discourse which has often centered on divisive arguments between “A” versus “C” (Epstein, 2004, 2005b; Halperin et al., 2004; Shelton et al., 2004; Shelton, 2005; Wilson; 2004, Cohen, 2004).


HIV PREVALENCE DECLINE IN UGANDA
Uganda is considered by UNAIDS (2004) and others to be one of the world's earliest and most compelling national success stories in combating the spread of HIV. This paper attempts to understand, based on the available evidence, what may have happened to bring about a decline in HIV prevalence (and more to the point, HIV incidence) in Uganda, not only epidemiologically but, at least as importantly, programattically as well. The east African country has experienced a dramatic decline in prevalence during the past decade, especially among younger age cohorts. According to Ministry of Health and other data (Okware et al., 2001), prevalence among pregnant women attending antenatal clinics has declined consistently since the early 1990s at nearly all of the country's sentinel sites (see Fig. 1). Similarly large—and even earlier—declines have been observed among military recruits, blood donors and other population-level cohorts (Low-Beer, 2002; Stoneburner and Low-Beer, 2004). Although it is true that there have been some exaggerated estimates of prevalence decline, as noted even by the skeptic Parkhurst (2002), this does not detract from Uganda's genuine prevention success.
Fig. 1. Fig. 1.
HIV prevalence among pregnant women in Uganda. Source: HIV/AIDS surveillance report, STD/AIDS control programme, Ministry of Health, Uganda, June 2001.
While there is not much data available regarding trends in HIV incidence it also appears to have fallen significantly. In one rural site, Masaka, seroincidence fell from 7.6 per thousand per year in 1990 to 3.2 per thousand per year by 1998 (Mbulaiteye et al., 2002). As with prevalence, the decline was especially pronounced among younger women. At most Ugandan antenatal clinic sites, seroprevalence among 15–19-year-old pregnant women, somewhat of a rough proxy for HIV incidence, tended to decrease significantly from the early 1990s, when these data were first collected, until the mid to late 1990s and
it has remained low since then (although there has been an increase recently, for the first time in a decade). Population-based data from Masaka suggests that prevalence among all young women (ie, not only sexually active/pregnant females) ages 15–19 began declining by the end of the 1980s (Mbulaiteye et al., 2002).Based on such trends and the fact that national seroprevalence among pregnant women (of all ages) peaked in 1992 and furthermore that epidemiological analysis and modeling suggests there would have been a lag of several years between the initiation of behavior change/incidence decline (especially among men) and the subsequent prevalence decline (in pregnant
women) (Shelton et al., 2006), it is most probable that HIV incidence in Uganda peaked sometime during the late 1980s (Low-Beer, 2002; Stoneburner and Low-Beer, 2004; Shelton et al., 2004). Regarding HIV prevalence, the U.S. Census Bureau/Joint United Nations Programme on HIV/AIDS (UNAIDS 2004) estimates that national HIV prevalence for all adults peaked at around 15% in the early 1990s and fell to about 4% by 2003 (although a 2004 population-based survey found approximately 7% adult prevalence; Measure DHS 2005). This degree of national prevalence decline is unique worldwide and has been the subject of curiosity and controversy since the late-1990s and more recently has come under even more intense scientific scrutiny (Allen and Heald, 2004; Green, 2003; Parkhurst, 2002; Stoneburner and Low-Beer, 2004; Wawer et al., 2005). Observed consistently over time and across many different geographic and demographic populations, Uganda's falling HIV
prevalence is unlikely to be due merely to measurement bias or only to a “natural die-off syndrome,” but at least in large part to a number of behavioral changes that have been identified in various population-based surveys as well as qualitative studies. While some have postulated that the prevalence decline was primarily a result of so many people succumbing to the disease that the rate of new infections was simply outweighed by the numbers of AIDS deaths (e.g., Wawer et al., 2005), a
number of other African regions have experienced nearly as old—and at least as severe—epidemics as Uganda’s, yet prevalence has yet to decline substantially at the population level. Moreover, the large decline in prevalence among younger age cohorts in Uganda cannot be explained by AIDS mortality, as very few people under age 20 die of AIDS.

TRENDS IN DECLINING CASUAL/MULTIPLE SEXUAL PARTNERSHIPS
Given that HIV seroincidence probably peaked sometime in the late 1980s, it is important to compare data on sexual behavior from that period to subsequent findings from the 1990s. It is not particularly useful to compare mainly between the 1995 and 2000 Demographic and Health (DHS) surveys, as some analysts have proposed (e.g. Singh et al., 2002), since much of Uganda's prevention “miracle” appears to have occurred in the late 1980s and probably into the early 1990s. Thus, some of the widely
publicized conclusions of a recent study in Rakai district, focusing on HIV surveillance and behavioral trends after 1994 (Wawer et al., 2005), although of interest in explaining some more recent trends, are of little help in understanding the main historical HIV decline in Uganda (see Bessinger et al., 2003; Shelton, 2005; Mosley, 2005; footnote on Wawer et al. study in Epstein, 2005a).
Unfortunately, little HIV-related data was collected in the 1988/9 DHS survey (and no males were then surveyed). The WHO's Global Program on AIDS (GPA) surveys from 1988/9 and 1995, although not fully nationally representative (Bessinger et al., 2003), nonetheless did sample large numbers of people in the most HIV affected parts of the country. In the GPA surveys, the proportion of single males ages 15–24 reporting premarital sex decreased from 60% in 1989 to 23% in 1995. There were similarly large declines in the number of respondents in the GPA surveys reporting casual sex in the previous year, from 35 to 15% among men and from 16 to 6% among women. Furthermore–and this appears particularly critical given the epidemiological importance of multiple partnership/sexual networking dynamics (Bernstein et al., 1998; Halperin and Epstein, 2004; Shelton et al., 2004; Wilson, 2004; Auvert et al., 2000), the proportion of males reporting three or more non-regular partners fell
even more dramatically between 1989 and 1995 (Fig. 2). The particular significance of partner reduction trends in Uganda will be explored below.
Fig. 2. Fig. 2.
Changes in sexual behavior among men in Uganda. Source: WHO/GPA surveys, 1989 &1995.


KEY ELEMENTS OF THE NATIONAL RESPONSE
The relationships between the various behavior change interventions that were implemented in Uganda and the ensuing decline in HIV prevalence are complex and not yet completely understood. However, changes in age of sexual debut, casual and commercial sex trends, partner reduction and condom use all appear to have played key roles in the continuing declines. Although it is believed that HIV knowledge, risk perception and risk avoidance/risk reduction options can ultimately lead to reduced HIV incidence, there is a complex set of epidemiological, socio-cultural, political and other elements that likely
affected the course of the epidemic in Uganda. Many of these elements appear to be absent or less evident in those African countries that have not yet experienced significant national prevalence declines, such as South Africa, Botswana and Malawi (Allen and Heald, 2004; Bessinger et al., 2003; Cohen, 2004; Epstein, 2004; Green, 2003; Hearst and Chen, 2004; Stoneburner and Low-Beer, 2004). These key elements are summarized in roughly chronological order below:
High-Level Political Support and Multi-Sectoral Response
In 1986, after 15 years of civil strife, Uganda's new head of state President Yoweri Museveni responded to evidence of a serious emerging disease epidemic with a proactive commitment to prevention. In face-to-face interactions with Ugandans at all levels, he emphasized that fighting AIDS was a “patriotic duty” requiring openness, communication and strong leadership from the village level to the State House. His charismatic directness in addressing the threat placed HIV/AIDS on the development agenda and encouraged constant and candid national media coverage of all aspects of the epidemic,
including/emphasizing behavior change. This early, high-level support fostered a multi-sectoral response, prioritizing HIV/AIDS and enlisting a wide variety of national participants in the “war” against the decimating disease popularly known as “Slim” (Epstein, 2004; Green, 2003; Kaleeba et al., 2000).
In 1986, Uganda established a National AIDS Control Program (ACP) and the national sentinel surveillance system, which has tracked the epidemic since 1987, began with four sites and by 2000 included 15; also of importance, there has been surveillance of AIDS cases since 1986. Eventually, in 1992, the multi-sectoral Uganda AIDS Commission (UAC) was created to more closely coordinate and monitor the national AIDS strategy. The UAC prepared a National Operational Plan to guide
implementing agencies, sponsored task forces and encouraged the establishment of AIDS Control Programs in other ministries including Defense, Education, Gender and Social Affairs. As of 2001, there were also at least 700 agencies—governmental and nongovernmental—working on HIV/AIDS issues across all districts in Uganda (Kirby, 2003).

Decentralized Planning and Implementation for Behavior Change Communication
Beginning in 1986, the Ugandan ACP (which later became the STD/AIDS Control Program, in 1994) launched an aggressive public media campaign that included print materials, radio, billboards and community mobilization for a grass-roots offensive against HIV and has since then trained thousands of community-based AIDS counselors, health educators, peer educators and other types of specialists. Led by their leaders’ examples, the general population in both urban and rural areas eventually
also joined the fight against AIDS, so that it became a “patriotic duty” to support the effort. Spreading the word involved not just “information and education” but rather a fundamental behavior change-based approach to communicating and motivating. Decentralization itself was actually a type of local empowerment that involved local allocation of resources—in and of itself a motivating force (Kaleeba et al., 2000; Marum, 2002; Wilson, 2004).
Although media—both mass media (e.g., the ominous, daily drum-beating on the radio in the late 1980s, still vividly recalled by Ugandans; Kirby, 2003) as well as various locally developed forms such as community dramas—clearly were important vehicles for raising awareness and fostering changes in behavioral norms, Uganda's approach to behavioral change relied primarily on community-based and face-to-face communication (Allen and Heald, 2004; Stoneburner and Low-Beer, 2004; Wilson,
2004). Strong nongovernmental organization (NGO) and community-based support led to flexible, creative and culturally appropriate interventions that helped facilitate individual behavior change as well as changes in community norms, despite extreme levels of household poverty following the civil war period. Such “low-tech” approaches also led to the sensitization and subsequent involvement in AIDS awareness and education of not only health personnel, traditional healers and traditional
birth attendants, but influential people normally not involved in health issues such as political, community and religious leaders, teachers and administrators, traders, leaders of women's and youth associations and other representatives of key grassroots community groups (Green, 2003; Kirby, 2003; Wilson, 2004). One of the contributions of international donors such as USAID was in supporting community-level BCC by directly funding salaries or in-kind support of peer educators and others
at the local level (Marum, 2002). In other countries, community health workers and peer educators are often expected to work as volunteers, without salary (Green, 1996).
Sustained interpersonal communication interventions reached not only the general population, but also key target groups including female sex workers and their clients, soldiers, fishermen, long-distance drivers, traders, bar girls, police and students and without generally creating a highly stigmatizing climate. In comparing DHS data from the mid-1990s, Uganda stands out among all African countries for which such data exist, in the proportion of respondents who cite either friends, relatives, or community meetings as sources of AIDS information (99.2%). This rate is twice that of many African countries and it seems to be a measure of Uganda's interpersonal BCC strategy (Green, 2003; Kaleeba et al., 2000; Stoneburner and Low-Beer, 2004).

Religious Leaders and Faith-Based Organizations on the Front Lines
Mainstream faith-based organizations wield enormous influence in Africa. Early and significant mobilization of Ugandan religious leaders and organizations resulted in their active participation in AIDS education and prevention activities (Kaleeba et al., 2000; Kagimu et al., 1998; Kirby, 2003; Sabatier, 1988). Also, Mission hospitals were among the first to develop AIDS care and support programs in Uganda; for example, the Catholic Church and Catholic mission hospitals provided
leadership in designing AIDS mobile home care projects and special programs for AIDS widows and orphans (Kaleeba et al., 2000). The three chairpersons of the Uganda AIDS Commission have included an Anglican and a Catholic Bishop. In 1990, the Islamic Medical Association of Uganda (IMAU) piloted an AIDS education project in rural Muslim communities that evolved into a larger effort to train local religious leaders and lay community workers. Documenting increases in correct knowledge and
decreases in risky behaviors, the IMAU project was selected as a “Best Practices Case Study” by UNAIDS (Kagimu et al., 1998; UNAIDS, 1999; Wabwire-Mangen et al., 1998).
In the early 1990s, the Anglican Church implemented an AIDS prevention program in 10 out of (then) 40 districts of Uganda. Clergy and laity were trained in AIDS prevention, using a peer education approach. AIDS education messages were delivered from the pulpit in sermons, as well as at funerals, weddings and other occasions. A USAID-funded evaluation of populations reached by this “CHUSA” project found a dramatic change in reported levels of risky behavior, especially partner reduction,
during the early 1990s (Ruteikara et al., 1995). These survey findings were supported by focus group discussions involving community leaders and youth, where it was asserted that, for example, “Before the onset of AIDS, one could have five sexual partners, or even have sex on a chain basis, but these days you realize that there is a lot of self-constraint. Burials, people falling sick from AIDS and religious leaders have awakened people … The number of sexual partners has [been]
reduced.” (Ruteikara et al., 1995).

Addressing Women, Youth, and Stigma and Discrimination
Linked to high-level political support and grassroots-level communication for behavior change was a strong emphasis on greater empowerment of women and girls; targeting youth both in and out of school; and aggressively fighting stigma and discrimination against people living with HIV/AIDS (PLWHAs). Since 1987, the first year of the School Health Education Program, teachers have been trained to integrate HIV education and sexual behavior change messages into curricula (Green,
2003; Kaleeba et al., 2000). At the same time, the country's President and his political party have attempted to empower women and youth by giving them more political voice, including in Parliament where by law women make up a minimum one-third of the members (in addition to four members elected by youth caucuses). At least as importantly, grassroots women's organizations have fought to empower women socially, economically and legally. Their campaigns have resulted in legal
reforms pertinent to the fight against AIDS, including strengthening of rape and defilement laws and laws governing property rights for women.
With regard to behavior change, many women and women's empowerment organizations supported approaches like “Zero Grazing,” which were aimed mainly at the behavior of males, particularly those older men with disposable income who were likely the principal “core transmitters” of the epidemic (Green, 2003: 169–172, Wilson, 2004; Murphy et al., 2003). Youth-friendly approaches, such as Straight Talk, eventually supported behavior change through promoting delay of sexual debut, remaining abstinent, remaining faithful to one uninfected person if “you’ve already started,” “zero-grazing,” and using condoms if “you’re going to move around.” In an African Medical and Research Foundation study in Soroti District (n=400), in 1994 nearly 60% of boys and girls ages 13–16 reported having experienced intercourse, but in 2001 that proportion had decreased to below 5% (AMREF, 2001). While it is entirely possible that such a magnitude of self-reported behavior change is somewhat exaggerated, such findings–coupled with various other behavioral data–suggest that a substantial
shift in behavioral norms likely has occurred in Uganda. Respecting and protecting the rights of those infected by HIV has been central to AIDS prevention since 1988, exemplified by a number of prominent openly HIV-positive Ugandans and by public events such as candlelight memorials and World AIDS Day observances. In the late 1980s, Philly Lutaya, a celebrated European-based Ugandan musician who went public about his HIV status, returned home and devoted his last months of life to giving testimonies in schools, community organizations, churches and elsewhere. Of critical importance, The AIDS Support Organization (TASO) was organized in 1988 and has advocated
against discrimination and stigma while pioneering a community-based approach for care of PLWHAs. The work of TASO and other care organizations have also made important contributions to prevention efforts, exemplifying the concept of a prevention-to-care continuum. Other national spokespersons included a Major in the Ugandan army who talked openly about his infection and how he used condoms to avoid infecting his wife and a Protestant bishop who disclosed that he learned of his
infection when his first wife died and talked publicly about using condoms to avoid infecting his new wife or future children. Openness on the part of the President, other government and community leaders and prominent activists has led, relatively speaking, to a remarkably accepting and non-discriminatory response to AIDS, in stark contrast to the situation in most other African countries (Halperin, 2006). This is important to recognize because some critics of the “Uganda model” have
asserted that promotion of fundamental changes in sexual behavior will lead to more discrimination and AIDS associated stigma.

Africa's First Confidential Voluntary Counseling and Testing (VCT) Services
In 1991, the first AIDS Information Center (AIC) for anonymous VCT opened in Kampala. By the mid-1990s, AIC was increasingly active in several urban areas as people increasingly became interested in knowing their serostatus. AIC pioneered providing “same day results” using rapid HIV tests, as well as the concept of “Post-test Clubs” to provide long-term support for behavior change to anyone who had been tested, regardless of serostatus. Uganda was nearly unique in Africa in the emphasis
it placed on VCT, at a time when the WHO/GPA and other international organizations were not yet recommending it as a prevention strategy.
Although a three-country randomized trial of the effect of VCT on STI incidence found no biological effect, some people, especially those testing HIV-positive, reported behavior change (Coates et al., 2000; Moses et al., 2000). However, two rigorous reviews/meta-analyses of dozens of developing country studies (Glick, 2005; Weinhardt et al., 1999), as well as a literature review (Wolitski et al., 1997) suggest that while VCT can motivate positive behavior change in some people, especially among those who test HIV positive, most clients do not report significant changes in sexual behavior as a result of undergoing VCT. A recent large, population-based study in Rakai, Uganda similarly found essentially no behavior change—nor HIV incidence decline—associated with VCT (Matovu et al., 2005). In any case, widespread accessibility of VCT services did not exist in most of Uganda until relatively more recently, certainly well after HIV incidence began declining during the late 1980s/early 1990s period. While there is no evidence that VCT led directly to the national reduction in HIV
incidence, its increasing availability probably contributed to the overall environment of greater openness surrounding the disease (Marum, 2002), as well as generally to care and support, anti-stigma and prevention efforts in Uganda's successful response to AIDS.

Condom Promotion
Promotion of condom use was also not a central element in Uganda's earlier response to AIDS (1986–1991), certainly in comparison to many other countries in eastern and southern Africa (Epstein, 2004; Kaleeba et al., 2000; Stoneburner and Low-Beer, 2000, 2004; Hearst and Chen, 2004). In fact, until the early to mid 1990s, there was resistance on the part of President Museveni and some religious leaders to promoting condom use (Kaleeba et al., 2000). The first edition of a government handbook on AIDS prevention advised, “The government does not recommend using condoms as a way to fight AIDS.”
(UNICEF/Uganda, 1988: 32) (This language was later softened to state that one “can still get AIDS even if a condom is used.”) A recent analysis concluded that this initial antipathy toward condoms might, ironically, have helped promote more fundamental changes in behavior: “In Uganda, the fact that condoms were not initially introduced and also the president's negative attitude towards them, played a part in the social acceptance of sexual behavioral change messages” (Allen and
Heald, 2004, p. 1151). Condom social marketing, under the SOMARC project, began in 1991, but condom sales did not reach substantial levels until the later 1990s; Population Services International (PSI) began its more successful condom sales program in 1997. However, beginning in the early to mid-1990s, millions of condoms have been distributed by the Ministry of Health through health
centers and NGO projects, purchased mainly with external donor funding. In the DHS surveys, ever-use of condoms reported by women increased from 1% in 1989 to 6% in 1995 and 16% in 2000. Male ever-use of condoms was 16% in 1995 and 40% in 2000. Nearly all of the decline in HIV incidence (and much of the decline in prevalence) had already occurred by 1995 and, furthermore, epidemiological analysis including some modeling exercises suggest that very high levels of consistent condom use would be necessary to achieve significant reductions of prevalence in a generalized-level epidemic (Bernstein et al., 1998; Hearst and Chen, 2004; Robinson et al., 1995; Stover, 2002). According to the 1995 DHS, about 6% of sexually active Ugandans used a condom with some regularity (condom use, last intercourse with any partner). This proportion rose to 11% of
sexually active Ugandans, or 8% of all Ugandan adults, by 2000 (Macro International, 1995, 2001). However, these low figures obscure the fact that condom use has now become quite high among those people who need them most, namely those still having multiple partners: in the 2000 DHS, 59% of men and 38% of women who reported having a non-regular partner said they had used a condom during last sex with such partners. (see the 2004 Uganda HIV/AIDS Sero-Behavioral Survey, DHS, 2005.) Condom use had reportedly risen to nearly 100% among commercial sex workers in Kampala by the late 1990s (Asiimwe-Okiror et al., 1998). While condom sales and reported use have increased significantly during the past decade, it is noteworthy that condom use in high risk sex was not higher in Uganda than levels found in other countries in the region (Stoneburner and Low-Beer, 2000,
2004), including some that have considerably higher levels of HIV. And using a measure of condom use in the general population, namely condom use at last sex with any partner, among those sexually active, current levels in Uganda are actually lower than in several other countries in the region, including some with higher HIV prevalence rates (Measure DHS; Hearst and Chen, 2004). That said, the experience of Uganda also suggests the need for widespread availability of condoms to
both “high risk” groups as well as the sexually active general population (Cohen, 2004; Halperin et al., 2004; Kirby, 2003; Shelton et al., 2004).

LOWER LEVELS OF MULTIPLE PARTNERSHIPS AND REDUCED SEXUAL NETWORKS IN UGANDA COMPARED TO MANY OTHER AFRICAN COUNTRIES
By the mid-1990s, in general Ugandans had considerably fewer non-regular sexual partners across all age groups. Population-level sexual behavior, including the proportion of people reporting more than one partner, were comparable in Kenya (1998), Zambia (1996) and Malawi (1996), for example, to levels reported in Uganda back in 1988–1989 (Stoneburner and Low-Beer, 2004). In comparison with men in these countries, Ugandan males in 1995 were less likely to have ever had sex (in the 15–19-year-old range), more likely to be married and to keep sex within the marriage and much less likely to have multiple partners, particularly if never married. Strikingly, the proportion of men reporting three or more non-regular partners in the previous year fell from 15 to 3% between the 1989 and 1995 GPA surveys. The latter figure was identical in both that GPA survey and the 1995 Uganda DHS (Bessinger et al., 2003). This apparently radical shift in behavior (even if the exact magnitude of change is uncertain due to sample size limitations, etc.) suggests a rather dramatic shift in behavioral trends within the important “core transmitter” population of men with multiple sexual partners (Bernstein et al., 1998; Epstein, 2004; Shelton et al., 2004; Auvert et al., 2000).
Such reported behavioral changes are consistent with the dominant AIDS prevention messages of Uganda's early response (i.e., 1986–1991), specifically: “stick to one partner,” and the ubiquitous “love faithfully” and “zero-grazing” admonitions readily understood even by the many illiterate residents of this largely rural nation. Such changes also seem related to the aforementioned more open personal communication networks for acquiring AIDS knowledge, which have been argued to more
effectively personalize risk and thereby result in greater levels of behavior change (Allen and Heald 2004; Low-Beer et al., 2000). Comparing DHS survey data with that from other African countries, Ugandans are considerably more likely to receive AIDS information through friendships and other personal networks than through mass media or other sources and are significantly more likely to know of a friend or relative with AIDS (Stoneburner and Low-Beer, 2004).

CONCLUSION: A “SOCIAL VACCINE” FOR AFRICA?
Many of the elements of Uganda's response, such as high-level political support, decentralized planning and multi-sectoral organization, do not affect HIV infection rates directly. Rather, sexual behavior itself must change in order for seroincidence to change. The “ABC” factors are what can be termed proximate determinants of sexually transmitted HIV infection, i.e, means of avoiding or reducing the risk of infection. One lesson from Uganda seems to be: address the ABC factors through multiple interventions and do this through the means exemplified (and often pioneered) by Uganda: empowering
women, mobilizing PLWAs and involving them in prevention, fighting stigma, involving faith-based organizations and the like. Another important element may have been the deliberate policy of fear arousal in order to combat denial, dramatize that AIDS is real and provoke Ugandans to feel at personal risk of HIV infection, unless they were willing to change behavior. The first director of TASO recounted, “Most of these initial campaigns adopted a ‘fear approach’ to HIV prevention, based on the
theme: “Beware of AIDS. AIDS kills” (Kaleeba et al., 2000: 12). Members of the AIDS Control Programme involved in the early days of the ACP likewise recounted, “At first, we focused on instilling fear in the population…”, after which options for avoidance of risk were promoted, starting with “avoidance of sexual contacts” (Okware et al., 2001: 1114). In short, the strategy was to instill fear of the consequences of AIDS, engendering a perception of personal vulnerability to HIV
infection, while at the same time clearly providing ways to avoid the feared outcome (Kirby, 2003; Green and Witte, 2006; Wilson, 2004) as well as working vigorously to reduce HIV-related stigma (Halperin, 2006). According to modeling by Stoneburner and Low-Beer (2004), behavior change, particularly partner reduction, since the late 1980s in Uganda appears to have had a similar impact as a potential medical vaccine of 80% efficacy. The historical and socio-cultural context, the various interventions and other factors are complex and may have been somewhat unique to Uganda
and it is not clear to what extent this success can be replicated elsewhere in Africa (not to mention in very different, more concentrated epidemics such as those in Asia or Latin America). However, it makes epidemiological sense to address all three ABC behaviors rather than to promote only one or two components of “ABC.” A great deal of resources have gone into primarily biomedical-based interventions (i.e., VCT, STI treatment, condoms) in South Africa, Botswana and other southern
African countries, yet without apparent impact on national HIV infection rates (Allen and Heald, 2004; Epstein, 2004; Green, 2003; Hearst and Chen, 2004; Wilson, 2004).
In conclusion, the data from Uganda would suggest that pervasive, fundamental changes in sexual behavior can take place, perhaps contrary to previous expectations about the feasibility of such change. And epidemiological analysis, including modeling studies, suggests that significant reductions in numbers of partners would have significant impact on reducing HIV infection rates at the population level (Auvert and Ferry, 2002; Bernstein et al., 1998; Robinson et al., 1995; Auvert et al., 2000). As the Zimbabwean researcher David Wilson argued in the British Medical Journal, “Partner reduction is good
epidemiology, not good ideology” (Wilson, 2004: 849). There will always be a need for condom promotion to individuals and groups, especially (though not only) to those at highest risk, and, indeed, Uganda more recently has also achieved relatively high levels of condom use with just such populations.

While we may never fully know “what really happened in Uganda,” the available evidence, bolstered by more recent and similarly encouraging findings from places such as Kenya (Kenya DHS, 2003; Green, 2003), Addis Ababa (Mekonnen et al., 2003; Shelton et al., 2004) Zambia (Agha, 2002; Bessinger et al., 2003; Fylkesnes et al., 2001; Shelton et al., 2004), and Zimbabwe (HAYES and Weiss, 2006), suggests that a comprehensive, behavior change-based strategy, ideally involving high-level political commitment and a diverse spectrum of community-based participation, may be the most effective prevention approach. A “consensus statement” published for the 2004 World AIDS Day in The Lancet (Halperin et al., 2004), which was endorsed by some 150 global AIDS professionals, including representatives of five UN agencies, WHO, World Bank, etc., as well as President Museveni of Uganda and various religious leaders including Archbishop Desmond Tutu, proposed that mutual faithfulness with an uninfected partner should be the primary behavioral approach promoted for sexually active adults in generalized epidemics. This appears to represent a fairly marked departure from many previous prevention approaches, which have tended to promote more biomedical strategies as the first line of defense for sexually active adults in all types of epidemics. A recent study of over 3,000 men who have sex with men in 6 US cities found, in multi-variate analysis using time-dependent covariates, that the primary independent risk factor for HIV seroconversion was greater numbers of sexual
partners (Buchbinder et al., 2005). The authors suggested addressing this and other risk factors, including male circumcision, in prevention efforts.
Meanwhile, a paper presented in February 2005 at the 12th Conference on Retroviruses and Opportunistic Infections (Wawer et al., 2005) seemed to perhaps challenge the main tenets of both the Lancet consensus statement and the present paper. As mentioned earlier, the authors (one of whom, Ron Gray, signed the Lancet statement) concluded that mortality and condom use were mainly responsible for the HIV prevalence declines in the Rakai district between 1994 and 2003. Whatever the authors’ intent with this presentation, much of the world press was quick to jump to the conclusion that the “ABC model” of AIDS prevention had now been invalidated. Representative headlines that appeared within days of this conference presentation included: “Uganda's HIV success has more to do with condoms than abstinence” (The Advocate, CA—February 25, 2005); “Uganda: Condoms Outshine Abstinence in Aids Battle” (AllAfrica.com, Africa—February 24, 2005); “Uganda's Decline in HIV/AIDS Prevalence Attributed to Increased Condom Use” (Medical News Today, UK—February 26, 2005); “HIV study downplays abstinence in Uganda” (Newsday, NY—February 25, 2005). There was similar coverage as well as editorials in the New York Times, Washington Post and elsewhere. These reactions appear to mainly reflect the “culture wars” in the United States and Europe
between partisans of abstinence vs. those of condoms, omitting the factor that was so crucial in Uganda's HIV decline: partner reduction and fidelity, or what in Uganda was widely termed “zero grazing” (Epstein, 2004, 2005b; Hearst and Chen, 2004; Shelton et al., 2004; Shelton, 2005; Wilson, 2004).
The authors of the Rakai study report that because after 1994 there were higher levels of condom use and lower levels of monogamy and abstinence, therefore condom use (and mortality rates) ought to accunt for the continuing HIV prevalence decline. However, analysis of the period 1994–2003 is too late to meaningfully explain the large decline in incidence in Uganda (see Epstein, 2005a; Mosley, 2005; Shelton, 2005) and in fact HIV prevalence in Rakai trading centers was considerably higher in 1990 (Wawer et al., 1997). In an earlier study in Rakai by some of the same authors as the new study,
only 4.4% of the population reported consistent condom use while 16.5% reported inconsistent use during the prior year (Ahmed et al., 2001) and HIV incidence among inconsistent users was similar to that among non-users (with STI incidence being significantly higher among the inconsistent users). During the pre-1994 period when HIV incidence fell the most in Rakai, there were higher levels of “A” and (especially) “B” behaviors and relatively very little condom use. After 1994, people in Rakai appear to have moved increasingly toward condom use and away from partner fidelity and abstinence as primary HIV prevention strategies, according to the new Rakai study (Wawer et al., 2005).
Whatever the reason for this shift in prevention strategies, HIV seroincidence may have risen a little in Rakai in recent years, suggesting that Uganda's earlier strategy of emphasizing fidelity and partner reduction may have been the crucial type of behavioral change and intervention responsible for Uganda's historical HIV prevalence decline (Hearst and Chen, 2004; Shelton et al., 2004; Stoneburner and Low-Beer, 2004; Epstein, 2004; Cohen, 2004). It is unfortunate that even the British Medical Journal referred to Uganda's pre-1994 interventions as an “abstinence program” (Roehr, 2005). This only helps to perpetuate the confusion and allow Uganda's achievement to become lost in the polemics of abstinence-versus-condoms raging in the north American “culture wars.”
In fact, such polemics may continue and even increase in intensity if HIV prevalence rates were to increase in Uganda, since competing interpretations would be invoked to explain such a rise. The 2004 Ugandan HIV/AIDS Sero-Behavioral Survey (UHSBS), which included a population-based serologic survey along with standard behavioral questions similar to those contained in the DHS surveys, found an estimated 7% adult HIV prevalence rate (Measure DHS, 2005). This surprised same analysts, who had been expecting the population-based rate to be at or below 4–5%, if for no other reason than similar population-based serosurveys in Africa have generally yielded lower rates than estimates based upon sentinel surveillance data from antenatal clinics (Halperin and Post, 2004).
Although this curiously somewhat different result in Uganda may be due to unexplained methodological or other factors, the 7% prevalence finding may also suggest the possibility that HIV incidence has risen a little in recent years, consistent with some other data, such as (mostly relatively small) increases in prevalence among young antenatal clients at some ANC sites in recent years. In comparing behavioral data between the 2000 Uganda DHS and the 2004 UHSBS (Measure DHS, 2005:
13–15), the level of multiple sexual partnerships appears to have increased somewhat (consistent with the Rakai data; Wawer et al., 2005), while condom use has remained fairly steady (and age of sexual debut may have continued to increase a bit). Since declines in casual and multiple partner sex appear to have been particularly important in explaining Uganda's historic HIV prevalence decline, any rise in this measure would be troubling and calls for further quantitative and qualitative investigation.

AUTHOR'S CONTRIBUTIONS
Green has been investigating the Uganda behavioral data since 1993, and various main aspects of this paper result from his work; in addition, he drafted the original outline for the paper, composed several sections, and was considerably involved in the editing/revision process. Halperin originally conceptualized the paper, wrote most of the sections, and was responsible for most of the editing and revision. Nantulya, who contributed to the early development of the prevention strategy in his native Uganda, assisted in the initial conceptualization and with other aspects of the paper. Hogle composed
the first draft by synthesizing the main research contributions of the other authors and of some other key researchers on this topic.

ACKNOWLEDGMENTS
The authors acknowledge Paul Delay, Helen Epstein, Doug Kirby, Jim Shelton, Jeff Spieler, David Stanton, Rand Stoneburner, John Stover and three anonymous reviewers for their helpful comments and input.

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Green's course at Univ. of Florida:
Title of course: AIDS Behavior and Culture

Required texts: Edward C Green and Allison Ruark, AIDS, Behavior, and Culture http://www.lcoastpress.com/book.php?id=294


Supplementary texts:


Elizabeth Pisani, The Wisdom of Whores: Bureaucracies, Brothels and the Business of AIDS.

Helen Epstein, The Invisible Cure: Africa. the West and the Fight Against AIDS

Jim Chin, The AIDS Pandemic: the collision of epidemiology with political correctness (2007)

John Kinsman, AIDS Policy in Uganda: Evidence, Ideology and the Making of an African Success Story