by hilzoy
In honor of World AIDS Day (which might be over by the time I post this, since my browser just crashed), here's a piece of good legislation that now, finally, has a chance to pass: H.R. 5674: the Protection Against Transmission of HIV for Women and Youth Act of 2006. It does two things: first, it requires the administration to adopt a strategy to ensure that HIV prevention funding is spent in a way that meets the needs of women and girls, and second, it repeals the current requirement that 33% of all HIV prevention funding be spent on abstinence programs.
This second point is really important, for reasons I'll explain below the fold.
The Bush administration has put various conditions on its HIV prevention funds:
"Starting in 2004, the United States recommended -- and by 2006 required -- that 33 percent of all prevention funding be earmarked for abstinence and fidelity programs. Condoms could be recommended only for high-risk groups, not for sexually active people in general. No funds would be provided to groups that don't explicitly condemn prostitution. Finally, the Bush administration seemed to be spreading a significant share of AIDS funding through faith-based groups."
This approach was based in part on the success of Uganda's "ABC" approach: Abstain, Be faithful, use Condoms. Unfortunately, not only have some of Uganda's statistics been questioned, but further study showed that most of Uganda's success was due not to abstinence and fidelity, but to condom use and, unfortunately, high death rates among people with AIDS:
"Abstinence and fidelity - cornerstones of the Bush administration's overseas AIDS prevention programs -- may be playing less of a role than previously thought in driving down HIV infection rates in Uganda, where the idea first gained credence, according to new findings presented here Wednesday. (...)The U.S. researchers found that the single greatest factor lowering the percentage of Rakai people infected by HIV was the premature deaths of those who were infected earlier with HIV and subsequently died of AIDS. As the number of AIDS patients decreased, the percentage of those who remained infected or became newly infected decreased in the late 1990s.
Dr. Ronald Gray of Johns Hopkins University, co-author of the Rakai study, said that much of Uganda's early bout with high rates of HIV infection coincided with a period of war in the 1980s. By the 1990s, the country was settling down to a period of relative peace and a return to normal sexual behaviors.
A rebel insurgency continues, however, in northern Uganda, and there are no data to determine whether the nation's AIDS prevention efforts are succeeding or failing in those areas marked by violence.
The push for abstinence until marriage, and the so-called "zero-grazing" policy discouraging sex with multiple partners, does not appear in the Rakai study to have made an impact, according to Gray.
"Over the past decade, we're just not seeing it," he said.
The Rakai findings are based on an extensive and continuing process of interviewing 10,000 adults each year -- a so-called population-based survey that is considered the gold standard for this kind of epidemiological research."
Meanwhile, the Bush administration has been pushing Uganda to emphasize abstinence and fidelity over condom use:
"Aids activists and development officials point to the 130,000 Ugandans infected with HIV last year alone - up from 70,000 in 2002 - and say the recent obsession with abstinence is handicapping the country's once-successful fight against the virus.Health workers see the fingerprints of America's Christian right all over the chastity message and believe the Bush administration is using its financial might to bully them into accepting evangelical ideology at the expense of public health.
Aids may have killed one million Ugandans and infected a further million but the latest crisis seems strange when you consider that foreign donors still hold up Uganda as Africa's Aids success story. What's more, under Bush's 2003 Emergency Plan For Aids Relief, where he pledged $15bn (£8bn) to fighting Aids in the worst-afflicted countries, Uganda receives more US money than ever: doubling in two years to $169.9m in 2006. But that cash comes with conditions: in a gesture to the Christian right in the US, at least one-third of all prevention money must go to "abstinence-only" projects - $10m in Uganda in 2005. Critics counting each new infection in field clinics say this has dangerously skewed Uganda's previous "balanced" approach which seemed to be working. (...)
"Because of the US, our government now says Abstain and Be faithful only," says Dr Katamba. "So people stop trusting our advice. They think we were lying about how condoms can stop Aids. Confusion is deadly."
And so it is proving to be: the number of infections is again rising, after years of decline. Questionable government figures say that 6.4 per cent of Ugandans have HIV/Aids. One in three civil war refugees in camps in the north has Aids, a local NGO says.
Uganda's evangelicals preach that abstinence is the only way to halt the spread of the virus. The trusted and influential first lady, Janet Museveni, is a born-again Christian. She has publicly equated condom use with theft and murder and said that Aids is God's way of punishing immoral behaviour. The first lady also offers scholarships to girls who can prove they are virgins. (...)
Condoms are no longer promoted to the general population. In line with US Aids policy under Mr Bush, condoms should be promoted exclusively to high-risk groups such as truck drivers, soldiers and "discordant" couples (where just one of the partners is HIV-positive). Everyone else should hear the rubber-free virtues of abstinence and fidelity only. Yoweri Museveni's government hungrily devoured the American abstinence policy and the attached cash. It is dependent on foreign donors for half its budget.
People on both sides of the argument agree that Washington is prolonging tens of thousands of Ugandans' lives through treatment - and that abstinence is crucial. "The evangelicals are absolutely right: abstinence is the best way of preventing the spread of HIV/Aids," says Sigurd Illing, the EU ambassador to Uganda. "But some people aren't receptive. We need an end to this bedevilling of condoms by people who take a high moralistic stance and don't care about the impact that this has on reality.""
This is a policy that kills people. We should reverse it immediately. We should also start giving money to agencies with proven track records, as opposed to favoring faith-based groups; and we should stop requiring organizations to explicitly condemn prostitution (not a good requirement to impose on organizations that do HIV prevention with prostitutes.) But H.R. 5674 would be an excellent start.
"further study showed that most of Uganda's success was due not to abstinence and fidelity, but to condom use and, unfortunately, high death rates among people with AIDS"
I'm not seeing the condom part of the above in the article - it seems like "early death is the main factor (maybe condom use in area x is helping)".
Top google link has a different interpretation.
Next says intervention didn't help.
Ok, anyway, understanding this will probably take some thought and cross-checking - googling "fluoride" isn't a good way to get at the truth.
Posted by: rilkefan | December 02, 2006 at 11:26 AM
I don't have time right now, rilkefan, but if you check through the Obsidian Wings archives, the last time this subject came up I posted a link to the actual study which confirmed that condom use was essentially irrelevant in halting the spread of AIDS in Uganda. It was in response to Tacitus invoking the ABC program, IIRC.
Posted by: Anarch | December 02, 2006 at 12:29 PM
Confused - here I see you saying no A, no B, yes C (via "anarch condoms site:obsidianwings.blogs.com", which I feared might have ... random results).
Maybe the original.
I have little doubt that condoms are essential in fighting AIDS and abstinence programs are at best of secondary utility but I'll look on any study with skepticism because of the associated taboos.
Posted by: rilkefan | December 02, 2006 at 12:49 PM
Wrong way 'round, sorry: must've flipped my bits in haste. And yes, that's the original post.
Posted by: Anarch | December 02, 2006 at 01:23 PM
rilkefan: I was thinking of passages like this (in the Chronicle article): "Research from the heavily studied Rakai district in southern Uganda suggests that increased condom use, coupled with premature death among those infected more than a decade ago with the AIDS virus, are primarily responsible for the steady decline in HIV infections in that area." And that interpretation seemed to be supported by the other reports of the study I found (my ability to get into the Hopkins library was on the fritz at that point, so I couldn't get the study itself. Grrr.)
Anarch: I read through the thread looking for your comment -- why did it have to be at the bottom? -- and was reminded of how little I miss that particular period, when I had basically resolved never to engage with Tac, since (as best I could tell) the posting rules didn't apply to him, and I didn't know what to do about that.
Posted by: hilzoy | December 02, 2006 at 04:34 PM
My point was that the assertion seemed unsupported by references to the paper or the paper's authors - the quotes there seemed to have a different import, as did my links above. If you say the scientific literature/discussion shows what you say, then never mind.
Incidentally, why isn't the study just publicly available?
"Anarch: I read through the thread looking for your comment"
Ctrl-f is your friend.
Posted by: rilkefan | December 02, 2006 at 04:42 PM