Evidence Based AIDS Prevention

"We need to move away from consensus-based AIDS prevention and towards evidence-based AIDS prevention." Harvard medical anthropologist Edward "Ted" Green

This is exactly the point I was trying to make yesterday, thought not as clearly as Green does.
(The quote comes from a sidebar to this piece. )

Green is a proponent of the ABC (Abstinence, Be Faithful, use a Condom) that was developed by Uganda to fight the AIDS epidemic. AIDS, which once affected 15% of the population, now affects about 6%. It's close to 30-40% in other countries.

Conventional wisdom holds that condoms ought to be the primary tool to prevent AIDS, along with hopes for a vaccine or other technological solution. But Green says the conventional wisdom is wrong. His stance isn't based on the relative morality of condoms versus abstinence--it's based on on his 10 years of studying AIDS in Uganda. And he thinks that the Ugandans, who developed a people intensive, instead of technology intensive, approach to fighting AIDS, are on to something.

Where we reporters can fall short is assuming that conventional wisdom is right.

Here's the piece on Green:

In the mid-1980s, facing a growing AIDS epidemic in a country where even basic medicines like aspirin were in short supply, Ugandan president Yoweri Museveni and his advisers devised a low-cost,
people-intensive way to fight the disease. They targeted the two main behaviors that were driving
the epidemic, says Harvard medical anthropologist Edward "Ted" Green--young people having premarital
sex and people of any age having multiple sexual partners.
The approach they used may have been as simple as ABC--abstain, be faithful, use a condom--but it was also ingenious. By mobilizing all sectors of Ugandan society--government, education, religious
groups, entertainment--Museveni made fighting HIV an act of patriotism for all Ugandans.
The idea was to make sure that "everybody understood that there is a threat of AIDS. You
will die [if you get it], so you must change your behavior," says Green. Condoms were made
available and targeted for those least likely to change their behavior and considered at high-risk
for HIV--long-distance truck drivers, soldiers away from home, and sex workers.
The result was that by 1989 the growth of incidence (the number of new infections) began to slow.
Prevalence (the total number of people infected) peaked at 15.1 percent of the population in 1991, and by 2001 dropped to 5 percent, making Uganda's HIV prevention program the most effective in the
world. A similar program was started in Senegal and prevented HIV from getting into the general
population. Senegal's HIV prevalence peaked at 1.1 percent in 1990, and by 1997 had dropped to 0.4
Green says that it is helpful to compare the example of Uganda with that of neighboring Kenya.
There, after years of initial denial, the government launched a small AIDS prevention
program, funded by outside donors and focused mainly on condoms for prevention. The result, says
Green, was that prevalence continued to increase and stands at about 20 percent today. The
government of Kenya also did not engage the religious community, which led to a "confrontation
between many people in the faith-based community Kenya and those who work in AIDS prevention,"
says Green.
"There would be rallies by religious leaders," says Green, "who would have bonfires and they would
burn condoms and denounce AIDS prevention as something that spread condoms and therefore
immorality." In 1999, the government adopted an ABC approach and by 2002 had begun to see a drop
in the rate of prevalence.
Green, who has worked in Africa for decades and began studying the Ugandan ABC program in 1993,
says it is essential that any AIDS prevention program in Africa include active participation by
religious groups. "Religious leaders and organizations in Africa are very powerful," he
says. "You either get them on your side and they help you, or you leave them out and they work
against you the way they did in Kenya before 1999."
Recently, Green has become one of the leading advocates for the ABC approach, which he holds for
scientific--not religious--reasons. While he is quick to point out that he is a "fairly secular
person and not a regular churchgoer," Green argues that--at least in Africa--the ABC method is most
effective way to prevent new infections of AIDS. "We need to move away from consensus-based AIDS
prevention and towards evidence-based AIDS prevention," he says.
"We have had these assumptions that when a certain level of the population is all using condoms
correctly and consistently prevalence will go down," he says. "Well, there is no evidence in
Africa that that is so. In fact, the countries with the highest levels of condom use and the
highest level of condom availability, also have the highest level of HIV infection."
While much of the scientific effort has gone into finding an effective vaccine for AIDS, Green and
his colleagues think that the Ugandans have created something more effective. Rand Stoneburner
and Daniel Low-Beer presented a paper at the 2000 World AIDS Conference that called the ABC approach
a "social vaccine," which was 80 percent effective in preventing the spread of HIV. Green says that
the first successful new AIDS vaccine will likely be about 30 percent effective.


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