AIDS Prevention Is Harder Than ABC


President George W. Bush's $15 billion, five-year AIDS initiative took a beating recently at the 15th International AIDS Conference in Thailand. For starters, the United States is taking a shamelessly unilateralist approach to dispensing its largesse, preferring to dole out assistance to 15 stricken nations like a neighborhood don at Christmastime rather than risk losing some PR by sending the money to a more effective global effort, namely the Global Fund to Fight AIDS, Tuberculosis and Malaria.

If the tenor of the Bush administration's approach to fighting AIDS seems arrogant, though, the philosophy behind it seems just silly – or at least it did until last week. The "ABC" approach to HIV prevention (Abstain from sex; failing that, Be faithful; as a last resort, use a Condom) has long been suspected by activists to be a cover for a right-wing agenda. And the fact that the Bush administration is going to spend $5 billion over the next five years trying to convince people not to have sex is, let's face it, pretty rich.  But new research unveiled in Bangkok suggests ABC might actually be so naïve it's dangerous.

According to the new UN report, "Women and HIV/AIDS: Confronting the Crisis," global HIV prevalence is rising rapidly among women. Forty-eight percent of the world's HIV-infected adults are now women, up from 35 percent in 1985. In sub-Saharan Africa, where women make up 57 percent of those infected with the virus, girls and young women account for a staggering 75 percent of HIV-positive youths aged 15-24.

Experts say women's powerlessness is behind the feminization of HIV. In sub-Saharan Africa, home to most of the world's 38 million HIV-positive people, early marriage is common, poverty is widespread and custom is kinder to men than it is to women, according them privileges and power in the marketplace and the bedroom. Being a woman and staying healthy is not, it turns out, as easy as ABC.

Thoraya Obaid, executive director of the UN Population Fund (UNFPA), put it best. Obaid has no love for Bush, who last week refused to fund UNFPA for the third year in a row, and her assessment was terse.

"Abstinence is meaningless to women who are coerced into sex," she said.  "Faithfulness offers little protection to wives whose husbands have several partners or were infected before marriage. And condoms require the cooperation of men."

Obaid's comment gets at the heart of the idea that the ability to exert control over one's sex life is increasingly critical to survival. But Africa offers one challenge after another in this regard.

Sexual coercion takes place in many arenas in Africa. One of them is in the context of conflict. In the Democratic Republic of the Congo and in Sudan's Darfur, rape is used as a weapon of war. Thousands of women have been gang raped, some so violently that without intervention, they will suffer incontinence for the rest of their lives.

When one considers that HIV is two to five times as prevalent among members of the military in Africa as among civilians, it becomes clear that rape can also be fatal. A study in Rwanda last year found that in a quarter of the country's provinces, 66 percent of widows assaulted in the 1994 genocide were HIV-positive.

"After killing our husbands, they turned to us," a Tutsi woman said of the Hutu militias. "They knew very well that they were infected with the virus and wanted us to experience the same agony."

Sexual coercion can also be a matter of domestic violence – an acute problem in South Africa – or an element of an economically necessary liaison.  Many young women facing poor employment prospects enter into relationships – sometimes with a more financially secure older man, sometimes with a young man, sometimes with more than one man – that provide them with money for groceries, rent or small luxuries. Dubbed "transactional sex," it is sex for survival in some measure, and therefore the relationships are inherently unequal. A woman can't say no in such a situation and preserve her economic security.

As for "being faithful," fidelity is not always under women's control, activists and researchers point out. Infidelity plagues transactional relationships almost by definition, and it also enters marriages – especially unions in which the husband is much older than the wife. Even in faithful marriages, sexual history is a threat that does not discriminate.

Needless to say, the availability of condoms matters little in these instances. Only if a woman has negotiating power with regard to sex can she insist that her boyfriend or husband use a condom. Only if she is omniscient can she be certain it's not necessary.

To be fair, the ABC method is credited with reducing Uganda's HIV infection rate from 21 percent to 6 percent in 10 years, starting in 1991. Researchers suggest that the campaign's "zero grazing" message advocating fidelity was the secret to Uganda's success. Some also say the national culture, and a vibrant women's rights movement, helped the effort along.

While acknowledging Uganda's success, Obaid and other women's advocates worry that Bush's ABC method will flop in southern Africa, the disease's epicenter, unless it is fortified by solid legal and economic measures promoting equality.

"The social and economic empowerment of women is key," Obaid says. "The epidemic won't be reversed unless governments provide the resources needed to ensure women's rights to sexual and reproductive health."

African women without the power to negotiate safe sex don't need lessons in abstinence. They need schooling, jobs, a social safety net, reasonable pay. They need legally enshrined equal rights. They need peace. They need debt forgiveness, national industries, foreign investment, dismantled trade barriers – all of which the Bush administration, if it decided to investigate, would find is a lot more complicated than ABC.

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