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What about Swaziland, which has a reputation for one of the highest HIV rates in the world? Do condoms work there? If not, what would?

As I have said, condoms have not worked in any country in Africa. The two countries with the highest infection rates, Swaziland and Botswana, have both launched MCP campaigns. "MCP" is shorthand for campaigns that discourage people from having multiple and concurrent sexual partners. We are starting to see prevalence decline in both of these countries.

Is the African church part of the problem here for creating a stigma and demonizing people with HIV?

That charge has been way overblown. There was some of that early in the pandemic, but the churches' involvement and intervention are essential. For one thing, they have always been right about where to put the emphasis — namely, on marital fidelity and abstinence, or delay of the age of first sex. All faith-based organizations promote this, whatever the denomination or religion. Faith-based organizations are some of the most powerful NGOs in Africa, and they play a leading role not only in general health and education in these countries, but also in caring for the sick and dying in the AIDS epidemics we find in Africa, from the very beginning. I think historians will look back and find great fault in the fact that the major AIDS donor organizations did really not bring the religious groups into prevention activities at or near the beginning of the pandemic.

What is the best HIV prevention strategy for the Obama administration to fund with new PEPFAR money?

Well, my views here also upset a lot of my colleagues, but I've always said that we cannot treat our way out of this pandemic. A sound public health approach is always based on good prevention strategies. We can justify treatment with expensive anti-retroviral drugs on humanitarian grounds, but it's hard to do on public health grounds.

So I would advise Obama, the candidate I voted for, to put more emphasis on prevention, and to face up to the hard realities of the best evidence available to date, which shows that condom promotion, testing and counseling, curing the curable STDs, or any of the other interventions widely endorsed and considered "best practices" always funded have simply not worked in Africa. (It's possible they may work in other regions, like condoms in Thailand, so it's easy for me to be misquoted on something like this.) In a number of studies, these interventions have actually been shown to not work.

The two interventions that work best in Africa are promotion of monogamy and fidelity, and male circumcision. We have even stronger science behind the latter. I assume people know about "the male circumcision factor" these days, so I will not say more here.

As for IDU (injecting drug use) epidemics, I would advise putting resources into preventing addiction in the first place and into treatment of drug addicts and facilitation of support groups to keep addicts from relapsing, groups like those in the 12-step programs.

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March (Web-only) 2009, Vol. 53