Do sexual abstinence and marital fidelity help in the global fight to prevent the spread of HIV? Public health expert Edward C. Green, a senior research scientist at Harvard University and author of Rethinking AIDS Prevention, has studied the spread of HIV and AIDS in southern African since the late 1980s. His analysis of the now-famous A-B-C strategy (abstain, be faithful, or use a condom) suggests a strong, causal link between this prevention strategy and the major reduction of HIV cases in Uganda.
But new research from Columbia University researchers found no evidence that abstinence and fidelity caused the overall decline of HIV in Uganda between 1994 and 2002. The study reported that increased use of condoms and the death of AIDS patients resulted in fewer HIV cases. Green rejected those new findings during an interview with Tim Morgan, Christianity Today's deputy managing editor. (An edited transcript.)
What's your reaction to new field research casting doubt on the role of abstinence and fidelity in lowering HIV in Uganda?
Every two or three years, somebody does a study comparing behavior in Uganda between the mid-1990s and now. And it's the same old stuff. Most behavioral change in Uganda was in the latter 1980s and early 1990s.
So benefits to public health from fewer people with HIV in that earlier period carried beyond the mid-1990s?
The first thing that happens is the rate of new infections goes down quickly when you're changing your behavior. And that's called the incidence rate. So the incidence rate started going down in the later 1980s and early 1990s and then it's the dynamics of epidemics that even if you don't really do anything after that, prevalence continues to go down for a number of years after the major fundamental behavioral changes of that sort.
Somehow the headlines coming out of regarding this report are: Abstinence doesn't work, but increased use of condoms does work.
It's bouncing all over the internet, those very headlines. All over the world is the headline: "Condoms work, abstinence doesn't." It's nonsense.
We know that the Bush administration has put big money into abstinence and fidelity programs throughout Africa. Do you suppose this kind of flawed news coverage is going weaken that resolve?
Yes, it may weaken the resolve. The spinmeisters make two claims about the study. One, since condoms went up and prevalence continued to go down, condoms made prevalence go down. We know that's not true because condoms went up in every country in Africa and in several countries condom user levels went higher than Uganda and infection rates didn't come down, they went up. We know the statement that condoms worked is not true.
Then there's another claim: When people die off, prevalence goes down because of death. That's also not true because infection rates and levels of death, however you want to measure them, have gone up higher in other African countries and prevalence hasn't come down.
Within Uganda in some parts, prevalence went up to 30 percent. In other parts, it only went to 4 percent and then it went down. It went down uniformly throughout Uganda. Uganda is actually a constellation of different mini-epidemics, all of which had sort of different dynamics. Some went up to 30 percent; others went up to 4 percent, and they all came down.
Does that mean another factor caused the HIV decline? You point to abstinence and fidelity.
I said it in my 2003 book that the single most important behavioral change was fidelity, and most of that is marital fidelity. It wasn't actually abstinence. Most Ugandans are between the ages of 15 and 49, and that's where we measure disease and behavior; most Africans, including Ugandans 15 to 49, are not abstaining. Most of them are, in fact, married and sexually active. But the difference is they've become monogamous and faithful. That's the big change. The second change is the proportion of youth engaging in sex, that went down in a big way between the latter 1980s and the mid-1990s.
Now, abstinence and fidelity are down nationwide in Uganda.
Oh yeah. We know it's countrywide. We outside experts, we donors, we world health organizations, all the funding organizations from the West, we've tried to steer Uganda away from the original program and tried to force them to conform to what we think is the way to prevent AIDS, which is condoms, drugs, and testing. So Uganda's national program has moved away from the focus on faithfulness and abstinence in recent years.
Will that program shift set in motion more HIV?
I think it will. That study we're talking about showed there were lower levels of abstinence and faithfulness in recent years. That's not good news. I know it's because the official program used to be to promote abstinence and faithfulness. If you read current documents, which are heavily influenced by outside groups that fund the programs, there's no abstinence and no faithfulness in the documents anymore.
In Uganda, are more people engaging high-risk sexual behaviors because they can get anti-HIV drugs?
The availability of drugs is quite a recent thing in the last two years. In America and Europe when the drugs became available, there was a move back towards riskier sex. That could be happening in Uganda. But even more than that, the focus on condoms as the first line of defense sells a false sense of security. People feel they can do what they want, use a condom, and it will be okay. That was not the message of the government in the early years.
What about this idea that condoms have to be provided everywhere alcohol and sex are sold? Do you agree or disagree with that?
That means bars and brothels. I'd go along with that. I think at bars and brothels you do need condoms. That's where there's a legitimate role for condoms. But what Western experts have gone into the developing world promoting condoms as the only proven method of preventing AIDS. So we take that approach with primary school children and rural village people, married people. It hasn't worked. People in the general population won't use condoms. There's a role for condoms in bars and brothels. Coming to primary schools with primarily a condom message or even high schools? No.
What's your view regarding President Bush's comment: "Abstinence is the only certain way to avoid contracting HIV; it works every time"?
That's true. And if you and your wife are tested and you're both HIV negative, then that's also 100 percent safe. Having sex within marriage and both partners are tested. And I'm sure if you asked President Bush that, he'd say, "Oh yeah, that's the other one."
What's the best role for abstinence advocacy in Africa as well as America?
In America, it's the abstinence people on one side and the condom people on the other side. Frankly, if we get away from morality and religion and just speak, epidemiologically, the virus doesn't know whether two partners are married or living in sin.
In Uganda the average of marriage for females is like 17.5 and I think it's around 19.5 or 20 for men. From a public health standpoint, that 'B' [be faithful] message is really, really important. It's not even in the debate now. You have the abstinence people versus the condoms people. We need the 'B' message.
So you're saying most everyone can rally behind that "Be Faithful" message?
You would think. But it is not true, even though we have an A-B-C policy; it's not really being implemented, unfortunately. The rank and file of these organizations that implement these programs in developing countries don't believe in the A and B components, they think it's something that's ideologically driven, or religiously driven. They don't believe in it.
So these organizations will give the abstinence money to condom social marketing companies and say, Add some abstinence language so we can justify. Wink, nod. There's no congressional mandate saying a portion of prevention dollars must be spent on promoting fidelity or monogamy.
Are we winning the fight against HIV/AIDS globally?
It's hard for things to get much worse than they have been for the first 20 or so years of responding to the pandemic. What we've done is we've taken the model that may be workable in San Francisco or New York or even Bangkok, and we've taken that all over the world and said this is the only model, regardless of culture, regardless of the type of epidemic. So, it's really hard to do worse than that.
What we have is a good A-B-C policy. There are times when I feel more optimistic, like a couple of weeks ago I saw the A-B-C guidance that came out of the office of the global AIDS coordinator: Here's how you implement and measure the abstinence, the "Be Faithful" programs. It's a great step forward. I hope that people will read that document and reconsider their biases against these interventions that many of them think are politically or religiously motivated.
Are you worried about the growth of HIV in India and China?
The business-as-usual approach of emphasizing condoms and treating sexually transmitted diseases, the medical risk-reduction approach, is a little bit more justifiable in Asia because there's not a lot of HIV in the general population. In Asia we have concentrated epidemics where most HIV is among sex workers, gay men, and injecting drug users. The risk reduction approach is more justifiable targeting those groups.
Apart from targeting those high-risk groups I just mentioned in Asia, I would hope that the programs that target the general populations, the people not in those high-risk groups, that they would emphasize abstinence or delay for youth and being faithful for sexually active adults.
And guess what? That was part of Thailand's program that most people don't know about. There was a campaign to get men to not go to prostitutes, to not have multiple partners, for young males not to have sex at an early age. And it worked. In the early years of the 1990s, the proportion of men reporting pre-marital and extra marital sex and going to brothels went down significantly.
Does religious faith enhance a young person's ability to sustain a commitment to sexual abstinence before marriage?
Most of my colleagues think that taking kind of a moral or religious approach to AIDS prevention is bad because it will marginalize and stigmatize people, and lead to people being cast into outer darkness by their peers and stoned to death and all this.
But that's simply not true. Two countries in Africa most effectively mobilized their religious leaders and communities to address AIDS prevention. Those two countries are Uganda and Senegal, and they stand out not only as the two success stories in terms of AIDS prevention, but they also stand out in having less AIDS-associated stigma than other countries in Africa.
The three other countries that seem to be moving in the right direction, where faith-based groups have played a big role, are Ethiopia, Ghana, and Zambia. We seem to have less stigma in these countries and more behavior change. Involving religious leaders and faith groups, religious schools in primarily promoting abstinence and faithfulness, can empower people. It can empower young people. Using the language of right and wrong and the Scripture can help young people to make a commitment to abstinence and to stick to it.
I'm thinking of an AIDS professional I know in Zambia. We were talking about the situation in his country and he says, "When I was 15, I had born-again experience in an evangelical church. I made a commitment to abstinence until marriage for religious reasons."
This was about 1985 before AIDS really came to southern Africa. He says, "I kept my commitment. As the years went by, I had some friends who also made commitments to abstinence; all of us are alive. And my friends who didn't make that commitment and who were sexually active, including those who used condoms, they're either dead or they're dying now."
Making a commitment in America doesn't have the same life-or-death consequences that is does in a country where HIV prevalence is 20 percent like in Zambia.
So you are affirming that the faith is crucial?
I think you can do it in a secular way. You can do it in a values-related way that involves religion or doesn't involve religion. You can do it in a non-religious, non-values-based approach. I don't know if one is better than the other. It can be done all ways but it can certainly be done that way. I've seen evidence that that's a good way to do it.
We know that much of southern Africa is majority Christian. Do you think that the faith component is particularly effective in that kind of Christian context?
If I understand your question right, I think the answer to that is, yes. Here's what they did in Uganda. I've done a lot of interviews all over the country about this. Three religious groups were brought in early. The Anglicans, the Catholics, and the Muslims. They were given government funds, modest funds, and some funds raised through churches and Islamic groups. They went out and spread the A and B message to people of all faiths. Muslim educators would make references to the Bible, and I mean they're very ecumenical and they respected everybody's religious differences. But they all agreed on the morality of keeping sex within marriage and discouraging pre marital and extra marital sex. Whether it's Christianity or Islam, I think it's all good. And I have to tell you, there's a deeply held belief among my colleagues that doing this will lead to dire consequences like people being marginalized and stigmatized. I just don't see it happening.
So public health experts believe there's going to be a backlash against those living with HIV?
What they're saying is that if you take the sort of moral, religious approach, then those who can't abstain or can't be faithful, who get infected, are going to be considered social lepers and cast out and so forth. But I'm telling you that I've been all over Africa and I've evaluated AIDS programs and I don't see that happening. In fact, what happens when religious groups and leaders become involved in AIDS, they quickly learn about stigmatization being bad and they take pains to make sure that doesn't happen. They say, fear the disease and not the carrier of the disease. Be afraid of AIDS, not the person who's sick. In fact, the person that's sick needs our Christian charity and love and support.
What is your advice to American Christians concerned about the HIV pandemic? Is public advocacy at the grassroots level important?
I'd love to see church groups in America mobilize resources and work with sister churches in Africa in ministering to the sick and the dying and AIDS orphans. What I'd like to see is churches everywhere, particularly in the countries that are hard-hit by AIDS, becoming mobilized and getting involved in prevention.
The AIDS experts? The message from them all these years has been: "You people in churches don't have a role to play because only condoms and needle exchange are effective. What you're preaching sounds nice but it doesn't work."
A lot of churches have not been involved in AIDS prevention because they believed what they were told by the experts. The role for churches in America? Mobilize resources, work with your denomination and the other churches in Africa and Asia and the Caribbean and Latin America, and work with them and help them promote abstinence and faithfulness.
Because all the organizations with all the money are promoting condoms. Somebody else needs to promote the A and B. There's a widespread belief that because of the Bush administration policy that's where the emphasis is today. But it ain't so.
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