AS A NEW member of the Presidential Advisory Council on HIV/AIDS, I want to respond
to some comments fellow anthropologist Doug Feldman made about me in this publication.
(“Critics say Bush choice for PACHA advocates abstinence,” news,
Aug. 22).
I have been engaged in a public debate with Feldman about AIDS for months.
He recently contacted the press to make the claim that I support “fidelity
only” programs and that I dismiss condom promotion as “a waste
of time and money.” I have never said anything like this.
My research findings from Africa have been very unpopular among American condoms-only
advocates. What I found in Uganda, for example, is that HIV-infection rates
were already declining before American-supported programs of condom social
marketing and treatment of STDs had begun. That means something other than
the standard package of interventions was probably responsible for declining
infection rates.
Those who work in the AIDS prevention industry did not want to hear this.
In fact, anticipating the wrath of colleagues, I almost kept silent about
Uganda. But then HIV-prevalence rates kept rising in most countries, while
they continued to fall in Uganda.
WHAT WAS GOING on there? What I and a few other researchers willing to speak
out found is that Ugandans were having fewer sexual partners, and teenagers
were waiting until they were a bit older to initiate sex. Indeed, the early
national response to AIDS in Uganda emphasized, “Stick to one partner,” and “Love
faithfully.”
Yet Americans and other foreign experts had begun advising Africans that condoms
were the “only proven intervention.”
Condom use in Uganda’s general population today is about as low as it
is throughout Africa, but condom user rates are quite high (59 percent) among
those men who still report having casual sex.
Let me emphasize that I am simply reporting what occurred in Uganda.
Before I first went to Uganda, I also shared the view of most my colleagues
that a strategy based on reduction in numbers of sexual partners was unrealistic
in poor countries where women have little power, there is a transactional dimension
to sex, and polygamy abounds.
Yet when people are facing the possibility of dying, they can do remarkable
things. “Love faithfully” was the main message and the main behavioral
response in Uganda, and HIV prevalence fell by 66 percent, whether or not Americans
approve of the way this came about.
NOW WHAT DOES this have to do with America and with gay men? I am not sure,
to tell the truth.
It appears from recent surveys and op-ed articles by gay journalists and scientists
that there is quite a bit of casual sex and barebacking these days, more than
there was in the latter 1980s. Infection rates seem to be rising again.
What to do? Urge more condom use? This cannot be the whole solution. We now
know condoms are not as protective as we once thought they were. A recent meta-analysis
of many studies found that HIV seroconversion occurred in approximately 20
percent of couples who used condoms consistently in vaginal sex. And if anything, “condom
integrity” is more challenged during anal sex.
Whatever we say about condoms, it is safer to have fewer sexual partners.
There are many monogamous gay couples.
I think we all know from common sense and from personal experience that those
people, gay or straight, who have less casual sex are less likely to become
HIV infected.
This should not be about moralizing or curtailing anyone’s sexual or
political freedom. This is just the epidemiology of an infectious disease.
I believe in giving people all the facts, and then letting them decide what
to do.
Edward Green is a senior researcher at the Harvard
School of Public Health and was recently appointed to the President’s
Advisory Committee on HIV/AIDS. He can be reached through
this publication.