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AFRO-NETS> HIV/AIDS through Unsafe Medical Care (15)

  • Subject: AFRO-NETS> HIV/AIDS through Unsafe Medical Care (15)
  • From: "Edward C. Green" <EGreendc@aol.com>
  • Date: Sat, 7 Dec 2002 08:58:54 -0500 (EST)

HIV/AIDS through Unsafe Medical Care (15)
The ABCs of AIDS prevention

Dear All,

regarding the posting by Peter Burgess of 14. Nov. "HIV/AIDS through
Unsafe Medical Care (14)" (I am still trying to catch up on my Novem-
ber mail), it is important to distinguish between proximal and distal
causation. Proximal causes of HIV prevalence decline must involve
some alteration of direct risk factors, e.g., fewer sexual partners,
higher condom user rates. Distal causes include such things as pov-
erty, lack of political will, lack of medical treatment. Burgess also
mentions dirty needles, a proximal cause.

But I was writing about sexually transmission, the primary mode of
transmission in the world, so let's leave aside needles for the mo-
ment. I was trying to make a simple point, because it astonishes me
that so many people have not caught on yet. People often try to com-
plicate the issue I was raising, with the result that the simple
point is again obscured.

So let me make it even clearer. Most HIV is transmitted through sex-
ual intercourse. Having multiple sexual partners drives AIDS epidem-
ics. This behaviour both causes and sustains AIDS epidemics to the ex-
tent that they are sexually transmitted. Yet AIDS prevention programs
do not for the most part address the behavioral pattern of having
multiple partners. This is in spite of research that underscores the
risk of multi-partner and early age sex.

Uganda has experienced the greatest HIV prevalence decline of any
country in the world, from 15% to 5% between 1991-2001, according to
UNAIDS. And this low-income country turned its epidemic around by
1991, before most of the foreign experts showed up to supply the
drugs and medical devices deemed essential for AIDS prevention.
Uganda's home-grown approach to AIDS, especially in the period 1986-
91, was simply to emphasize fundamental behavioral change for most
of the population, while promoting condom use for those likely to en-
gage in high-risk sex. The result was that people were soon reporting
fewer sexual partners and youth were delaying the age of first sexual
experience. Condom use later rose among sex workers, and in sexual
acts involving non-regular partners.

Many of us in public health feel a bit uncomfortable when thinking
about an approach that emphasizes "Abstain and Be Faithful". Such
language sounds judgmental, moralistic. Americans are often quick to
assume that stigmatization of those who aren't "faithful" would re-

Yet, interestingly, there is probably less stigma associated with
AIDS in Uganda than in virtually any other African country. Less
stigma and more empowerment of women. It's hard to measure degree of
stigma but there are some measures of the latter. For example, the
Uganda DHS 2000 asked women and men whether women "have the ability
to negotiate safer sex." The numerator was defined as "The number of
respondents who believe that, if her husband has an STI, the woman
could refuse to have sex with him or propose condom use." The denomi-
nator is total number of respondents. Looking at the data available
for Africa, Uganda has the highest percentage of women able to nego-
tiate safer sex, by this definition: 91%. This compares with 73% in
Malawi, 87% in Rwanda, 55% in Tanzania, and 71% in Zimbabwe (from
DHS/MEASURE data on website).

This is getting too long. Mr. Burgess wondered if I meant to say
something like "...we are not putting enough emphasis on ending sex
in Africa..... or are you saying something else?" Such rhetorical de-
vices (End sex? Abstain forever?) are commonly used to shift atten-
tion away from fundamental behaviour and back to the familiar area
favoured by the pharmaceutical companies, the medical establishment,
consulting firms, etc., namely drugs and medical devices. But let's
not end on a confrontational note. All interventions are needed:
those that promote basic behaviour change, condoms, and drugs. It's
called the ABC approach. Just don't forget the A and B. Or perhaps I
should say it this way: don't dismiss A and B until you have tried to
promote them and then looked objectively at the results.

Edward C. Green
Harvard School of Public Health

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