Hooked on failure

Before the Bush Administration, the United States fought AIDS in Africa and around the world with one weapon: condoms. Under President George W. Bush, the emphasis became abstinence and faithfulness-a program with Christian roots and a successful track record in Uganda, where AIDS has declined dramatically. But, with millions in AIDS-fighting dollars rolling out under Mr. Bush and results now rolling in, condoms are still winning out.

Global condom distribution by the United States under the Bush administration has tripled from five years ago.

U.S.-funded programs distributed 190 million of the contraceptive devices in 1999. This year they will hand out 550 million. Despite the mounting evidence that abstinence programs are more effective in reducing AIDS rates, old public-health habits are dying hard.

"It's worse than nothing's changed," said Edward Green, a senior research scientist at Harvard. Mr. Green visited Uganda in August, having spent 20 years fighting AIDS in Africa and working as a behavioral science specialist at Harvard's School of Public Health. Despite the administration's new AIDS rhetoric, Mr. Green said he found no signs of an extreme makeover in Uganda. "The unique indigenous program that Uganda developed is being gradually destroyed," he told WORLD.

When Uganda became the first African country to beat back its AIDS epidemic, Mr. Bush adopted its "ABC" prevention model as U.S. policy. It became the trademark of his Emergency Plan for AIDS, a $15 billion, five-year program to fight the disease. Fifteen countries, including Uganda, are to benefit from the plan.

"ABC" stands for Abstain, Be faithful, or use Condoms in the case of high-risk groups such as prostitutes. The approach fostered healthy behavior among most of the population and helped drive down Uganda's HIV rate from 21 percent in 1991 to about 6 percent today.

In January Congress appropriated the emergency plan's first $2.4 billion. Of that, $80 million was devoted to Uganda. But instead of pursuing faith-based and other groups geared to the ABC model, the U.S. Agency for International Development (USAID) office in Kampala has funded old-school family-planning groups who have peddled millions of condoms to Africa for years. Contraceptive supplier Population Services International (PSI)-a Washington, D.C.-based nonprofit organization-received the first installment of $12 million in abstinence and faithfulness funds. A further $2 million is earmarked for faith-based groups. But it will be distributed by a consortium of five large aid groups led by CARE International, groups long recognized as hostile to an abstinence-focused mission.

Long-term planning for Ugandan AIDS policy is also in the wrong hands. The Deliver Project, funded entirely by USAID, is mapping the logistics of condom, drug, and other contraceptive distribution to continue fighting AIDS the old way. Last year it pressed the Ugandan government to craft a condom policy that tracks condom usage and effectiveness.

Mr. Green now speaks of "salvaging" the country from the grasp of U.S. and other Western donors: "We're going to reach a point where infection rates will start going up again and then experts will say ABC never worked, that there was probably something wrong with the data all along."

Mr. Green's warning is noteworthy: Once a condom social marketer himself, he has become a crusader for Uganda's ABC approach through firsthand research in Africa, testifying before Congress and now serving as a member of the Presidential Advisory Council on HIV and AIDS. He returned to Uganda in August at the request of Janet Museveni, alarmed herself by U.S. funding trends.

Mrs. Museveni, along with her husband, President Yoweri Museveni, devised ABC in 1986 in the face of a burgeoning epidemic and armed with only meager state funds. With little Western interference-Uganda was emerging from the disastrous dictatorship of Idi Amin-they relied on low-cost measures to change people's sexual behavior. They told teenagers to abstain until marriage, and told the sexually active to employ "zero grazing"-a catchphrase for staying faithful to one's partner. Studying Uganda's success, Mr. Green discovered that the emphasis on fidelity had the most impact. But now, the homegrown AIDS treatment revolution is struggling under U.S. influence. "Uganda is being pushed more towards condoms and pills," Mr. Green said.

The local USAID mission is pushing hardest, using PSI Uganda. Until last year, the group functioned under a family-planning project of USAID's population office that did social marketing. "Social marketing" is industry lingo for commercial-style campaigns aimed at changing people's behavior. In Africa, the term is synonymous with selling and promoting low-cost condoms. In October 2003, PSI assumed full management of the project's social marketing, absorbing its donor funding from USAID and the Centers for Disease Control and Prevention.

At the same time, PSI received U.S. tax dollars to teach abstinence education. With those funds PSI launched Kikosi, a monthly comic-book series about AIDS prevention aimed at 15- to 19-year-olds, targeting 600,000 high-school students on "abstinence, stigma, care, and support." The storyline follows Birungi, a high-school student who contracted HIV/AIDS when her uncle raped her, and who becomes a radio DJ on the Kikosi radio program to increase AIDS awareness. Woven in, however, are multiple use-a-condom reminders, illustrating long-standing skepticism that teenagers can control their sexual urges.

Even in the issue supposedly devoted to abstinence, a main character does some heavy making out with her boyfriend before refusing to have sex. Another character calls into the Kikosi radio program, assuring the hosts that she and her boyfriend have not slept together. But she hopes that when they do "start having sex, he will be faithful to me, though we must take an HIV test first."

Behind the characters in the same issue, billboards sport catchphrases such as "True Love Waits" and "Sex can wait, but my future cannot." Also appearing are blue billboards for PSI's Protector condoms, with the slogan, "So strong. So smooth." The condom advertisements appear more often in other issues. One Kikosi issue is devoted entirely to the troubles main character DJ Smooth encounters when he refuses to use a condom with his girlfriend.

Teenagers noticed early the veiled safe sex message of Kikosi. PSI threw a Kikosi publicity bash with music, dance, and skits on Aug. 19 at London College, a Kampala high school. Students from the school complained that the program was too sexually provocative.

"I must confess most of the students were not impressed about the outcome of the event," wrote 12th-grader Gloria Limo, "This was because the Kikosi members did not promote abstinence, which we expected them to bring out to students." Another student said the comics "promoted condom use and sex."

Martin Ssempa, a pastor and 16-year abstinence educator, collected these and other written complaints from the students after he attended the PSI event. He said he has been lobbying the local USAID mission for months to get funding for a faith-based program that reaches 5,000 college and high-school students a week: "They just say, 'Wait, maybe next month.' They need to come down to the people who are really doing the work-they're not leveraging them."

Mr. Ssempa complains too that groups such as PSI meet official U.S. policy on ABC by drizzling abstinence slogans onto old condom campaigns. "It is like a Frenchman trying to speak Chinese," he said. "They just can't live with the fact that you can teach abstinence to young people."

The agency usually funds smaller faith-based groups indirectly, by first awarding large groups such as PSI and tasking them to disburse the money. This year USAID did fund several homegrown abstinence and faithfulness programs. The largest recipient-run by Mrs. Museveni-received $3 million to reach elementary-school children. In general, however, the system leaves educators such as Mr. Ssempa at the mercy of organizations philosophically opposed to them.

Bush AIDS appointees in Washington argue that changing traditional hostility to ABC is long and slow work. Anne Peterson, USAID assistant administrator for Global Health, says 90 percent of government-distributed condoms in Africa go toward AIDS prevention, geared toward high-risk groups such as prostitutes and couples where one partner is HIV positive and the other is negative. "Five years ago the secular public-health world would laugh if you suggested abstinence or faithfulness as a public-health message with any merit," Ms. Peterson said. "They saw it as an imposed religious mandate. To change that view means moving people out of firmly held stereotypes of what can work or not."

In the desperate battle against AIDS, that will gobble time Uganda and other countries may not have. Because Western donors control the AIDS war coffers, African governments often feel the pressure to conform to their ideas. That was obvious, says Mr. Green, in the crafting of two major AIDS policy documents. One is the master plan for all anti-AIDS measures until 2006, or the National Strategic Framework, backed by USAID.

Mr. Green formally requested that USAID Kampala mission director Vickie Moore address the document's gaping holes. "The only place I found abstinence, fidelity, or ABC is mentioned in the 63-page document is just in two comments in passing that Uganda's prevention policy is to promote ABC," he wrote in a letter. "Tellingly, it is mentioned under 'emerging issues,' a conscious or unconscious acknowledgment that the donors have not promoted the A or B of ABC so far." Ms. Moore did not respond directly to his request, said Mr. Green, instead punting it to a lower-ranking official.

The other worrying document is the first draft of Uganda's National Condom Policy and Strategy from June 2003. According to the acknowledgments, CDC and USAID staff helped craft the document. Among its AIDS policy goals was the use of "condom focal persons" for each of Uganda's 56 districts, tasked with overseeing local condom distribution. The whole plan is detailed, offering multiple pipelines to supply free and low-cost condoms and ensuring that the condoms remain high-quality.

Murmurs from religious and other government leaders soon prompted AIDS officials to withhold final approval of the document. Local experts are now creating a parallel policy for abstinence and faithfulness, with input from the faith community and experts such as Mr. Green.

Despite a White House change in policy, the scale of President Bush's five-year emergency initiative is at odds with its intent. More AIDS-fighting money equals more of everything-including condoms and outmoded prevention schemes.