The Ugandan solution has been a simple, low-cost program called ABC -- Abstain, Be faithful, or use Condoms if A and B are not practiced. President Yoweri Museveni preaches this with evangelistic fervour. "I am not in favour of condoms in primary and even secondary schools... Let condoms be a last resort," he said recently at an international AIDS conference in his capital, Kampala. "I have grown-up children and my policy was to frighten them out of undisciplined sex. I started talking to them from the age of 13, telling them to concentrate on their studies, that the time would come for sex and that peer groups at school gave them wrong advice from bad families. Indeed, I succeeded in this."[2]

The Bush Administration has modelled its African AIDS policy on the Ugandan experience, although it is not putting all its eggs in one ideological basket. Like Bush's policy on stem cell research, his approach to AIDS is a pragmatic compromise. It even supports the use of condoms. Although it is not widely known, the US exported 550 million condoms to developing nations in 2004.[3]

To many AIDS activists, the Musevenis and their American allies seem both dewy-eyed and dim-witted. "ABC is a middle-class, middle-aged response to an epidemic, all overlaid with a kind of morality that doesn't hold any more," comments Mary Crewe, director of the Centre for the Study of Aids at the University of Pretoria. [4] "Governments should be promoting condom use, not treating condoms like contraband," said Jonathan Cohen, of Human Rights Watch. "The clear result of restricting access to condoms will be more lives lost to AIDS."[5]

Clear as a bell to Mr Cohen, perhaps, but Ugandans feel differently. In fact, African countries where condoms are freely available also have some of the highest rates of HIV prevalence in the world. An incredible 37 per cent of all adults in Botswana are HIV positive -- compared to less than one per cent in the US and Western Europe. Its president, Festus Mogae, has been sending a bleak message to his people in recent times: abstain from unsafe sex, or die.[6]

So, in the light of Western scepticism about home remedies, the best news on the African AIDS front came last month with an effective endorsement of the ABC approach by some of the world's leading figures in the war on AIDS.

In a statement in the world's leading medical journal, The Lancet[7], 140 public figures, activists, public health workers, scientists and academics from 36 countries, agreed on three basic principles. The signatories included such disparate figures as President Museveni, South Africa's Nobel laureate Archbishop Desmond Tutu, AIDS groups, abortion-rights groups, and church groups.

Astonishingly, the media almost completely overlooked one of the year's few good-news stories in the fight against AIDS.

The first principle endorsed by these experts is that approaches must be adapted to local cultures and respect human rights. Second, that the ABC approach is legitimate. Third, that it is legitimate for community-based groups, including religious organisations, to tell people to change their sexual behaviour - not just to offer them "non-judgemental" medical solutions.

Even though The Lancet statement calls for condom use for sexually active people and "accurate and complete" information about condoms, it casts strategies based on abstinence and fidelity (known as "zero-grazing" in Uganda) in a surprisingly positive light. The key sentences are worth citing in full:

"Thus, when targeting young people, for those who have not started sexual activity the first priority should be to encourage abstinence or delay of sexual onset, hence emphasising risk avoidance as the best way to prevent HIV and other sexually transmitted infections as well as unwanted pregnancy. After sexual debut, returning to abstinence or being mutually faithful with an uninfected partner are the most effective ways of avoiding infection... [P]arents should be supported in communicating their values and expectations about sexual behaviour... When targeting sexually active adults, the first priority should be to promote mutual fidelity with an uninfected partner as the best way to assure avoidance of HIV infection."

Finding common ground was such a remarkable achievement that one of the experts who drafted the consensus was disappointed at the meagre media coverage.

"I was surprised that a landmark statement signed by 140 scientists plus the President of Uganda, got so little notice," said Dr Edward C. Green, a senior research scientist at the Harvard Centre for Population and Development Studies, and a member of President Bush's advisory council on HIV and AIDS, in an email interview.

"Maybe journalists who have been sceptical of ABC took it as a rebuke? Or they thought it was so common sense as to not require commentary? Or this is old news since ABC is now official US policy? But even if the last is true, the new policy is hardly being implemented as of yet. It is very slow to get started. Old habits are hard to break and there is incredible resistance to what for Africans is indeed just plain common sense."

Janet Museveni's enthusiasm for "self-control" is normally derided as an unrealistic goal for youth. However, Dr. Green points out that Uganda's success is due more to an emphasis on fidelity than abstinence, especially in a society where people marry at a quite an early age.

"The word abstinence has often been misused," he says. "Most people aged 15 to 49 (the age group in which we track HIV infection rates and behavioural trends) are not abstaining. This is not realistic. Uganda's dominant message was 'Stick to one partner!' or 'Zero-Graze' or 'Love Faithfully!' The major behavioural change in Uganda was not 'abstinence'; it was fidelity or monogamy."

In a recent book, Rethinking AIDS Prevention [8], and elsewhere, Dr. Green argues that there is a fundamental difference between fighting AIDS in the West and in Africa. In the West, a risk-reduction model has been followed on the premise that tightly-knit high-risk groups such as homosexuals and drug addicts cannot change their behaviour and that the best way of coping with the disease is by promoting condoms. Outside of high-risk groups in the general population this model is inappropriate -- but it was imposed on Africans anyway.

"What Americans and Europeans forgot when designing these approaches is that African cultures are still largely bound by tradition and religion, and that they have not undergone the general sexual revolution, and certainly not the gay-lesbian revolution, of the West. This should have been Anthropology 101," Dr. Green wrote last year in a journal article.[9] Westerners have to realise that Africans do not share their horror of "moralising about behaviour".

In fact, Ugandans seem to enjoy moralising. "Abstinence, oh-yeah!" was the catchcry at last week's rally of abstainers in Kampala.[10] Janet Museveni describes her government's policy as "behaviour development, behaviour reinforcement and behaviour change". And her husband is proud to trumpet chastity. "We made it our highest priority to convince our people to return to their traditional values of chastity and faithfulness or, failing that, to use condoms," President Museveni told American pharmaceutical executives last year. "The alternative was decimation." [11]

Or, as Dr. Green put it in our interview, "How did we ever think we could solve AIDS with just condoms, drugs and testing? That would be like solving the global lung cancer problem with just better filters on cigarettes, and lower-tar cigarettes."

Michael Cook is the editor of BioEdge, an email newsletter on bioethics. Email: mcook@australasianbioethics.org

NOTES

[1] "Virgins rejoice in HIV battle". New Vision (Uganda), 10 December 2004

[2] "Museveni Opposes Condoms in Schools", AllAfrica.com, 30 November 2004

[3] "Bush Seeks 'Immediate Release' of $500M to 15 PEPFAR Countries", kaisernetwork.org, 24 June 2004

[4] "Abstinence row overshadows Aids Day", Daily Dispatch (South Africa), 30 November 2004

[5] World AIDS Day: Condom Restrictions Cost Lives, Human Rights Watch

[6] "Stark AIDS message for Botswana". BBC, November 30, 2004

[7] "The time has come for common ground on preventing sexual transmission of HIV", The Lancet, 27 November 2004

[8] Green, E.C., Rethinking AIDS Prevention. Westport, Ct.: Praeger Press, Greenwood Publishers (2003).

[9] "Culture Clash and AIDS Prevention.", The Responsive Community. Vol. 13(4); 4-9 2003.

[10] "Ugandan virgins rally to promote abstinence". Reuters, December 10, 2004.

[11] Joseph Loconte, "The White House Initiative to Combat AIDS: Learning from Uganda", Heritage Foundation, Executive Summary #1692, 30 September 2003.