Rethinking AIDS Prevention: Learning from Successes in Developing Countries.  Edward C. Green, Westport, CT: Praeger, 2003. 374 pp.

In Rethinking AIDS Prevention, Edward Green controversially calls for a paradigm shift away from donor myopia concerning condoms in favor of a focus on Primary Behavior Change (PBC), which includes fidelity, partner reduction, and delay of sexual debut. Although it isn’t an entirely new argument, Green presents excellent evidence of the inadequacies of condom campaigns in Africa and successes of PBC in developing countries around the world.

Condoms, though certainly appropriate only for high-risk groups such as commercial sex workers and truck drivers, are unfortunately touted as the only realistic prevention for mainstream society even though they are exogenous, inconsistently used, and less than 100% effective. Green argues that PBC is actually a better method of disease prevention for most Africans. The goal here is behavior change, which runs much deeper than simply turning society on to condoms and/or drugs, two technological solutions that may in fact actually increase risky behavior. Studies have shown that by delaying sexual debut of young adults, their lifetime number of partners greatly decreases. Therefore, a wider range of programs that focus on PBC yet still incorporate condoms when appropriate, are desperately needed.

If the evidence presented by Green is accurate, then why is so much international aid being dumped into these ill-suited programs? His answer is that donors overlook it, ignore it, or do not want to believe it. Some of the problems include biased surveys that focus on condom usage at the cost of questions on other forms of AIDS prevention; the ease of monitoring condom usage compared to the difficulty of measuring PBC; and programs that are based on western post-sexual revolution ideology. This last excuse means that “those who work in public health are loathe to appear to make value judgments about sexual behavior. Therefore they are more comfortable promoting condoms and treating STDs than advocating having fewer partners” (62). The pre-AIDS American sexual revolution instigated free love and the desire to avoid sexual judgments. This openness was reflected in policy decisions affecting a continent that had not undergone the same revolution. In the race to avoid association with the religious right, donors missed the fact that socio-cultural variables are just as important as medical. The only way to turn this 20-year oversight around is to overcome biases against partner reduction and abstinence and actually listen to Africans because they, like many Americans, are indeed choosing Abstinence and Being Faithful over Condoms (ABC). Green argues that PBC in
Africa is cheaper than anti-retrovirals and can be achieved for less than US$ 1.80 per person. He presents a compelling argument for both the health behavior specialist and the layperson in search of an alternative take on the behavioral potential to overcome high rates of HIV transmission. He mixes academic research with international articles and profiles in order to present a colorful, informative account of a topic too many other authors paint in redundant shades. The point is that programs must reprioritize and expand further than the promotion of condoms, and although the argument is certainly persuasive, it does require minor work. 

To begin with, Green ties in several case studies (
Zambia, Senegal, Thailand, Jamaica) but focuses mainly on Uganda’s success with PBC programs, which is attributed to the government’s ‘zero grazing’ campaign in the 1980s. By the time the donors entered and insisted on condom promotion, infection rates were already declining. USAID and the World Bank supported much of President Museveni’s approach, so Uganda has had more PBC than other countries. Education began in the late 1980s and the government advocated female empowerment, media usage, and the mobilization of religious leaders. It also promoted open discussion of the disease and allied with NGOs, political leaders, teachers, and traditional healers. The 1990s brought to Uganda much of what occurs in the rest of Africa: condom marketing, decentralization, salaried workers, and special programs for high-risk persons.

This part of his analysis is not problematic. But there is a difficulty in measuring which variables had the most influence, and it is entirely possible that Uganda’s success is due not to the message, but the messengers and their quick response. The government coordinated quickly to avoid ambiguity, it promoted stigma-free discussion and created alliances, and there was an autonomous, non-sectarian women’s movement. These combined factors are virtually invisible elsewhere on the continent, even now. Other countries instead offer confusing and overlapping messages. Politicians are unconcerned with the disease, equal rights laws that are not enforced, and competition between AIDS-prevention organizations is prevalent. We cannot know if decreased rates would have followed anything other than a PBC message, but the possibility must be kept in consideration, especially since some people are using condoms.

Green too briefly touches on the role of interpersonal communication and the use of discussion forums even though these are activities that target tailored messages to each region. Outside studies show that behavior change stemming from local developmental theatre is difficult to measure, yet small scale, personal drama of this sort can be more effective than mass media, which overlooks particularities. Often included in this form of education are Life Skills programs that teach women how to negotiate. Uganda’s implementation of these was effective, yet South African school programs (such as that of the organization DramAide), although successful in doses, seem not to have permeated enough of society to stop the infection rate from climbing.

Governments should certainly take note of Rethinking AIDS Prevention because the role of poverty here is two-fold. The HIV infection rate is driven by affluent men; those with “cash, car and [a] cellphone” who attract more partners (313). But female poverty leads to transactional sex since women are subordinates due to economic dependence and traditions of male dominance. Governments must make a stronger effort to affect change through employment opportunities for women and the enforcement of rape and marriage laws, otherwise women are stuck in a situation where saying no is at best financially unsound, and at worst, deadly.

More research is certainly needed into the PBC hypothesis, but it’s on the right track thus far. Green is currently advising the Bush administration, which brings up the curious question of whether or not there is any real danger of placing the end goal above the intentions (which occurs when programs refuse or are banned from discussing truthfully all possible routes of prevention). It may be a difficult pill for many in AIDS work to swallow, but in this case the end must justify the means. Too much money has been spent recklessly in pursuit of something that simply does not work. But Green notes that the condom and anti-retroviral companies stand to lose a chunk of money if PBC takes precedence over condoms, and it follows that if the international patent rights battle is any indication, these companies will not relinquish this control without a fight. This has, sadly, become the norm in the field of AIDS policy in
Africa today. 

Kenly Greer Fenio
of Florida