Broken Promises: How the AIDS Establishment has Betrayed the Developing World

Harvard University researcher Edward Green rose to prominence in the AIDS controversy with his 2003 book, Rethinking AIDS Prevention. His new book, Broken Promises: How the AIDS Establishment has Betrayed the Developing World, chronicles the continuing battle over how to prevent the spread of HIV/AIDS in sub-Saharan Africa. Green, a key player in the struggle, documents how two radically different strategies have competed for funding and support.

The first is ABC: Abstinence (or delay of sexual debut); Be faithful (only one sexual partner); Condoms for those who engage in high risk behavior in spite of warnings and for couples where one is already infected. This is a risk elimination strategy.

The second is the condom code. The supporters of condoms as the primary prevention method insist that any program be "sex positive". In other words, there is no need for anyone to change their sexual behavior as long as they use a condom every time. This is a risk reduction strategy since new infections would not be eliminated, only reduced, given the known failure rate of condoms and the fact that even the most motivated sexually active persons rarely achieve 100 per cent usage.

Green and others studied the results of condom programs:  

We simply compared the prevalence of HIV among people in three groups: those who never used condoms, sometimes did, and always did. And we found no association between HIV status and consistent condom use ... those who reported using a condom with every sex act were just as likely to have HIV as those who had never used one at all ... we also found that inconsistent users had the same or greater HIV prevalence as non-users. And sporadic use is the norm in Africa and in countries everywhere. (pp 223-4)

As an anthropologist with years of experience in field work, Green was trained to listen to the local people. He familiarized himself with their traditions and customs. He takes great pains in the book to point out that he is not a social conservative or a religious zealot, but a professional who respects the people he studies. Before becoming involved in the battle over AIDS prevention, he worked for population control groups and on a condom marketing study. He approached the problem of AIDS in sub-Saharan Africa with an open mind, seeking to discover which strategies worked (that is, decreased new infections) and which strategies failed.

In 1993 he visited Uganda as part of a team studying sexually transmitted diseases, including HIV, among prostitutes. While there, he saw the success of an indigenous HIV prevention program, the original ABC. Early in the epidemic President Museveni of Uganda recognized the danger posed by HIV and spearheaded a comprehensive program which stressed fidelity and delay of sexual debut. Museveni engaged the entire society in the effort to prevent new infections. He included faith based organizations and traditional healers in the effort. Fear was used to spur behavior change. The program had been successful and new infections had decreased.

Unfortunately, western experts arrived on the scene with their sex-positive strategy. A and B were pushed into the background and all the money and marketing went to C. However, in spite of well funded marketing campaigns in Uganda, as well as in other African countries where this strategy was implemented, new infections increased rather than decreased. The experts reacted to this failure by insisting that they needed more funding, and so more funding was provided.

The evidence for the failure of condom marketing and distribution programs and the success of fidelity/delay was clear, yet many of western experts and those funding prevention programs continued to insist that condoms were the only solution and all Africa needed was more condoms. Not only was the money spent on these programs wasted, but money to deal with Africa's other health care needs dried up.

Through his first book, Rethinking AIDS Prevention, Green had been able to convince some key leaders that behavior change was more effective than condom promotion. Others were convinced by their own research that prevention should focus on fidelity/delay, with condoms used only as a back-up. The Bush administration was supportive, but those pushing sex-positive condom marketing pushed back. In Broken Promises, Green reports on how the supporters of positive behavior change would win one battle, only to lose the next.

Green was facing an entrenched AIDS establishment run by gay AIDS activists, population controllers, and suppliers of condoms, all committed to the sexual revolution and determined to impose that revolution on Africa. Green was appalled by the racism he found among those involved in condom promotion. They commented privately that AIDS spread in Africa because African men are incapable of controlling their sexual urges and therefore the only answer is condoms. This in spite of research which showed that Africans when faced with the facts about HIV transmission are able to substantially change their behavior and these changes reduced new infections in several countries.

In 2004 in Washington DC, Green gave a 40 minute slide presentation to a conference of specialists in the field of AIDS. He spoke on how Uganda's program emphasizing abstinence, be faithful, and condoms as a last resort had brought down HIV prevalence. He received muted applause. Then a female college student came to the microphone and exclaimed, "I think people should be able to have as much sex as they want, with as many people as they want." She received a thunderous, standing ovation.

In spite of mounting evidence of the failure of condom programs, the AIDS establishment ridiculed as anti-scientific anyone who did not support their strategy. When Pope Benedict XVI was asked about AIDS in Africa, he said that "if Africans do not help by responsible behavior, the problem cannot be overcome by the distribution of prophylactics. On the contrary, they increase it." For this he was roundly condemned, but according to Green, "He had summarized the best current research on AIDS prevention in Africa."

Green says that the rejection of programs with records of success was driven by a rigid set of assumptions:

First, sexual freedom — the belief that "each person has the inalienable right to choose his or her sexual behavior and express it freely, without inhibiting, judgments or censure from society ... this value has trumped essentially all other concerns, even health and life."

Broken Promises: How the AIDS Establishment has Betrayed the Developing World by Edward C. Green

Second, harm reduction — the assumption that you can't change behavior but only reduce the consequences of it, an assumption the Uganda program proved wrong.

Third, cultural relativism — the assumption that no one has the right to criticize cultural practices such as prostitution or gay promiscuity or sex between adults and adolescents. For example, it is well known that in some African countries older men entice girls into sex with gifts in what is known as "the sugar daddy phenomenon". Rather than condemning this sexual abuse of minors, says Green, an advertisement for Botswana, funded by American taxpayers, "showed a fourteen-year-old girl who smilingly tells us she had added flavor (and by implication, gifts and an allowance) to her life by entering into a sexual relationship with a man twice or more her age and she could do it by using Lovers Plus condoms 'every time'." Fortunately, in that case public outrage forced the US contractor to pull the ad.

These three assumptions led to "AIDS exceptionalism" — the decision to exempt HIV/AIDS from standard public health practices such as contact tracing, partner notification, routine testing, and encouraging behavior change. This was justified by claiming that it was done out of "respect for those already ill". In other words, family and sexual partners of the infected would become infected because the sex positive AIDS establishment didn't want to make those already infected feel guilty about their behavior.

HIV has infected some forty-six million people in Africa and eighteen million have died. Green believes this could have been brought under control two decades ago, had ABC been employed, but because it was not "we are now experiencing the greatest avoidable epidemic in history."