The ABCs of AIDS - a response to

Our response here thus aims to frame the issues Edward C. Green and Alison Herling Ruark address (see AIDS and the Churches: Getting the Story Right) as we understand them, and respond briefly. We hope it is taken as an invitation to dialogue and continuing exchange. I have great respect for the motivations and intent of Green and Ruark and hope they accord us the same.

What the Green and Ruark commentary does not address is the context and purpose of the Berkley Center report. The report's purpose is to provide information and encourage dialogue; it is an academic and not an advocacy document, and it sets out to offer a straightforward and honest assessment of how often sensitive issues are framed and discussed. It provides a broad overview of how the extraordinary array of often very different faith-inspired institutions and activities are approaching HIV/AIDS. It seeks to bridge large communication gulfs that impede understanding, learning, and partnership among many faith and secular organizations. Its foundation is that faith communities have large and underappreciated roles to play, and that lack of communication, mutual preconceptions, and disparaging views are a barrier to both cooperation and partnership, undermining many programs and policy dialogue. The Berkley Center report is a living document, to be elaborated and updated; ongoing learning is part of the endeavor.

The Berkley Report takes as a backdrop something acknowledged time and again in widely varied discussions about religion and HIV/AIDS: that religion is "part of the problem, part of the solution." This perspective needs to be part of the discourse. Within the vastly varied religious communities that are in some fashion engaged by the HIV/AIDS issues, there is a plethora of reactions. I have heard deeply thoughtful religious leaders acknowledge that they came late to an appreciation of the pandemic, that preconceptions influenced their initial reactions, that some leaders have taken harsh stances (for example, refusing to bury people whose families acknowledge that they died of AIDS), and that their focus on ideal behaviors can obscure what is real and live. Nevertheless, the deep compassion, outreach, and action of many faith communities are inspiring. Yet many secular organizations still have scant appreciation of the active roles that faith institutions play and thus tend to distort their motives.

The Green and Ruark article argues that the Berkley Center report gives too little "credit" to the success of abstinence and faithfulness efforts, especially in Uganda. A recent World Bank strategic document says of priorities on HIV/AIDS: "prevention, prevention, prevention." This reflects an appreciation that the war against the pandemic, despite enormous resources, is not yet succeeding, as new infections continue to increase. Treating one's way out is not a solution; it would be absurd to allow people to get sick and focus on giving them treatment. The basic facts are clear: Sexual behavior and above all multiple simultaneous sexual partners are the problem, because that is how infection is spread. There is no ambivalence there. The questions turn on what can change behavior. The Berkley Center report, somewhat obliquely (as this is not the centerpiece of the argument), notes that there are competing moralities at work. This is pretty obvious, and even different faith traditions have different views — for example, on homosexuality and loving relationships outside marriage. But the real question still is what influences behavior. Is it preaching, or knowledge, or political leadership, or results of testing, or seeing people around suffering and dying?

My own view (based on hundreds of discussions and experience in some fifty countries) is that two factors have paramount importance: information, so people can make informed decisions, and joint leadership across sectors (the more unlikely the better). The impact is enormous where religious and political leaders have joined forces (as in Uganda and Senegal). The broad HIV/AIDS community, based on mounting evidence, is rightly and highly skeptical of approaches that focus solely on promoting abstinence and faithfulness (however desirable these goals). The "best practice" these days is an approach that has multiple layers and approaches, used for different circumstances. More complex questions arise as to how partners with different ethics work together. Again, pragmatism shows that, driven by caring, good sense, and the realities of each situation, communities can work out approaches where no institution is asked to work against its basic values but where there is respect for differences and a commitment to a broader end.

The Berkley Center did review the very extensive literature about both scientific and more operational findings that pertain to these debates. We underscored the unfortunate mingling (on all sides) of scientific, ethical, and moral factors in assessing evidence. My view is that the jury is very much out, but that different approaches work in different situations. A thorough review of the arguments for and against abstinence programs in Uganda specifically is available on the Human Rights Watch website. A summary of the extensive Mathematica evaluation of U.S. abstinence and related programs can be found at www.mathematica-mpr.com/welfare/abstinence.asp.

In any event, the Uganda case is fiercely debated these days, and Dr. Green is a pioneer in research about what Uganda's success means. But the story is evolving (with worrying recent trends), and the significance of reduced infection rates is hotly debated. The Berkley report and the World Bank case study on Uganda presented at the Shanghai Scaling Up Poverty Conference reflect widely held practitioner views that the causality is complex and multiple and that the "Green explanation" is an important part of the story — but by no means the whole.

To be crystal clear, we are not "uncomfortable" with abstinence/faithfulness messages, and fully recognize that sexual behavior is a large part of the issue, but are persuaded that a single approach is not only unrealistic but damages the multipronged approaches that are vital to adapting to differing circumstances and reaching different groups and constituencies. The results of abstinence-only approaches is at best mixed. Let's keep studying the evidence and look to multiple approaches that focus above all on information and leadership for the present.

The Green and Ruark article sees "conventional wisdom" in the stress that the Berkley Center report places on HIV/AIDS as a development issue, linked to poverty. Links between poverty and HIV/AIDS are obviously very complex: Many wealthy people succumb, and, most tragically, intelligent people like teachers have higher incidence levels. But HIV/AIDS is surely a development issue, and poor countries with terrible health infrastructures are poorly equipped to respond to the pandemic. Poor people tend to have less knowledge, less ability to assess scientific information, and fewer options to earn their livings. The operational point is that HIV/AIDS needs to be part of the development approach in a series of complex and interlocking ways, especially in poorer countries with severe fiscal constraints. And everywhere, despite some complexities around education levels and HIV/AIDS, information and education are keys to the long-term solution.

Too many areas of Africa are still shaken by conflicts, and HIV/AIDS is part of that story. Ironically, conflicts such as Mozambique's civil war can retard the spread of the pandemic, because communications are truncated and population movements are inhibited. The onset of peace and reconciliation can reverse these conditions, with devastating consequences. Ironically, people with few resources may have fewer sexual partners. But the Mozambique story is a horrible morality story, as the pandemic spread with incredible speed as people resettled and resumed their normal lives after peace. The emerging understanding of how widespread sexual violence is, especially in conflict situations, also points to transmission routes; the potential for moral and pragmatic leadership by faith leaders is enormous.

Stigma against people with HIV/AIDS is pretty widespread — even children suffer it in schools across many countries — and faith communities are by no means alone in stigmatizing people. But with their moral voice and moral sway, their role has special importance, and wise faith leaders work hard to combat such tendencies. The moral challenge that faces many faith communities is how to accept and love people when you disapprove of their behavior.

The Green and Ruark article also comments on the Berkley-report discussion of the active debate about the ABC approach. It generates passions on all sides: At the Toronto HIV/AIDS meeting, crowds booed people who mentioned ABC. To be forthright, I am convinced that, despite the strong commonsense appeal of ABC, it is time to move on to richer and more complex slogans. Pastor Rick Warren illustrates how this can work to the common good. He talks of STOP and SLOW, appreciating that both are necessary: STOP means "Save sex for marriage, Teach men to respect women, Offer treatment in churches, and Pledge yourself to one partner"; SLOW means "Supply condoms, Limit number of partners, Offer needle exchange, and Wait for sex until older." Again, multiple approaches and slogans are what we need.

The diversity of faith traditions, teachings, and communities is remarkable. The central reality is that they matter and need to be studied, debated, and assessed. Harsh polemics may be inevitable where moralities clash and facts are not easy to establish, but they do not help much. What we are after is thoughtful and respectful engagement across different traditions and perceptions of what is happening. The common ground that HIV/AIDS is devastating communities and causing untold suffering calls for working together.

Katherine Marshall
Berkley Center for Religion, Peace, and World Affairs
Georgetown University
Washington, D.C.

Edward C. Green replies:

Much of the confusion over identifying effective responses to AIDS epidemics could be cleared up if only the fundamental differences between two basic types of epidemics were acknowledged and truly understood. In most of the world, we find so-called concentrated epidemics, where most HIV infections are found among sex workers, gay men, and injecting drug users. The global AIDS industry got off to the wrong start twenty years ago by assuming this was the only type of epidemic we would face. AIDS-prevention thinking went something like this: Gay men don't want to change their behavior, thanks very much; drug users cannot change behavior because they're addicted; and sex workers need the money they make and are therefore unlikely to change their behavior. So, if we start with the premise that sexual behavior cannot — or should not, for some — be changed, we end up with a very limited set of prevention options, namely risk or harm reduction. We do not get at (or "interfere with") the underlying behavior driving the epidemic; we simply reduce the risk or harm by providing condoms, clean needles, treating the curable sexually transmitted diseases, etc.

Katherine Marshall mentions that most of the AIDS communities — at least the Westerners among them — are very unhappy at the prospect of changing sexual behavior. Readers should understand that various alliances of Western-controlled AIDS activists that make up this "community" are by no means representative of any sort of national or naturally aggregating population. At what other forum than a global AIDS conference do we encounter loud booing at the very mention of words like faithfulness or abstinence? These audiences should not be taken as representative of countries, regions, or anything else.

At what other forum than a global AIDS conference do we encounter loud booing at the very mention of words like faithfulness or abstinence? These audiences should not be taken as representative of countries, regions, or anything else.

What is the other basic type of HIV epidemic? Some of us began to realize many years ago that AIDS epidemics in eastern and southern Africa were completely different from the types of epidemics that generated what was to become the universal response. In the "hyperepidemics" of parts of Africa, most HIV is found in the general population, among regular people, not high-risk groups. Now in Africa, most people are rural, religious, and fairly conservative when it comes to sexual behavior, despite lurid stereotypes of oversexed African men forcing themselves on women and girls without a thought. Africans do not have the reflexive, knee-jerk negative response to words like abstinence and fidelity, such as we find among Western AIDS activists. Most Africans in fact like these ideas and the programs that ought to develop around them (but are often shot down by Western donors). It is we Western AIDS experts that have the negative bias about restraining sexual behavior in any way, not Africans.

We already discussed Uganda in our original essay. We now have examples from seven or eight African countries where the proportion of men and women reporting more than one sexual partner in the past year has declined significantly, and this is followed by a general decline in HIV prevalence at the national level. We do not see any such associations with levels of condom use, however measured. In fact, we consistently see an unwanted association between higher levels of condom use and higher HIV-infection levels.

Again, recognizing the different transmission patterns and AIDS-prevention requirements of generalized versus concentrated epidemics would resolve a lot of highly emotional and bitter argument over AIDS prevention. It should also be understood that one does not necessarily need to take a religious or moral approach to transmit the public-health message about the health and survival merits of restraining sexual behavior. We say this because the word morality seems to be anathema to so many Euro-American AIDS activists. Messages of fidelity, monogamy, and delay of first sexual experience can be transmitted in a secular manner — for example, through life-skills programs at schools — and/or these messages can come through religious leaders and organizations. We don't know which of these approaches are best. What we do know is that, except for Uganda and a number of FBOs around Africa, there's been little or no financial support for programs of sexual-behavior change, even though these are precisely what are needed most in the hyperepidemics of Africa. We in the West need to get past seeing African epidemics as American epidemics. We need to overcome our ideological biases, our financial self-interests, and we need to do a good deal of listening and learning from Africans. Think about it: We in the United States have not brought down our own HIV-infection rates, yet we are advising Africans countries that have brought down HIV infection about how to prevent AIDS. We should be learning from Africans.

We too think that Rick and Kay Warren's use of SLOW/STOP to capture risk-reduction (SLOW) and risk-avoidance (STOP) measures is masterful and includes, of course, the critical ABC (Abstain, Be faithful, use Condoms) behaviors. I was one of the first colleagues from whom Rick and Kay Warren sought feedback on the new acronyms. SLOW/STOP is great for teaching purposes, and I have used it often myself. But it is also more complicated than ABC — it requires remembering more words — and we are not aware of any country in Africa or elsewhere that has adopted SLOW/STOP as a national AIDS policy, whereas ABC (partly because of its simplicity) continues to be widely used in Africa, including in national AIDS policies and strategies. While many in the AIDS community may feel it is time to "move on" from ABC, this is really the decision of countries and communities themselves. "ABC" is a simple, life-saving message, and perhaps we "experts" should show greater humility when suggesting that our improvements are necessary.