The Greening of AIDS Prevention

Broken Promises: How the AIDS Establishment Has Betrayed the Developing World is the recent book by Edward C. Green, the former director of the AIDS Prevention Research Project at the Harvard School of Health. He has been conducting research in Africa, Southeast Asia, and other parts of the world for upwards of three decades, in the fields of applied anthropology and international health. In an interview with National Review Online, Green, current director of the New Paradigm Fund, talks about clarifying recent AIDS research and how it vindicates some controversial positions taken by the likes of the Pope in Rome and George W. Bush.

Kathryn Jean Lopez:   In 2009, on his way to Africa, Pope Benedict XVI said: "If there is no human dimension, if Africans do not help by responsible behavior, the problem cannot be overcome by the distribution of prophylactics. On the contrary, they increase it." Does this recent study even the New York Times noticed vindicate Pope Benedict with science?

Edward C. Green:   Yes, and Broken Promises is an extended vindication of Pope Benedict, at least as far as the so-called generalized HIV epidemics of Africa are concerned. And this is in fact what the Pope was talking about. To summarize: We have seen HIV decline in Africa when the number of multiple and concurrent sexual partnerships has declined and when more people have been faithful. The role of condoms in HIV success stories such as Uganda and Zimbabwe has been debated, but we have certainly never seen more condom use alone bring about declines in HIV. The parts of the continent with the highest condom use – in southern Africa – have the highest HIV rates, and at the level of individuals, there tends to be an association between condom use and being HIV infected, perhaps because people who use condoms take more sexual risks. When you stop and think about it, who uses condoms? It's rarely married people or even familiar partners in ongoing relationships. Condoms are mostly used with sex workers and casual sex partners. When condom-user rates rise, it might be because casual or commercial sex is on the rise.

There is, by the way, some evidence that consistent condom use among sex workers reduces risk of HIV transmission to customers. The Pope even said something along these lines (in 2010, as I recall). The evidence for this is strongest in Thailand. Yet even there, considered a model for a condom-focused AIDS-prevention program, high condom-user rates proved hard or impossible to sustain over time.

Lopez:   The latest study, though, comes from The Lancet. Why should we buy anything The Lancet sells? Isn't it the same place that called the Pope's previously noted comments "outrageous and wildly inaccurate"?

Green:   You have a point there! Although we are talking about one of the most prestigious medical journals in the world, the recent editor (and I haven't checked to see if he's still there) certainly had a pro-condom bias. On the other hand, Dr. Norman Hearst and I published a letter in defense of the Pope's comments in The Lancet, a few months after its anti-Pope editorial. So one hopes that truth and science prevail in the end. At least unpopular viewpoints are more often getting published nowadays.

I know all about sexual liberation and I like to say I was at least a two-star general in the Sixties Sexual Revolution, but we have to ask ourselves, when we are using literally billions of taxpayer dollars, is our aim to spread the Gospel of Sexual Freedom, or is it to reduce HIV infections?

Lopez:   Has AIDS aid, when it comes to Africa, been co-opted by ideology? Is this an opening for something to change?

Green:   Co-opted by ideology? Indeed it has. The original title for my new book was to be AIDS and Ideology, but my publisher thought that sounded too cerebral. In my book, I describe not only the financial self-interest of organizations geared to continue lucrative U.S. government contracts and grants in family planning (contraception); I also show how an ideology of Sexual Liberation über Alles has pretty much removed most public health or medical value from what we call global AIDS prevention. Now, as an aging hippie who came of age in the 1960s, I know all about sexual liberation and I like to say I was at least a two-star general in the Sixties Sexual Revolution, but we have to ask ourselves, when we are using literally billions of taxpayer dollars, is our aim to spread the Gospel of Sexual Freedom, or is it to reduce HIV infections? When you break down the elements of global AIDS prevention, it's hard to escape the conclusion that it's often more about the former, although I think that much of this operates below the level of conscious decision-making, and/or disguises itself as political correctness or being non-judgmental.

I sometimes put it another way: If our aim is to reduce HIV infection rates (and that's a big "if"), then why are we so reluctant to talk about partners' being faithful to one another, or to mention the dreaded A-word, abstinence (which was known in Uganda as "delaying sexual debut")? Why do we restrict ourselves to drugs and devices (such as condoms)? Actually, things have changed for the better, to some extent.

Lopez:   Is your book – and increasing research, including the recent Lancet piece the New York Times reported on – a vindication, too, for the direction that George W. Bush took with funding, with his PEPFAR program? How much of that is still intact?

Green:   Well, this is not easy to answer. PEPFAR (created under George W. Bush) and USAID adopted the ABC policy (Abstain, Be faithful, or use a Condom) for the so-called generalized HIV epidemics of Africa, and perhaps part of the Caribbean as well. But policy changes at the top do not change the culture of organizations such as USAID (to which I remain indebted for a long, satisfying career as a consultant) or the CDC overnight, or even over an eight-year period. USAID, from which PEPFAR pretty much sprang, more or less specialized in family planning, and when the U.S. government first geared up to address AIDS in Africa and beyond in the mid-1980s, it naturally thought about such things as promoting condoms for "dual purpose": avoiding unwanted pregnancy and death from AIDS. That seemed like a no-brainer, but alas this approach didn't work in AIDS – and it didn't work very well in family planning either.

As I say in my book, what we see in the first seven or eight countries in Africa where HIV prevalence has declined is that a few years earlier, the proportion of men and women reporting more than one sex partner in the previous year had declined significantly. Monogamy in fact is the norm pretty much everywhere, except maybe in southern Africa...

I go into all this in detail in my book. Suffice it to say here that the first two components of the ABC policy were vigorously and effectively resisted by many in USAID and PEPFAR. Condom supply and promotion greatly increased during the two Bush administrations. In spite of our wrongheaded policies, most people have common sense, and so many or most Africans changed their sexual behavior in the direction of greater caution and fewer partners. HIV prevalence has been declining in Africa since about 2000. Curiously, in the Institute of Medicine's "assessment" of PEPFAR, nobody thought to mention this decline in infection rates.

The weak argument was "we are not sure we can take credit for such changes." True, but this report went even further and stated that "the rate of new HIV infections continues to grow." Not true! Even the U.N. quietly admitted this on its website not too many months after this IOM report.

Lopez:   But isn't "fidelity" quite idealistic about human behavior? Dangerously so?

Green:   Not at all. As I say in my book, what we see in the first seven or eight countries in Africa where HIV prevalence has declined is that a few years earlier, the proportion of men and women reporting more than one sex partner in the previous year had declined significantly. Monogamy in fact is the norm pretty much everywhere, except maybe in southern Africa, where significant minorities of men and even women have multiple and concurrent partners. And contrary to Western, quasi-racist stereotypes, Africans tend to have a lower lifetime number of partners than Americans, Brits, or Western Europeans. Even The Lancet got around to acknowledging this a few years ago (although the article, by Wellings et al., concluded that this just goes to show, we need more condoms!).

Lopez:   Have you seen minds change on AIDS policy over the years?

Green:   Yes, but not nearly as many as one would want to see. Faithfulness or "not having multiple and concurrent sex partners" is now part of what PEPFAR, USAID, and some other donors promote and fund. There are currently programs to promote fidelity in the dozen or so countries in Africa with the highest HIV rates. Alas, these programs are threatened by the current promise that we can eradicate AIDS if only we put enough money into drugs. I am talking about "treatment as prevention," the belief that if we get everyone on ARV drugs, we can lower viral loads (degree of infectiousness), and this is how we can best prevent AIDS.

Don't get me started on this topic, but you may remember my colleagues and I wrote something for National Review Online last June.

HIV rates are declining in most of the world, except for our country and our friends in the U.K. and also in other European and Western countries, including, I think, Canada and Australia. Therefore we must be doing something wrong in AIDS prevention both here and in the U.K. (and elsewhere).

Lopez:   How can aid groups use this information constructively?

Green:   What we need to understand is that eradicating AIDS by somehow getting everyone on treatment (and note that we cannot find all of the HIV-infected even in America, let alone in remoter parts of the Third World) – oh, and part of this idea is to get expensive ARV drugs to those at high risk of becoming HIV infected, before they are infected – well, this is just a pipe dream. We couldn't eradicate syphilis a few decades ago, and that required only a single injection. If this didn't work in America, how can we expect something that is much more complicated and expensive to treat (AIDS) to be a candidate for eradication in Africa and everywhere else in the world?

Now because I myself have loved ones who are HIV-infected, I like to say: Keep on trying with the drugs and with condoms, but don't bet the house and the farm on this approach. Do what Uganda and a few other places once did (before "we" interfered), which was to promote faithfulness in marriage – or let us say in partnerships; the virus doesn't know whether partners are married or not – and encouraging delayed sexual debut, or later age of first sex.

Lopez:   Are there domestic lessons here as well?

Green:   Yes, there are. HIV rates are declining in most of the world, except for our country and our friends in the U.K. and also in other European and Western countries, including, I think, Canada and Australia. Therefore we must be doing something wrong in AIDS prevention both here and in the U.K. (and elsewhere). In both countries, MSM (men who have sex with men) comprise the sub-population with the highest HIV-infection rates. Our prevention strategy is to make gay men knowledgeable about AIDS risks and prevention, and for prevention to be based on condoms and drugs. There is little or no attention given to influencing behavior in the direction of greater caution. Alas, condoms and drugs seem to work no better in the U.S. or U.K. than they do in Africa, even though we're talking about two very different types of HIV epidemics.

Interestingly, HIV-infection rates have declined among IDUs (injecting drug users) in the U.S. I'm not sure we know the reasons why. Provision of new syringes has not been a formal part of AIDS prevention in the U.S. until very recently, under Obama. Incidentally, I have quite a bit to say in my book about the misguidedness of IDU prevention programs in Africa and the Third World generally. My basic criticism is that, just as we have failed to address sexual behavior or sexually transmitted HIV, so we have failed to address drug addiction (and have completely skipped over alcoholism) in our global IDU programs, which are based on provision of clean needles and/or methadone.

Lopez:   If there were one portion of Broken Promises you could highlight to policymakers in Washington, the U.N. . . . and Bill and Melinda Gates and Bono, what would it be?

Broken Promises by Edward C. Green

Green:   I think I've already said it: Abandon the pipe dream that we can eradicate AIDS through drugs or condoms (note that the majority of players are actually saying less about condoms nowadays) and understand that we have to deal with behavior (in the context of culture)! I am talking about sexual behavior and drug- or alcohol-addictive behavior. We simply can't get around behavior and rely on technology fixes. Incidentally, I tried to find a way to reach Warren Buffett a few years ago when I heard that he planned to turn his billions over to the Gates Foundation. The message I was never able to get to him was: Please don't throw good money after bad. Your friend Bill Gates certainly means well and he is to be applauded; but he's being misled by the so-called AIDS experts. Drugs and condoms will not reduce HIV-infection rates at national or population levels.

By the way, I have formally debated the first AIDS adviser for the Gates Foundation, so I never even tried to get my message across there.

Lopez:   When you read the New York Times headline, "Contraceptive Used in Africa May Double Risk of H.I.V.," what was your response?

Green:   We have actually known since the 1980s that there at least seemed to be an association between hormonal contraceptives, whether oral or injectable, and greater vulnerability of women to HIV infection. So the headline doesn't surprise me. However, my colleagues who work in contraceptive promotion believe the issue is not yet settled.

Lopez:   This study involved a shot (injection), but as you've well shown, there is much evidence that contraception hurts rather than helps.

Green:   Well, let's not mix up condoms for contraception and condoms for HIV prevention here. This also gets into a complicated and multifaceted debate. When we are talking about poor, malnourished, overworked women in Africa (for example), then the health and even survival of both mothers and babies is greatly increased if births can be spaced by three or four years, rather than having a baby every year until the mother drops, exhausted or dead. But there are tradeoffs. If greater vulnerability to HIV infection is indeed the case, as suggested in this latest study, then using hormonal contraceptives is certainly a big tradeoff. I have to ask myself, would I want my wife to be on hormonal contraceptives, especially if I am African and infection rates around me are high? Anyway, as you know, I used to work in family planning and I still support the objectives of the overall effort. And I am not well-versed enough in the literature to know if the findings of this latest study are the final word. There may be a tradeoff between the risks of too many pregnancies, too soon, for malnourished African women, and (or versus) a possible increased risk of HIV infection by taking hormonal contraceptives.