'Love Carefully'

UNAIDS revised their estimates of the numbers of HIV cases worldwide downward from 40 million to 33 million, and cut the number of annual new HIV infections by more than 40 percent from previous estimates.

Skeptics wondered whether the history of consistent U.N. overstatement of the HIV problem was a deliberate ploy to raise more funds. Helen Epstein, author of The Invisible Cure, was not surprised: Her work shows beyond any doubt that the politics of AIDS often dominates the science of AIDS.

Trained in biology, Helen Epstein began her interest in HIV and AIDS with a postdoctoral project at the Uganda Cancer Institute in 1993, and her new book, based on a series of articles she wrote for the New York Review of Books between 1995 and 2006, is invaluable for anyone interested in the politics of AIDS in America. She argues that Western aid agencies are gravely culpable in their handling of the AIDS epidemic because they allowed their preconceived notions to interfere with their objective interpretation of the data. The Lifestyle Left comes off much worse than the Religious Right.

Epstein criticizes some Bush administration African initiatives, but not because their message was wrong. Their error was to transfer American abstinence-only programs into the African context, where they did not realistically apply. Abstinence Only is a fine concept if you are trying to reduce teen pregnancy; it isn't so great in a culture where adults have multiple concurrent partners, as in societies that permit polygamy or concubinage. Epstein suggests that the ABC strategy -- Abstain, Be Faithful, Use Condoms -- was only imperfectly applied. The right emphasized the Abstain while the left emphasized the Condoms; the Be Faithful part of the strategy did not get sufficient attention, except in Uganda.

The Ugandans themselves, not Western experts, developed a messaging strategy uniquely adapted to the local situation. The slogans "Love Carefully" and "Zero Grazing" -- meaning, in the words of the head of Uganda's AIDS Control Program, "avoid indiscriminate and free-ranging sexual relations" -- were posted on public buildings, broadcast on radio, and bellowed in speeches by government officials.

According to Epstein, "The genius of the Zero Grazing campaign was that it recognized both the universal power of sexuality and the specific sexual culture of this part of Africa, and it gave people advice they could realistically follow."

By far the lion's share of the blame for the African AIDS debacle lies with the Lifestyle Left. They pride themselves on being scientific, yet these are the very people who were most beguiled by their preconceived notions that condom promotion would control the spread of HIV. They clung to this superstition, even in the face of hard data to the contrary.

Condom promotion strategies take sexual behavior as a given, and attempt to reduce the risk associated with that behavior. Partner reduction strategies, by contrast, focus directly on changing sexual behavior. Here is Helen Epstein's even-handed assessment of the data:

Partner reduction has played a key role wherever HIV rates have fallen -- from the market towns of East Africa to the red-light districts of Asia to the gay enclaves of the United States. . . . Part of this decline was attributable to the increased use of condoms, but partner reduction was even more important. In San Francisco, the proportion of gay men with multiple anal sex partners fell by 60% between 1984 and 1988, and similar changes were recorded in New York, Chicago and other cities. In Zimbabwe and Kenya, the HIV rate began to decline in the late 1990's. Rates of condom use had been increasing throughout the decade, but it was not until rates of multiple partnerships began to decline that HIV rate in these countries also fell.

This means that the Religious Right was much closer to the mark than the Lifestyle Left. Abstinence Only is a special case of partner reduction. The flaw of the right was that it did not sufficiently adapt its partner reduction strategies to the local situations.

The left's flaw was much more serious. It was simply not open to the conclusion that behavior change was more significant than the risk-management of existing behaviors. By the 1990s, Uganda had the greatest success in controlling the spread of HIV of any African country, even though it started the decade with the highest rates of new HIV infections. "Before" and "after" data on sexual behavior were available. A Belgian medical anthropologist, who had worked for the World Health Organization for many years, first analyzed this data and concluded in 1997 that there had been steep rises in condom use and in the age of sexual debut, but almost no change in the proportion of people with multiple sexual partners.

By the end of the 1990s, some AIDS experts were beginning to doubt this conventional wisdom. Condoms were heavily promoted, and condom sales in Africa soared, but the HIV rate continued to climb throughout the continent -- except in Uganda. In 2001 anthropologist Daniel Halperin, a veteran AIDS researcher, reanalyzed the data. The Ugandan HIV decline, he concluded, had coincided not with a uniquely marked increase in condom use but with a plunge in the proportion of people with casual sexual partners.

You would think that this might be exciting and welcome news. Although Epstein is too polite to say so, her account suggests that U.N. officials were blinded by ideology.

When I read through every UNAIDS document I could find that had been produced in the decade before . . . 1996, I found almost no mention of partner reduction. . . . When independent consultants, some of them hired by UNAIDS itself, reported to the agency that partner reduction, not condoms, was largely responsible for Ugandas's HIV decline, their reports were ignored or never made public. The agency's "Best Practice" collection of briefing documents contains issues on condom programs, voluntary testing and counseling, STD treatment services and many other things, but as of this writing, there was no Best Practice document about encouraging partner reduction or fidelity. It was only in 2006 that UNAIDS officials began to stress that the reduction of multiple sexual partnerships should be a key goal for AIDS prevention programs in southern Africa.

The question is why the AIDS establishment did not take this research more seriously, and sooner. Always the lady, Epstein allows the words of others to suggest answers.

A US government contractor [who] had been running condom campaigns in Africa for decades, admitted, "AIDS produces so much emotion, it is hard to look at the evidence. There was a sense that promoting fidelity must be totally wrong if it was a message favored by the Christian Right. We've made an emotion-based set of decisions and people have suffered terribly because of that."

The Invisible Cure also reports situations similar to those reported by Edward C. Green in The Weekly Standard ("AIDS in Africa -- a Betrayal," January 31, 2005): Advocates of partner reduction, even sober-minded researchers presenting evidence at an international AIDS conference, "were accused of 'moralizing' and practically booed off the stage." Why would people do such a thing? Her continuation of the story suggests an answer:

Participants [at the International AIDS conference] engaged in a rowdy celebration of sexuality, safe and otherwise. In the corridors, actors in giant condom costumes twirled through the crowds and a trained elephant passed out free condoms with its trunk. Off-site, a topless go-go bar for the "HIV positive and proud to be sexy" had to close when another elephant trampled a conference-goer to death.

Simply stated, Western hedonists are too committed to the privilege of living out their own lifestyle choices to face the evidence. And their risky lifestyles are deadly to people in the Third World, who have fewer resources to manage the consequences of HIV.

When Helen Epstein finally located Maxine Ankrah, the African-American sociologist who collected the first round of Ugandan data, she described the considerable difficulty she had in locating Ankrah's report. Dr. Ankrah had shown that partner reduction had brought about the Ugandan miracle, but her paper had disappeared without a trace.

"I have no evidence that this was anything other than an honest mistake," Epstein told her, "but it is possible that the reason WHO and UNAIDS never released your report or made any reference to it is that they did not like your results."

Anyone can sympathize with Dr. Ankrah's reaction: "You know, for a long time, I wondered whether there was something wrong with that study. But I was so careful. If those people really were protecting their preconceived notions, they will have a lot to answer for."