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God and the Fight Against AIDS

1.

In 2003, President George W. Bush asked Congress for $15 billion to fight AIDS in developing countries. During the 1990s, HIV spread rapidly, especially in Africa, where some 250 people were dying from AIDS every hour. The US had been accused of not doing enough to fight the epidemic, and when the bill passed, many conscience-stricken Americans, moved by images in the press of dying women and children, praised the administration. But some were not sure. Much of the money will go to church-affiliated charities or faith-based organizations, including some evangelical Christian groups that have very little experience with AIDS.

While Catholic and Protestant churches have been running AIDS programs since the 1980s, few evangelical Christian groups have done so. Indeed, as the deadly virus spread around the world, many evangelical Christians were silent or worse. Jerry Falwell called AIDS God’s judgment on promiscuity, and former Senator Jesse Helms, a longtime congressional ally of the evangelicals, told The New York Times in 1995 that AIDS funding should be reduced because homosexuals contract the disease through their “deliberate, disgusting, revolting conduct.” When lawmakers moved to amend the Americans with Disabilities Act to protect people with HIV from discrimination, some evangelical Christians lobbied against them. In a 2001 poll, only 7 percent of American evangelicals said they would contribute to a Christian organization that helped AIDS orphans.1

Shortly after the 2000 election, some evangelical Christians began to change their tune. “We cannot turn away,” Helms wrote of the global AIDS crisis that had by then killed 20 million people over two decades. “It is true,” wrote Ken Isaacs of Samaritan’s Purse, an evangelical charity run by Billy Graham’s son Franklin, “that when we choose to act outside of God’s mandate for sexual purity, we should be prepared to deal with the consequences.” “However,” he went on, “God calls Christians to tell others of the redeeming love of Christ and the eternal life they can have through him.” Also, with so many people on the verge of death, “AIDS has created an evangelism opportunity for the body of Christ unlike any in history.”2

It is worth noting that during the 2000 campaign, Bush, a born-again Christian, promised to provide more federal funding to faith-based groups working on various social problems. Thus it may be no coincidence that some of the same people who once treated the issue of AIDS with indifference suddenly seemed so concerned about it. Do evangelical Christian groups have a role to play in fighting the AIDS epidemic? Maybe they do, but at the moment they are engaged in an unseemly battle with secular AIDS organizations over US government contracts that could derail what little progress there has been in combating the epidemic.

Most of the $15 billion in the AIDS plan is to be spent on treatment and care for people with AIDS, but $1 billion is earmarked for HIV prevention through abstinence-only-until-marriage education. Since 1996, the US government has spent hundreds of millions of dollars on similar programs in American schools. These programs teach children that heterosexual intercourse within marriage is the only safe and acceptable form of sexual behavior. Teachers in those programs are barred from mentioning condoms and birth control—except their failure rates.

Human Rights Watch and other activists point out that every abstinence-only program that has ever been evaluated has failed to reduce rates of teen pregnancy or sexually transmitted diseases, and they fear that the $1 billion abstinence earmark will have similarly dismal results in other countries. Human Rights Watch has now accused the US government of violating the right of young people to information about sexuality, condoms, and other methods of contraception that could save their lives.3

The US administration used the success of Uganda’s HIV prevention program to justify the $1 billion earmarked for abstinence-only programs. During the 1990s HIV infection rates in Uganda fell, from around 15 percent to around 6 percent, a success that is unique on the continent. In 2000, researchers at USAID began to question why HIV infection rates had fallen only in Uganda and not in other African countries such as Zimbabwe and Malawi, where the epidemic had been raging for almost as long. The difference, they concluded, was that most countries relied too heavily on condom promotion alone, whereas Uganda had a range of programs that encouraged abstinence and faithfulness as well as condoms—a strategy that came to be known as ABC—for Abstain, Be Faithful, or Use Condoms.

In 2002, during the congressional debates over the President’s $15 billion AIDS bill, the virtues of ABC were hotly debated, and unfortunately distorted. Republicans argued in favor of earmarking funds for abstinence-only-until-marriage programs, while Democrats tried to defend funding for condom programs. In the midst of the pro- ceedings, Uganda’s First Lady, Janet Museveni, flew to Washington and presented a formal letter to Republican lawmakers stating that abstinence was key to Uganda’s success. Her involvement helped secure the $1 billion abstinence earmark that appears in the final bill.

Mrs. Museveni’s claim that abstinence had triumphed over AIDS in Uganda is incorrect. Between 1988 and 2001, the average age at which young Ugandan women started sexual activity rose by less than a year, even though the national HIV rate fell by some 70 percent.4 Most Ugandan girls begin having sex at around age seventeen, a year or so younger than in Zimbabwe, where HIV rates are about five times higher. More than half of all Ugandan women have been pregnant by age nineteen. HIV rates in pregnant teenage Ugandan girls fell rapidly during the first half of the 1990s, but during this time, the rate and ages at which these girls became pregnant—a marker of their sexual activity—barely changed at all.5 Moreover, a study carried out in a rural area of Uganda found that young women who abstain from sex until they are twenty are just as likely to become infected with HIV by age twenty-four as young women who first had sex in their teens.

Nevertheless, about four years ago, Uganda’s leaders began lecturing the nation about virginity and “moral” conduct. President Yoweri Museveni has claimed that abstinence until marriage is a traditional African value. Before colonial times, if an unmarried girl became pregnant, “the punishment then for the boy and girl was death,” he told an audience of AIDS researchers in 2001. “The girl would be tied in dry banana leaves, set on fire, and rolled down a cliff, and the boy speared.” But these traditions broke down when the Europeans took over, he said. Society became permissive and eventually HIV began to spread.6 Last year, the First Lady led a march for virginity through the streets of Kampala, and the king of the Baganda, Uganda’s largest tribe, has pledged that all female virgins will receive a free washing machine on their wedding day. Not to be outdone, leaders of the Karimojong tribe have called for a ban on miniskirts, though Karimojong people traditionally wear no clothes at all.

For decades, corrupt African leaders—from Kenya’s Daniel Arap Moi to Malawi’s Hastings Banda to Zimbabwe’s Robert Mugabe—have been blaming Western decadence for Africa’s problems. Even Idi Amin took time out from murdering cabinet ministers and religious leaders to crack down on miniskirts and makeup. Therefore it is worrying that Museveni, whose undemocratic tendencies have been criticized, is drawing increasing attention to the personal morality of others. Nevertheless, the renewed emphasis on abstinence was puzzling. While virginity until marriage may have been valued in the old days, faithfulness in marriage never was. Uganda’s traditional chiefs and kings had hundreds and sometimes thousands of wives and concubines; polygamy, of both a formal and informal nature, remains extremely common in Uganda, and the sexual affairs of President Museveni himself are a frequent subject of gossip, as are those of other government officials including those who set the nation’s AIDS policy. Among members of parliament, sexual harassment by male colleagues is a fact of life for many female MPs, and prostitution, though officially illegal, flourishes in Kampala’s good hotels, including those owned by close political associates of the President and his wife. Porn magazines abound. Sexual matters such as breast implants and premature ejaculation are fervently discussed in mainstream newspapers and on the radio. According to po-lice reports, among the most fre-quent culprits in cases of defilement—or sex with a minor—are Christian pastors, along with teachers and policemen, and a local NGO recently urged pastors to use condoms because they were endangering their congregations.

The preaching about abstinence in Uganda thus seemed at odds with the culture. But Africa’s masks and secrets are often impenetrable to outsiders. Was this a charade to impress the right-wing bureaucrats in the Office of the US Global AIDS Coordinator who oversee the spending of the $1 billion earmarked for abstinence-only?

2.

I arrived in Uganda in September 2004 with this question in mind. As I usually do, I stayed at Makerere University in Kampala. It was the beginning of the school year and students were arriving from all over the country. The freshmen dressed in the formal way of 1940s American college men and women, in long skirts and slacks and buttoned-up white shirts with collars. Each year, upperclassmen at Lumumba Hall, a men’s dormitory, welcome the freshmen by displaying their dorm mascot on the grass in front of the building. The mascot is a life-sized sculpture of a man made from scrap metal, with a large drain pipe for a phallus. In order to educate their peers about HIV, the students dress the phallus in a new condom every day, and a fresh box of condoms—free for the taking—is placed at its feet. “He symbolizes the culture of our hall of residence,” one of the students explained to me. “He has girlfriends, but he always uses a condom.” One afternoon shortly after I arrived, a pastor from a nearby church marched up to the statue, removed its condom, set a match to the box of free condoms, and then prayed over the fire: “I burn these condoms in the name of Jesus!” he boomed, and then promised each student a free Bible.

Uganda is in the throes of a born-again Christian revival. With the arrival of the first missionaries in the nineteenth century, nearly all Ugandans became either Catholic or Protestant, but during the past ten years, thousands—perhaps millions—of them have been swept out of their dusty, austere churches into bright new amphitheaters that even on weekdays are filled with music and prayer and swaying worshipers speaking in tongues. Born-again Christianity is catching on throughout sub-Saharan Africa, from the slums of South Africa to the windswept plains of Maasailand, but Uganda’s Christian traditions, and its position bordering heavily Muslim Sudan, Kenya, and Tanzania, have made it a magnet for American evangelical missionaries, who have poured huge sums into the country during the past ten years. In the major towns, “crusades”—massive religious gatherings—are held nearly every week, often attended by thousands of people.

At one of these events, I watched a pastor in a silk suit and patent leather shoes warn an enormous crowd against the sins of fornication, homosexuality, pornography, and “nude dancing”—the striptease shows that have recently become popular in the capital. He healed people’s livers, backaches, and broken legs, passed around gigantic collection baskets, and jitterbugged vigorously to Christian rock hymns accompanied by a chorus of Ugandan youths. Around one third of the Ugandan population has been “born again” in the past decade, and new churches are springing up in warehouses, shacks, school auditoriums, and village clearings. At traffic circles in the center of Kampala, men in black suits waving Bibles preach through glimmering exhaust fumes to stalled commuters. Two of Uganda’s four TV stations beam in religious programs from around the world, twenty-four hours a day, and quotations from scripture have become part of everyday speech.

Shortly after I arrived, I paid a visit to Martin Ssempa, the pastor who burned the condoms at Makerere. He is an authority on abstinence education in Africa and has given presentations at USAID and led the prayer at Mrs. Museveni’s March of Virgins. Ssempa runs a church and sponsors a Billy Graham–style sex- and alcohol-free abstinence rally every Saturday night on Makerere’s campus. In his sermons, he condemns homosexuality, pornography, condoms, Islam, Catholics, certain kinds of rock music, and women’s rights activists, who he says promote lesbianism, abortion, and the worship of female goddesses.7 He told me that Satan worshipers hold meetings under Lake Victoria, where they are promised riches in exchange for human blood, which they collect by staging car accidents and kidnappings. In his headquarters, just down the hill from Makerere, there is a special room for exorcisms.

Ssempa is stocky and bald, with a broad avuncular smile. He wears colorful Hawaiian-style shirts and wire glasses. Although born in Uganda, he spent years in the US and his Ugandan accent has a warm American twang. We talked about Satan, homosexuals, pornography, and other sins, and he asked me whether I had any idea where he could obtain $4 million to buy land for his church. Our meeting was interrupted by numerous phone calls. As I listened and took notes, he shouted in English and Luganda. There had been some sort of crisis. Population Services International—or PSI—a secular organization that had been distributing condoms in Uganda for years, had recently received US government funding to carry out an abstinence program. PSI had used the money to produce a new comic book in which the main characters, a teenage boy and girl, flirt with each other, make out on a couch at her house, and then decide to abstain from sex. In one of the frames, they walk by a condom billboard on the street.

Look at this!” Ssempa yelled, pointing at the drawing of the condom billboard. “It’s horrible. You can’t promote condoms and abstinence at the same time!” It would only confuse young people, he said, and send the message that it was really OK to be promiscuous.

They won’t get away with it. I have spoken to the First Lady’s office. We need to ensure that George W. Bush’s money gets into the right hands,” he told me, “Those who are doing abstinence-ONLY, as determined by the legislation.”

Last fall, Ssempa and his congregation prayed fervently for a Bush victory in the US presidential elec-tion. He reminded me of the African bureaucrats who played the US and the Soviet Union off each other during the cold war. This time, it was a battle over moral rather than political ideology, but just as in the cold war, a rich country was using foreign aid to fight its battles in developing countries. Now that there is finally a huge amount of money for AIDS programs in Africa, a scramble for it now appears to be underway in Uganda, and faith-based groups like Ssempa’s are going to considerable lengths to get rid of the organiza-tions that have been receiving US government contracts for years, especially those that promote condoms.8 This could have serious consequences, because condoms have helped to control Uganda’s epidemic. HIV infection rates fell most rapidly during the early 1990s, mainly because people had fewer casual partners.9 However, since 1995, the proportion of men with multiple partners has increased sharply. Condom use increased at the same time, and this must be why HIV infection rates have remained low.

But condom programs in Uganda are now threatened. Under pressure from both the Ugandan and US governments, billboards advertising condoms, for years a common sight throughout the country, were taken down in December 2004. Radio ads with such slogans as “LifeGuard condoms! Ribbed for extra pleasure!” were to be replaced with messages from the cardinal of Uganda and the archbishop about the importance of abstinence and faithfulness within marriage. In November 2004, Engabu, a highly popular Ugandan condom brand, was pulled from the shelves because of alleged problems with its manufacture. At the same time, the government now insists that all condoms entering the country be subjected to additional quality control tests. However, Uganda does not have the equipment to carry out such tests, and this has resulted in a shortage of condoms.

Meanwhile, American evangelical Christian magazines such as Citizen, published by Focus on the Family, a Washington, D.C., organization that lobbies against gay rights and abortion, and World, edited by Bush adviser Marvin Olasky, have claimed that USAID is pouring money into condom programs in Uganda and ignoring abstinence and monogamy, which, according to the articles, are the only interventions that really work.10

Condoms have a controversial history in Uganda, and official attitudes toward them tend to shift with the ebb and flow of US government funds. During the 1980s and early 1990s, condoms were not widely available in Uganda, and many people did not believe they really worked. The government did not promote their use and religious leaders denounced them as immoral and “un-African.”11 Health experts at USAID and other international agencies were concerned about this because they were skeptical that Uganda’s existing AIDS programs would work. In 1986, the Ugandan Ministry of Health had launched a campaign known as “Zero Grazing”—Ugandan slang meaning “don’t have casual sexual relationships,” but did not promote condoms.

Then, in the early 1990s, the World Bank, USAID, and other donor agencies set out to make condoms more appealing, not only to citizens, but also to policymakers and religious leaders. By then, population experts had had considerable success encouraging the use of a variety of contraceptives—all initially unpopular—in other developing countries, with an approach known as “social marketing,” which uses advertising and marketing techniques to encourage people to adopt healthful practices. They had found that when condoms and other contraceptives were distributed free of charge in bland medical packaging, people found them unappealing. But when packaged in bright, colorful sleeves, and advertised on billboards and radio spots as sexy and fun, they were much more popular.

Selling condoms in shops, even at very low prices, rather then distributing them free, also added to their cachet. In Uganda, USAID began funding condom social marketing programs in the early 1990s. At the same time, the agency increased funding for the Ministry of Health, the Uganda AIDS Commission, and various church-affiliated organizations run by some of the leaders who most vocally denounced condoms. This new funding had the effect of toning down public criticism of condoms. Meanwhile, the Zero Grazing campaign was gradually phased out.

By the late 1990s, international contractors that specialize in social marketing, such as Population Services International, authors of the comic book that Ssempa complained about, were selling hundreds of millions of condoms each year in Africa. Organizations like PSI don’t make money on the condoms they sell, but they do obtain lucrative government contracts to carry out social marketing programs. Uganda’s social marketing campaigns were especially dynamic, and, as the Makerere student informed me, condoms had become part of Ugandan culture.

Then, shortly after Mrs. Museveni returned from Washington in 2003, where she had helped Republicans lobby for the $1 billion appropriated for abstinence programs, Ugandan officials resumed denouncing condoms after a ten-year hiatus. In a speech at an international meeting of AIDS experts in 2004, President Museveni said AIDS was “a moral problem,” caused by “undisciplined sex,” and that condoms should be reserved for prostitutes. Mrs. Museveni has accused those who promote condoms of racism. “They think Africans cannot control their sexual drives,” she said in a speech last year. “We will prove them wrong!” She has warned young people that organizations that promote condoms are only after their money. On a similar note, Information Minister James Butoro, like Mrs. Museveni a born-again Christian, accused condom social marketing organizations of “profiteering.”

As it happens, Mrs. Museveni’s Uganda Youth Forum (UYF) began receiving US funding to promote abstinence only until marriage to young Ugandans in 2004.12

A large number of new faith-based abstinence organizations like Ssempa’s Campus Alliance to Wipe Out AIDS (CAWA) and Mrs. Museveni’s UYF have sprung up in Uganda in recent years, including the Glory of Virginity Movement (GLOVIMA), the Family Life Network (FLN), and American groups such as True Love Waits. Many of these organizations hope to receive US funding from the $1 billion appropriation for abstinence-only education. US law forbids organizations receiving federal funds from evangelizing, but every abstinence event I attended involved much praying and discussion of Jesus. As Human Rights Watch points out, it was sometimes hard to tell what the aim of these organizations actually was—preventing AIDS or saving souls.

While I was in Uganda, I met Emily Chambers, a pleasant twenty-six-year-old woman who is in charge of AIDS programs in East Africa for Samaritan’s Purse, a US-based charity run by Billy Graham’s son Franklin that had just been chosen to receive a multi-million-dollar US government contract to carry out HIV prevention programs. Among other things, the organization plans to train African Christian pastors to carry out abstinence-only education.

I knew that Samaritan’s Purse was in favor of abstinence-only, but inevitably some of the pastors they plan to train will be approached by people wanting to know more about condoms. I asked Ms. Chambers whether Samaritan’s Purse would recommend that pastors refer such people to other organizations. “We don’t know about that yet,” she said. But when I asked her about the role of faith in abstinence programs, her eyes opened wide. “It’s HUGE,” she exclaimed. “Abstinence is near impossible without the helping hand of the Lord.”

Later, I met a group of girls who were members of GLOVIMA, the Glory of Virginity Movement, a Ugandan abstinence club run by an evangelical church. When I asked them how they intended to ensure that their future husbands would be faithful to them, only one hand went up. A little girl in a tartan dress stood up very straight and said, “I will pray for him.”

3.

It is a great shame that no American or Ugandan has tried to revive the Zero Grazing campaign, because that program probably contributed greatly to the decline in Uganda’s HIV rates. Africans are at higher risk of AIDS than people elsewhere not because they have so many partners, but because they often have more than one long-term partner at a time.13 Ugandan tribes, like many in Africa, are traditionally polygamous. Men are entitled to marry as many wives as they can afford to support, and they sleep with them at closely spaced intervals. But polygamous cultures, in which many people conduct several ongoing sexual affairs at once, create fertile ground for the spread of HIV. If all the men slept only with the women they were married to and the women did the same, HIV would not spread. However, extramarital affairs inevitably occur, as they do everywhere. In addition, economic hardship has meant that these days many men have difficulty providing for even one family, but they nevertheless continue to conduct informal relationships with mistresses, who may have additional partners themselves, sometimes out of economic necessity.

Thus the practice of formal and informal polygamy creates a network of simultaneous or “concurrent” sexual relationships that links sexually active people not only to one another but also to the partners of their partners—and to the partners of those partners, and so on—creating a giant web that can extend across huge regions. If one member contracts HIV, then everyone else in the web may, too.14 Polygamous men generally seek out young women, even as they themselves age. In this way, formal and informal polygamy pumps the virus from one generation to the next.

Long-term “concurrency” is far more common in Africa than in Asia and in the West, where heterosexual people tend to practice “serial monogamy.” Martina Morris, a sociologist at the University of Washington, has shown that long-term concurrency is more of a public health danger than serial monogamy because it permits HIV and other sexually transmitted diseases to spread to others quickly, rather than confining them in a single relationship for months or years. Moreover, a recently infected person is much more likely to transmit HIV than a person who has been infected for a while. Thus, when a serially monogamous HIV-positive person eventually finds a new partner, his ability to infect that partner has been reduced. If someone at the hub of a network of concurrent relationships becomes infected, however, he or she is likely to infect his or her other partners very rapidly.

In 1986, Ugandan health officials had not heard of “long-term concurrency” and Professor Morris had not constructed the computer models that traced the transmission of HIV. Nevertheless, the Ugandans knew that HIV was spreading rapidly through networks of sexual relationships, and it was killing people. They also knew it would be unrealistic to insist that all men abandon their extra wives and mistresses, many of whom depend on the men for the opportunity to work on the land and for money and consumer goods for themselves and their children. Zero Grazing was a compromise. It recognized that sexual arrangements in Africa are often different from the Western nuclear ideal and serial monogamy. Zero Grazing was mainly addressed to men, and its real message was:

Try to stick to one partner, but if you have to keep your long-term mistresses and concubines and extra wives, at least avoid short-term casual encounters with bar girls and prostitutes. Also, you mustn’t casually seduce and exploit young women, who may be susceptible to your charms and wealth.

During the Zero Grazing campaign, the proportion of Ugandan men and women with casual partners fell by 60 percent. On surveys and in focus groups conducted throughout the country, most people said that they were protecting themselves from HIV by reducing their partners or “sticking to one.”15 By the time the Zero Grazing campaign was replaced by condom promotion and other programs in the early 1990s, the decline in the HIV infection rate was well underway. After 1995, when condom social marketing programs took off, the proportion of men with “non-regular” partners rose again. But HIV rates continued to fall, albeit far more slowly. Then, after 2000, HIV rates rose slightly. The reason HIV rates have not soared, even though more men have multiple partners, is almost certainly that the men are using condoms. The reason HIV rates are no longer falling is probably that these men are not using condoms consistently, especially in the longer-term, concurrent relationships where HIV transmission is most like to occur.

I asked David Apuuli, the affable head of the Uganda AIDS Commission, why the government did not revive the Zero Grazing campaign, which seemed to have been so effective. He giggled, poked me with his elbow, and winked theatrically. “You know what that was all about, don’t you?” What Dr. Apuuli meant was this:

What kind of an idiot are you? What do you think the Christians are going to say if we start talking about Zero Grazing? Zero Grazing recognized that polygamy, both formal and informal, was normative and legitimate. That would not fly in the current political and religious climate. Mrs. Museveni would have a fit, and the Bush administration, which pours billions of dollars a year into Uganda, would be very dismayed if the country they hold up as a triumph of abstinence education started promoting Zero Grazing.

But there may be other reasons why Zero Grazing is unlikely to be revived. For one thing, there is no multimillion-dollar bureaucracy to support it. For condoms, there are the large contractors like PSI with headquarters in Washington and thousands of employees in plush offices all over the world. Abstinence-only education is supported by a similarly well-endowed network of faith-based and abstinence-only education organizations, mainly in the US. Zero Grazing was devised by Ugandans in the 1980s, when they were facing a terrible problem, and had to deal with it largely on their own. Now that AIDS is a multibillion-dollar enterprise, donors with vast budgets and highly articulate consultants offer health departments in impoverished developing countries a set menu of HIV prevention programs, which consists mainly of abstinence and condoms. Beleaguered health officials have no time, money, or will to devise programs that might better suit their cultures.

Another reason why abstinence programs are favored over Zero Grazing may have to do with the sexual hypocrisy common to all known societies. The revival of interest in virginity in Africa is not always driven by American money. In southern Africa, many communities have revived the custom of virginity testing—in which older women examine unmarried younger women to ensure their hymens are unbroken. Virginity testing has become so popular among the Zulus that it is sometimes carried out en masse, at football stadiums. Meanwhile, Swaziland’s King Mswati III decreed in 2001 that all young, unmarried Swazi women should abstain from sex for five years and wear special tassels in their hair, as a signal to men to leave them alone. Fines were imposed on subjects who broke the rule.

Like other abstinence programs, Swaziland’s was not a success. Today, four years after the decree, 40 percent of all Swazi adults are HIV-positive—the highest HIV infection rate in the world. While the King frowns on premarital sex, he tolerates polygamy, and indeed has thirteen wives of his own, at last count. He chooses a new bride each August at the annual Reed Dance Festival, where thousands of topless girls in traditional grass skirts dance and sing his praises. In 2003, when the King chose a seventeen-year-old, he fined himself one cow.

The South African anthropologist Suzanne Leclerc-Madlala attributes the revival of interest in virginity to an increasing sense among elders, especially men, that they are losing control of young people and women. All around they see worsening economic and social conditions and the horror of AIDS, and because they are only human, they blame this state of affairs on the loosening morals of increasingly educated, urbanized women and young people, rather than examining how their own behavior also contributes to these problems.16

4.

After two weeks spent visiting pastors, watching Joyce Meyer sermons on TV, and shopping at stores with names like Trust in God Hardware, I felt I needed a change of scene. One of the women’s dorms on Makerere campus has a reputation. “Go there some Saturday night,” said a professor I knew. “That’s when the men in their big cars come and pick up the girls and take them out. Sometimes you just see men sitting in front of the entrance, waiting. They call it ‘benching.’” The dorm in question wasn’t far from where I was staying, so one Saturday night I walked over. As I approached, I saw some people sitting along the edge of the parking lot, facing the entrance of the building. At first I thought they were “benchers,” but about half of them were women, their eyes glistening with tears. They were watching a Christian movie about a girl who has just told her boyfriend she is suffering from cancer. I watched as they prayed together, and then I spotted a couple walking away from the dorm. As I drew closer to find out what was going on, I realized they were discussing Saint John’s Gospel.

Afterward, I wandered over to Pastor Ssempa’s abstinence rally at the Makerere campus swimming pool. There must have been three thousand people there and I couldn’t get past the huge overflow crowd on the street outside. The show consisted of skits, comedy routines, testimonies from former sinners, prayers, and thundering Christian rock music, sung in local languages by Ugandan stars. The entire audience all swayed together, dancing and singing and waving at the night sky. The music was so powerful the ground itself seemed to tremble.

As the music became increasingly ecstatic, a few members of the audience began to twitch and shake in a peculiar way. Then a woman some distance away from me began to writhe quite violently, and in a fit that might be described as orgasmic, she suddenly flew backward into the crowd and had to be pulled up by her friends.

She was battling the spirits,” one of the students explained to me.

Afterward, as I was walking back to my hotel, the rumble of the music still in my ears, I departed from the crowds of students and followed a dark road lit only by the moon and the occasional approach of slow-moving, yellow-eyed cars. Many of the sidewalks on campus are broken, and here and there the smashed concrete opens into dark, stinking sewage channels below, as if they had been torn open by some spasm of the earth. Flocks of bats hung from the jungley black branches of bottlebrushes and eucalyptus, and giant scavenger birds loomed on the crests of the trees, their long stiff beaks chattering like tom-toms. Disco music surged from numerous nearby bars, and images of nude dancers and homosexuals and pornographers and beer-addled prostitutes merged with the memory of the hysterical woman at the rally.

Sexuality truly does belong to the world of magic and unreason. It is impossible to plan and control it totally. We were made that way. If sex were an entirely rational process, the species would probably have died out long ago.17 But the delirious, illogical nature of sex makes setting a realistic HIV prevention policy very difficult. Cheerful, sexy condom ads that fail to address the real dangers of AIDS may promote a fatal carelessness; but an exclusive emphasis on abstinence until marriage may well lead to an even more dangerous hysterical recidivism. 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.

—March 31, 2005

Letters

God and Aids May 26, 2005

God, Aids & Circumcision May 26, 2005

  1. 1

    The Hope Factor: Engaging the Church in the HIV/AIDS Crisis, edited by T. Yamamori et al. (Authentic Media, 2003) p. 250.

  2. 2

    The Hope Factor, p. 194.

  3. 3

    See Health and Development Networks, “Condom U-Turn Puts Many Young Ugandans at Risk,” May 26, 2004; Human Rights Watch, “The Less They Know, the Better: Abstinence Only HIV/AIDS Programs in Uganda,” March 2005; Center for Health and Gender Equity, “Where Is the ‘C’ in ABC: Implications of US Global AIDS Policy and Funding for HIV Prevention in PEPFAR Focus Countries,” March 2005; Thomas J. Coates, “Science vs. Assumption in Public Health Policy: Abstinence Alone Not the Answer,” San Francisco Chronicle, May 25, 2004; and Esther Kaplan, With God on Their Side (New Press, 2004).

  4. 4

    Ruth Bessinger, Priscilla Akwara, and Daniel T. Halperin, Sexual Behavior, HIV, and Fertility Trends: A Comparative Analysis of Six Countries; Phase I of the ABC Study (Measure Evaluation, 2003), at www.cpc.unc.edu/measure /publications/special/abc.pdf (accessed June 22, 2004).

  5. 5

    Even by year. Virtually the same number of fifteen-, sixteen-, seventeen-, eighteen- and nineteen-year-olds became pregnant in 1988 as in 1995, a period when HIV rates in the same group of pregnant girls fell by nearly half. Teenage pregnancy rates did fall significantly between 1995 and 2001, but the use of modern contraceptives, including condoms, nearly tripled during this time, so it is difficult to attribute this to abstinence alone.

    Table: HIV prevalence among 15-19 year old pregnant women

    Table: Teenage pregnancy in Uganda

  6. 6

    Speech given at “AIDS Care in Africa: The Way Forward,” meeting sponsored by the Rockefeller Foundation, Kampala, Uganda, April 19–21, 2001.

  7. 7

    See also Andrew Rice, “Evangelicals vs. Muslims in Africa: Enemy’s Enemy,” The New Republic, August 9, 2004, and Human Rights Watch, “The Less They Know, the Better.”

  8. 8

    Similar funding battles between HIV prevention groups focused on abstinence and those focused on condoms are underway in other African countries. See Center for Health and Gender Equity, “Where Is the ‘C’ in ABC.”

  9. 9

    See Rand Stoneburner and Daniel Low-Beer, “Population-Level HIV Declines and Behavioral Risk Avoidance in Uganda,” Science, April 30, 2004, pp. 714–718. A previous report attributed the decline in infection rates in Uganda mainly to condom use and abstinence. (See Asiimwe-Okiror et al., “Change in Sexual Behaviour and Decline in HIV Infection Among Young Pregnant Women in Urban Uganda,” AIDS, Vol. 11, No. 14, November 15, 1997, pp. 1757–1763.) However, this report miscalculated partner reduction. The authors report that the proportion of people with casual partners—defined as relationships lasting less than a year—fell very little between 1989 and 1995. However, instead of calculating the proportion of all sexually active people who have casual partners, the authors reported only those people who were in long-term relationships—lasting more than a year—who also had casual partners. In other words, they omitted from their calculation all those who had partnerships lasting days, weeks, or months only. This population contains many young people who are at very high risk of HIV. When they are included in the calculation, the proportion of those with casual partners fell by around 60 percent, as Stoneburner and Low-Beer have shown.

    Recently, various US newspapers suggested that increased condom use and the death of AIDS patients were the main reasons for the decline in HIV infection rates in Uganda. See Lawrence Altman, “Study Challenges Abstinence as Crucial to AIDS Strategy,” The New York Times, February 24, 2005; and David Brown, “Uganda’s AIDS Decline Attributed to Deaths,” The Washington Post, February 24, 2005.

    These news reports were based on a study from the Rakai district of southern Uganda that has been underway for more than a decade. The reports on the study were misleading for several reasons. First, although AIDS certainly increased death rates in Uganda, it has done so throughout eastern and southern Africa. However, HIV rates in Uganda fell by 75 percent in the 1990s, but have since risen or stabilized everywhere else. The HIV epidemic in Zimbabwe, Zambia, and Malawi began only a year or two after Uganda’s. If deaths from AIDS were the main reason for Uganda’s decline, we should by now have seen huge declines in HIV infection rates similar to Uganda’s in these countries. However, HIV rates in these countries today are between three and five times higher than they are in Uganda, and have fallen very little, if at all, during the past fifteen years.

    Because HIV infection has no cure, deaths need to occur for HIV prevalence to decline. What happened in Uganda (but not elsewhere) is that sexual behavior changed, so that when people died of AIDS, they were not replaced by an equal number of newly infected people. In other countries, there has been very little prevalence decline, despite a great many deaths. See also Albert H.D. Kilian et al., “Reductions in Risk Behaviour Provide the Most Consistent Explanation for Declining HIV-1 Prevalence in Uganda,” AIDS, Vol. 13, No. 3 (1999), pp. 391–398.

    Although increased condom use probably has contributed to the decline of HIV infection rates in Uganda, it is unlikely to have been the main reason for this success. The survey of sexual behavior in Rakai district referred to in Brown’s and Altman’s articles was conducted between 1994 and 2003. However, there appears to have been significant behavior change in Rakai and throughout southern Uganda before 1994, which the study described in the news articles did not measure. According to scientific reports on the Rakai project (see references below), HIV rates in Rakai fell rapidly between 1990 and 1996, and much more slowly, if at all, thereafter. In 1990, the HIV prevalence rate in Rakai trading centers was around 35 percent. In 1996, it was around 16 percent. Today, it is around 14 percent. Condom use began to increase rapidly in Rakai only in the mid-1990s. In 1996, when the decline in HIV prevalence was well underway, only 12 pecent of people surveyed in Rakai had used a condom in the six months preceding the survey. Thus it is unclear how it is possible to claim that condoms were the main reason for the decline in infection rates that occurred before 1996. Nor was death, or abstinence, for that matter. (See Maria J. Wawer et al., “Dynamics of Spread of HIV-1 Infection in a Rural District of Uganda,” BMJ, November 23, 1991, pp. 1303–1306; and Maria J. Wawer et al., “Control of Sexually Transmitted Diseases for AIDS Prevention in Uganda: A Randomised Community Trial, Rakai Project Study Group,” The Lancet, February 13, 1999, pp. 525–535.

    Consistent with the findings of Low-Beer and Stoneburner, focus groups conducted in Rakai itself during the 1980s and early 1990s showed Zero Grazing and “sticking to one” were the most commonly reported responses to the question “What are you doing to protect yourself from HIV?” (See for example Joseph K. Konde-Lule et al., “Focus Group Interviews About AIDS in Rakai District of Uganda,” Social Science and Medicine, Vol. 37, No. 5, September 1993, pp. 679–684.)

  10. 10

    See Priya Abraham, “Hooked on Failure,” World, November 6, 2004; and Candi Cushman, “Burying the Truth,” Citizen, March 2005.

  11. 11

    See Maryinez Lyons, “The Point of View: Perspectives on AIDS in Uganda,” in AIDS in Africa and the Caribbean, edited by George Bond et al. (Westview, 1997).

  12. 12

    Some of the money for Mrs. Museveni’s program is to be channeled through the Children’s AIDS Fund or CAF, a US organization. In November 2004, CAF, which is run by a couple who are close friends of President Bush, was promised US government funding, even though the grant proposal it submitted to USAID was deemed “unfit” by a review panel. USAID administrator Andrew Natsios argued that CAF had ties with Janet Museveni’s Uganda Youth Forum, who “is a pioneer in abstinence and be faithful messages,” and should therefore be given special consideration. Randall Tobias, the US Global AIDS coordinator, apparently agreed. CAF was formerly known as Americans for a Sound AIDS Policy. In the 1990s, it lobbied to increase federal funding for “Abstinence-only- until-marriage programs,” and against extending Americans with Disabilities protection for people with HIV. The disbursement of funds under the President’s Emergency Plan for AIDS Relief is disturbingly opaque. According to the Center for Health and Gender Equity, an organization that tracks US government spending on reproductive health, millions of dollars disbursed so far have not been publicly accounted for, in addition to that promised to CAF. See David Brown, “Group Awarded AIDS Grant Despite Negative Appraisal,” The Washington Post, February 16, 2005, p. A17.

  13. 13

    See Christopher Hudson, “AIDS in Rural Africa: A Paradigm for HIV-1 Prevention,” International Journal of STD & AIDS, Vol. 7, No. 4 (1996), pp. 236–243; Martina Morris and Mirjam Kretzschmar, “Concurrent Partnerships and the Spread of HIV,” AIDS, Vol. 11, No. 5 (1997), pp. 681–683; and Daniel T. Halperin and Helen Epstein, “Concurrent Sexual Partnerships Help to Explain Africa’s High HIV Prevalence: Implications for Prevention,” The Lancet, July 3, 2004, pp. 4–6.

    Table: Frequency of concurrent and suspected concurrent relationships

  14. 14

    Polygamy is also common in the Middle East, where HIV infection rates are extremely low. However, these cultures are very likely protected by the widespread practice of male circumcision, which probably cuts the risk of HIV transmission by some 70 percent, and by intense surveillance of women’s behavior, so that while many men have multiple concurrent partners, few women do. See my “Why Is AIDS Worse in Africa?” Discover, February 2004, and John Donnelly, “Circumcised Men Less Likely to Get AIDS,” The Boston Globe, November 16, 2004.

  15. 15

    Tom Barton, “Epidemics and Behaviours: A Review of Changes in Ugandan Sexual Behavior in the Early 1990s,” unpublished report for UNAIDS, Geneva, 1997. Zero Grazing may be a natural reaction to the threat of AIDS. Just as in Uganda, partner reduction, combined with strategic, consistent condom use in casual relationships, has been responsible for HIV declines in Thailand and in the gay community throughout the developed world. See Susan Kippax and K. Race, “Sustaining Safe Practice: Twenty Years On,” Social Science and Medicine, Vol. 57, No. 1 (July 2003), pp. 1–12; Daniel Low-Beer and Rand L. Stoneburner, “Behaviour and Communication Change in Reducing HIV: Is Uganda Unique?” African Journal of AIDS Research, Vol. 2, No. 1 (2003), pp. 9–21; Martina Morris and Laura Dean, “The Effect of Sexual Behavior Change on Long Term HIV Prevalence Among Homosexual Men,” American Journal of Epidemiology, Vol. 140 (1994), pp. 217–232.

    Rates of casual sex have recently been declining in many African countries, including Kenya and Rwanda, and HIV rates are also beginning to fall in these countries. Professor Susan Watkins of the University of Pennsylvania has observed similar behavioral changes in Malawi, although statistics there are unreliable, so it is hard to say whether this has reduced the spread of HIV. (See Susan Cotts Watkins, “Navigating the AIDS Epidemic in Rural Malawi,” Population and Development Review, Vol. 30, No. 4, December 2004, pp. 673–705.) It has taken much longer for these changes to get underway outside of Uganda, possibly because there have been no campaigns to encourage partner reduction, and because social and economic factors in other countries may make this kind of behavior change more difficult. (See my “Fidelity Fix,” The New York Times Magazine, June 13, 2004.)

  16. 16

    Suzanne Leclerc-Madlala, “Protecting Girlhood? Virginity Revivals in the Era of AIDS,” Agenda, Vol. 56 (2003), pp. 16–25.

  17. 17

    Thanks to Alex Coutinho of the AIDS Support Organization in Uganda for discussions on this point.

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