The Politics of AIDS: Engaging Conservative Activists

Holly Burkhalter

From Foreign Affairs, January/February 2004

Summary:  American evangelicals have put the fight against AIDS on Washington's map, even while clashing with other activists over strategy. Now all must unite behind a comprehensive approach stressing effective practices in prevention and treatment.

Holly Burkhalter is Director of U.S. Policy and of the Health Action AIDS campaign at Physicians for Human Rights.

By the time legislation implementing the president's vision -- the United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003 -- was completed, conservatives in the House had succeeded in redirecting one-third of its AIDS-prevention funding toward programs urging abstinence before marriage. The conservatives are inspired by Uganda's "ABC" (Abstinence, Be Faithful, and Use Condoms) program, which has helped lower prevalence dramatically, and are particular fans of its A and B components, which, if faithfully adopted, might offer nearly total AIDS protection. As Chuck Colson and William Bennett of the organization Empower America argued in a recent essay, "African nations that promoted condom use alone, and which have the highest condom user rates on the continent ... also suffer the highest HIV prevalence rates. Clearly, condoms must no longer be considered the first line of defense against HIV. ..."

Unfortunately, however, scientific evaluation and medical surveillance paint a different picture. Studies of Ugandan AIDS prevalence that try to assess the relative contributions of abstinence, multiple-partner reduction, and condom use in lowering infection rates have found that abstinence actually made the smallest contribution, while condoms and partner reduction had the largest impact. David Serwadda, a Ugandan physician who chairs the Global HIV Prevention Working Group, has stated, "As a physician who has been involved in Uganda's response to AIDS for 20 years, I fear that one small part of what led to Uganda's success -- promoting sexual abstinence -- is being overemphasized in policy debates."

At home, meanwhile, the U.S. government currently provides $100 million per year for abstinence education, making the aid conditional on schools' commitment to neither endorse condoms nor provide instruction on their use. Kenneth L. Connor, president of the Family Research Council, has suggested extending such policies to Africa, on the grounds that "responsible moral behavior is the first and best line of defense against AIDS, and is the only message we should send young people worldwide."

But here again, researchers who have compared abstinence-only and comprehensive sex-education programs in the United States have found little evidence that the former had any effect on sexual behavior or contraceptive use among sexually active teenagers. And sexually inactive teens who received comprehensive sex-education were more likely both to delay sexual initiation and to use condoms once they did start having sex than their peers who received abstinence-only instruction.

Another problem with the abstinence approach is that it fails to single out certain marginalized groups who are especially at risk of HIV/AIDS infection. Outside southern Africa, for example, AIDS prevalence is highest among sex workers, intravenous drug users, and homosexuals. Since these groups suffer discrimination and persecution within their own countries and are often denied access to government health and prevention programs, experts concerned with stopping the spread of the pandemic believe those groups should be singled out for special attention. Yet USAID is reportedly now under heavy pressure to scale back or eliminate outreach, peer counseling, and condom distribution to at-risk groups. The National Institutes of Health and the Centers for Disease Control, moreover, are reportedly screening out research proposals containing the words "homosexual," "prostitute," and "drug user" in their titles, and whistle blowers within the agencies have reported pressure to approve scientifically unsound HIV projects.

ON COMMON GROUND

The AIDS pandemic is almost incomprehensible in its enormity, and in most of the developing world it is still in its early stages. As the world's richest, most powerful, and most scientifically advanced nation, the United States can and should play a uniquely active role in combating this scourge.

The entry of religious conservatives into the struggle has helped galvanize U.S. AIDS policy and has given the issue a welcome hearing in Congress and the White House. They have put treatment on the political map, and have focused attention on certain unjustly neglected issues such as sex trafficking and transmission through unsafe health care practices. The challenge now is for all those concerned about AIDS to fight the pandemic on all fronts, preventing transmission where it occurs and treating all those in need.

Whatever their views on other issues, conservatives, liberals, and the medical community should be able to reach at least a rough consensus on the most effective practices in both prevention and treatment. The AIDS pandemic will not wait while one successful prevention program is traded for another or scarce resources are squandered on unsound approaches. If a common front can be matched with some common sense, the results could be truly impressive.