Rethinking AIDS Prevention

The focus of this book is on heterosexual transmission of HIV in less-developed countries and on sexually transmitted AIDS only. Green calls for a paradigm shift away from a focus on condoms in favour of a focus on Primary Behaviour Change (PBC), which includes fidelity, partner reduction, and delay of sexual debut. Green presents evidence of what he considers to be the inadequacies of condom campaigns in Africa and the successes of PBC in developing countries around the world.

Green ties in several case studies (Zambia, Senegal, Thailand, Jamaica) but focuses mainly on Uganda's success with PBC programmes, which is attributed to the government's 'zero grazing' campaign in the 1980s. Green argues that, for most Africans, PBC is a better method of disease prevention than condom use. He asserts that studies have shown that by delaying sexual debut of young adults, their lifetime number of partners greatly decreases. Therefore, says Green, a wider range of programmes that focus on PBC yet still incorporate condoms when appropriate, are desperately needed.

If the evidence presented by Green is accurate, then why is so much international aid being dumped into these ill-suited programmes? His answer is that donors overlook it, ignore it, or do not want to believe it. Some of the problems he cites include biased surveys that focus on condom usage at the cost of questions on other forms of AIDS prevention; the ease of monitoring condom usage compared to the difficulty of measuring PBC; and programmes that are based on western post-sexual revolution ideology. This last refers to "those who work in public health are loathe to appear to make value judgments about sexual behavior. Therefore they are more comfortable promoting condoms and treating STDs than advocating having fewer partners" (62). The pre-AIDS American sexual revolution instigated free love and the desire to avoid sexual judgments. This openness was reflected in policy decisions affecting a continent that had not undergone the same revolution. From Green's perspective, in the race to avoid association with the religious right, donors missed the fact that socio-cultural variables are just as important as medical. He suggests that the only way to turn this 20-year oversight around is to overcome biases against partner reduction and abstinence and actually listen to Africans because they, like many Americans, are indeed choosing abstinence and being faithful over condoms.

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