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The U.S.'s Failed HIV Policy

By Julie Mellin

The breed of camaraderie shared by Peace Corps Volunteers is often compared to that of the military, sports teams, or police officers—all groups thrown into a high-stress, results-driven environment that force quick emotional bonding. Like the others, we Peace Corps Volunteers tend to pounce quickly on those who can’t take the heat. During my two years in Botswana, every time a volunteer decided to leave early, we all responded with immediate, heavy criticism. “Sure, leave, you couldn’t handle it anyway,” we said to ourselves. We saw them as failures.

In retrospect, the complaints often cited by deserters about being unable to “help those who don’t want to help themselves” and feeling as much a part of the “bureaucratic American machine” as ever make a lot more sense than I wanted to admit. 

Botswana, arguably the country most affected by HIV in the world (estimates of prevalence rates have ranged over the years between 17 and 33 percent), has tried—and repeatedly failed with—a number of prevention strategies since the appearance of the virus in 1985. These strategies have variously included male circumcision, voluntary counseling and testing, education campaigns, and free and broad condom distribution.

One of the campaigns most highly funded by the international community (especially George W. Bush’s PEPFAR), is the ABC method: Abstain, Be Faithful, and Condomize. The ABC method is meant to alter behavior that has been identified as increasing the risk of HIV infection. In Botswana’s case, these behaviors center around intergenerational and multiple concurrent sexual relationships; lack of condom use; and sexual and gender-based violence. Despite the above-mentioned efforts and PEPFAR’s investment of over $482 million so far (that’s for Botswana alone—PEPFAR has spent about $30 billion on HIV/AIDS projects worldwide), the HIV prevalence rate has remained steady for the past seven years. In fact, the last Botswana AIDS Impact Survey indicated that prevalence had actually slightly risen to 17.6 percent—and according to UNAIDS, the prevalence rate is closer to 25 percent. Although an estimate of the number of new infections does not exist (2008 BAIS numbers are “still under analysis”), public health experts and statisticians agree that HIV prevention methods in Botswana have failed.

The ABC method, a combination of several American “safe sex” campaigns developed in the 1980s, was never tested in the US or in an international setting. It was also used (equally ineffectively) during the HIV epidemic among gay men in the United States in the 1980s.  The ABC method’s basis in traditional Christian and individual-based values is in direct opposition to Tswana cultural beliefs—as it was for the gay population most at risk in the 1980s.

The ABC campaign’s assumption that an individual is accountable only to his or herself disregards the reality of sexual politics in Botswana. Perhaps we’re encouraged to do that in America. But in most African cultures, traditional values and compliance with community-wide practices discourage acting in one’s own interest alone. Rather than acting on some sort of thinly-veiled moral crusade to change African culture, HIV prevention should have only one goal—lowering the number of new HIV infections.

Given the prevalent values about sexuality and gender in Botswana, the main behaviors pushed by the ABC method are completely out of the control of the average female, as well as culturally implausible. Historically, women in Botswana have been regarded as inferior to men. According to customary law, women are considered the property of their father and later in life, their husband. This belief lays the groundwork for the man’s dominance in sexual decision-making and the woman’s corresponding inability to negotiate behaviors that could prevent the spread of HIV such as using a condom or having only one girlfriend at a time.

One of the programs I helped implement during my time as a Peace Corps Volunteer in rural southeastern Botswana involved conducting participatory trainings for young women (aged between about 13 and 20) on sexual negotiation, assertiveness, and other life skills relevant to HIV prevention. Many of these women were in, or felt pressure to be in, sexual relationships with older men that they were not comfortable with. They tended to describe sexual experiences as unpleasant or painful and confusing. Several young women described sexual encounters in which there was no light (common, as we lived in a settlement with no electricity) and, since cultural norms discouraged them from touching a man from the waist down, no way of telling whether or not their male partner was wearing a condom. Often, they wouldn’t know if a condom had been used until they went to the bathroom after the encounter. When asked why they didn’t insist upon, or at least ask their partners to use a condom, the women’s answers ranged from discomfort with bringing up the issue to fear of economic, physical, and emotional repercussions.

Botswana men’s practice of having multiple girlfriends has long been a culturally endorsed and is now closely entangled with women’s vulnerability to HIV/AIDS. Traditional beliefs say that male sexuality is by nature incapable of being restrained and must be respected; a woman should expect and tolerate sexual infidelity; and sex for fun is to be found outside of marriage, while marital sex is purely for producing offspring. Basically, a man must show his sexual prowess with multiple partners and a woman’s sexuality should be repressed in favor of pleasing her male partner.

The significance placed upon a woman’s fertility is often another key impediment to abstinence and condom use. Singlewomen must have children quickly to show fertility and “womb cleanliness” before a man will consider marrying them and men father children with multiple women to prove their masculinity and strength. Social maturity and respect for family are believed to be shown through having children—if a woman insists upon using condoms she would appear disrespectful. Yet, we are spending hundreds of millions of dollars to support a campaign telling her to do so.

Although changing these cultural norms might be a sustainable (very) long-term solution, and one that is slowly happening, it is not going to work overnight—and the process should certainly not be pushed by foreigners.

Figuring out a community’s sexual culture must be the first step in developing effective HIV interventions. A variety of social functions are played out through sexuality—we use it everywhere (including here in the United States) to regulate cultural rules about identity, procreation, property, relationships, and religion. An understanding of these complicated dimensions of sexuality is vital in designing an effective HIV policy. Prevention strategies should be based upon local context and involve the actual participation of community members—not only in implementing the prevention strategies but in designing them.

Uganda, for example, is often seen as the “HIV success story” of Africa—a key difference between it and Botswana being the involvement of the community. Changing risky behaviors was, of course, central to Uganda’s success. Unlike in Botswana, Ugandans talked about altering their sexual behavior through personal channels. In addition, a higher percentage of Ugandans knew someone living with AIDS or who had died of AIDS. Alarm, advice, and awareness of the issue took root through discussions at the community-level, not some top-down public health campaign.

Who are we to appear with our expensive bag of solutions halfway across the world and tell everyone what their problems are, and how to fix them? The United States can help encourage, organize, and pay for (it wouldn’t be hard to redirect those PEPFAR funds!) local campaigns that identify the relevant beliefs and values within which potential solutions could be found. But the United States will never be able to able to change a culture—nor should it—through an untested, culturally irrelevant prevention campaign staffed by foreigners.


Julie Mellin is an editorial assistant at World Policy Journal.

[Photo courtesy of Flickr user JakeBrewer


Anonymous's picture
Redirecting PEPFAR funds

I commend the author on an honest opinion sparked from eye witness accounts of HIV in the context of a country and a culture. I agree that some of the solutions the author suggests are indeed durable in terms of generating an improvement of gender imbalance and other broad development issues. Gender imbalance is a known HIV risk factor, however I am apprehensive to assume the suggesting interventions will have the epidemiological impact of HIV incidence at the population-level which is needed in Botswana at this moment. At the risk of medicalizing the problem, we do have scientifically proven, within the context of Sub-Saharan Africa, interventions that deliver the population-level disruption of incidence that Botswana needs. Supporting the scale up and roll out safe male circumcision to assist the Government of Botswana in meeting the targets it has set for its nation is a good use of PEPFAR money. We have the evidence and mathematical models behind us; we know the prevention impact we can achieve with this program. Ensuring universal access to ART for PLWHA across Botswana at an earlier CD4 level has seen to drastically reduce incidence among the sexual partners of PLWHA (and this study was conducted in Botswana). Ensuring universal access and initiating ART at an earlier CD4 level is an expensive endeavor PEPFAR contributes to. Although I am not in disagreement with the author on the issues she suggests being critical, I feel suggesting PEPFAR money be redirected away from the biomedical interventions proven to have efficacy may be self-defeating in the long run.
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