by Robert Wyrod, author of AIDS and Masculinity in the African City

This guest post is published in advance of the American Sociological Association conference in Seattle. Check back every week for new posts through the end of the conference on August 23rd.

U.S. Spent Over a Billion Promoting Abstinence to Fight AIDS in Africa. Money Well Spent?

AIDS is arguably the most politicized disease in human history. Nothing captures this as powerfully as the slogan Silence=Death. This was the rallying cry of the AIDS Coalition to Unleash Power (ACT UP), the pioneering social movement that successfully challenged the U.S. government’s loathsome apathy to AIDS in the 1980s and 90s and made fighting the disease a national priority.

A decade later, politics again shaped U.S. AIDS policy, but this time in Africa. In 2004, the George W. Bush administration created the President’s Emergency Plan for AIDS Relief (PEPFAR), the largest health initiative in history focused on fighting a single disease. Billions of dollars were allocated to HIV prevention and AIDS treatment in countries hardest hit by the pandemic, mostly in sub-Saharan Africa. Most controversially, one third of all HIV prevention funding was earmarked for programs promoting abstinence and faithfulness to one sexual partner—a decision mandated by Bush’s conservative evangelical allies in Congress.

So what has the billion-and-a-half dollars spent on abstinence and fidelity programs in Africa accomplished? Now, we finally have some answers. In the most comprehensive independent study to date, published this May in Health Affairs, Stanford University researchers conclude that these programs have been a failure and the money essentially wasted. By comparing 14 African countries that received PEPFAR funding with eight that did not, the study found no differences in the age men and women first had sex, the number of sexual partners men and women had, or in the number of teenage pregnancies. Washington’s ideologically-driven preaching of abstinence and fidelity, therefore, appears to have had no impact on sexual behaviors linked to greater risk of HIV infection.

None of this comes as a surprise to the sociologically minded. Not only is there ample evidence that abstinence programs elsewhere in the world have failed, including in the United States, PEPFAR’s focus on individual behavior change is also naively unsophisticated. Sexual relationships, like all social interactions, are profoundly shaped by broad social-structural forces, from economic disparities to gender inequalities to racism. Simplistic, morally-laden exhortations for a person to “choose” abstinence or monogamy fail to address the sociological complexity of sexuality. They also often make people less open about their sexual behavior and stigmatize other proven prevention approaches, especially condoms.

There is, in fact, now a rich body of sociological research on AIDS in Africa that makes clear why PEPFAR’s abstinence and fidelity programs have accomplished so little. A key theme in all of this work is how persistent, and often increasing, forms of social inequality exacerbate the risk of HIV infection for African women and men.

Particularly surprising for me given Uganda’s AIDS success was how these forces reproduced men’s sexual privileges in ways that placed both women and men at risk of HIV infection. For example, I found unemployed men would sometimes try to compensate for being failed family providers by having multiple sexual partners. Interestingly, more successful men would sometimes exhibit their economic status by also having multiple partners. Women, however, were stigmatized if they had multiple partners and monogamous women often had little ability to challenge their male partners’ sexual behaviors, making them more vulnerable to HIV infection. From my time in this community it became apparent that addressing these inequalities was the key to a true solution to the AIDS crisis in Africa, something well beyond PEPFAR’s simplistic preoccupation with changing an individual’s sexual behavior.

PEPFAR’s AIDS treatment programs, I should note, have been and continue to be a tremendous success, providing life-saving drugs to millions of Africans. In addition, PEPFAR’s emphasis on abstinence and fidelity in prevention has declined, with the one-third mandate removed in 2008 at the end of the Bush presidency. Nonetheless, about $50 million per year is still being spent promoting abstinence and faithfulness programs; hardly a trifling amount that clearly could be better spent. Equally important is making a sociological perspective on the AIDS pandemic more prominent in the global response. Without addressing the social inequalities that shape sexual behavior, millions of African women and men will remain vulnerable to HIV infection for generations to come.

Robert Wyrod is Assistant Professor in the Department of Women and Gender Studies and the International Affairs Program at the University of Colorado Boulder.