TORONTO - Tom Davis raised his arms like a rock star when a few friends clapped and cheered at his unpopular little speech-a gesture of private triumph while the rest of the crowd murmured and heckled him in the cavernous session hall. "I didn't want to go up there," he joked later, taking consoling hugs from his colleagues, fellow workers in the fight against AIDS.
Davis, health programs director with Food for the Hungry, was not a scheduled speaker at last month's International AIDS Conference in Toronto but an ordinary delegate who shuffled up to an aisle microphone at question time. His point: that the Bush administration's worldwide $15-billion, five-year initiative to fight AIDS is doing some good. These days, those are fighting words.
The biannual AIDS conference is the world's most prestigious meeting on research and policy, and an important bellwether of how international activists and bureaucrats view U.S. policy as it pertains to the disease. The answer is, not well. And with billions of dollars up for grabs, the fight quickly turns ugly.
The Bush initiative is taking a sound thrashing over one element of its work, called the "ABC" approach to prevention. The concept is easy: It teaches different parts of an epidemic-hit population to Abstain from sex, Be faithful to one partner, and use Condoms. For Uganda, it was this common-sense approach that tamed its AIDS crisis. But now that U.S. dollars are backing it, advocates of other strategies want to undermine ABC.
Prominent expert Stephen Lewis, UN Special Envoy for AIDS in Africa, told the Toronto delegates: "No government in the Western world has the right to dictate policy to African governments around the way in which they respond to the pandemic. That kind of incipient neocolonialism is unacceptable."
Experts presented studies to go with the sentiment. For example, one Kenya survey of 1,400 adolescents showed limited understanding of ABC's methods: Half could define and explain the importance of abstinence, while only 23 percent could do the same for faithfulness, and even lower-13 percent-for condoms.
In another session, "ABC in Africa: What's the Evidence?", an expert presented a review of 10 abstinence-based programs that showed minimal impact. Another focused on cultural intractability in a Kenyan fishing district with an unusually high HIV rate, where locals explained their infidelities: "Traditionally, among us Luo people, most of our customs end with sex . . . whether it is the planting season or when you want to harvest, everything ends in sex."
Seeming to expect the onslaught, the President's Emergency Plan for AIDS Relief (PEPFAR) took a preemptive strike in June. At its own annual conference, experts examined studies to show ABC is working in several countries. Ironically, their most compelling data also came from Kenya. It focused on nationwide Demographic and Health Surveys, considered the gold standard in assessing people's sexual behavior.
Since the late 1990s, Kenya's HIV rate has declined from 10 percent to about 7 percent in 2003. Other indicators: "Between 1998 and 2003, more unmarried young men began abstaining. The number who reported having sex over the previous year declined from 56 percent to 41 percent; the number of men who reported having multiple partners was cut in half."
So AIDS-fighting turns on a war of ideas waged by Powerpoint slide and Beltway lobbying in Washington. By law, one-third of all prevention funds must go to abstinence-until-marriage and faithfulness programs, an earmark designed to ensure the A and B stay in ABC. That amounts to almost $130 million this year, only 7 percent of the total for the 15 focus countries under the Bush plan.
In June, Rep. Barbara Lee (D-Calif.) introduced the PATHWAY Act, a bill to increase women's access to condoms and education and to improve female property rights. But it would also strike down the abstinence earmark. Her legislation grew out of a report from the Government Accountability Office in April, in which unnamed U.S. field staffers complained the AB carve-out was siphoning money away from other HIV programs, though funding has increased across the board ("Abstinence under attack," April 29, 2006). That conclusion came despite the fact that last year the United States shipped nearly 200 million condoms to the 15 focus countries, almost double the amount shipped in previous years.
Some of the hostility to the AB portion of the Bush plan boils down to skepticism that teenagers will remain abstinent, and so not promoting condoms puts their lives at risk. Some of the worst anger, however, is directed at the "faithfulness" injunction: Activists say many Third World women, particularly in Africa, do not have the power to refuse sex, and often contract HIV from their husbands.
"The easy response to that is that the 'B' message has to be given to the man," said Ray Martin, executive director of Christian Connections for International Health. "We would acknowledge that ABC by itself doesn't work for everyone, but just because it doesn't work for everyone, doesn't mean it doesn't work for some. People act as if male behavior is a given, and we don't buy that."
At a quiet display for faith-based groups at the conference, Martin distributed a just-published primer, "The ABC Approach to Preventing the Sexual Transmission of HIV: Common Questions and Answers." Interest in the booklet was high, he said, but he and other ABC proponents remained on the fringe, as Ngozi Iwere found.
Iwere is a longtime Nigerian activist and feminist who directs the Community Life Project in Lagos. The group works with multiple community and faith-based groups to help prevent AIDS.
After making presentations at the conference, Iwere complained, "We can see all the knocks that ABC is getting, and I got really worried at this conference that we're about to throw away the baby with the bath water. People have been saying that abstinence is not realistic, and for us in Africa and at the community level, we ask, 'Realistic for whom?'"
Later, Iwere told WORLD that Toronto displayed the worst criticism of ABC she has seen so far. "I left the conference not being sure what we were going to do for sexual prevention, beyond tools such as condoms and microbicides."
Microbicides are the new rage in prevention, but are still in the early stages of research. They are products-gels, creams, and long-release sponges, for example-with chemicals that can kill the AIDS virus when applied topically. Hailed as a breakthrough for women, who could conceivably use them without their sexual partners' knowledge, microbicides are still at least four years away from public use.
That leaves what to do today in limbo, and verbal sparring such as Davis had in Toronto. When he pointed out at one session that the United States is the largest government donor of condoms in the world, one panelist wasn't convinced and responded, "U.S. government funding does not translate into an increase in condom availability in some places. Whether it's true or not, I don't know."
Davis said data-based conclusions matter more than impressions. For two years, he has handled a PEPFAR-funded youth abstinence program in four countries-Ethiopia, Mozambique, Haiti, and Nigeria. Though relatively new to ABC, he has worked on other behavior- change projects since 1983. ABC's success is not measured in all or nothing, he said. In an abstinence program, not all youth will avoid sex until marriage. But even those who delay having sex and have fewer partners can help cut the virus' transmission rate.
"I did speak up on behalf of ABC," he told WORLD about the conference. "I did not plan to, but when I heard how they were maligning the strategy-and not using scientific data to do it-I felt like I had to." He took glares, thumbs-down gestures, and a few people mouthing "Boo!" at him. In this fight, facts never seem to be enough.