A Very Different Thanksgiving

Yesterday, a reader commented about the article I posted about HIV prevention and the failure of abstinence only education. Since I rarely get comments, and this one asked a pertinent question, I felt I should respond.

The issue is, if women aren't in position to say "no" to sex, then how can they force their husbands to use condoms? It's a good question, but one that I think has several answers.

First, women empowerment is measured in degrees, not absolutes. While it might be difficult or impossible for African women to say "no" to sex, significant evidence demonstrates that, when combined with HIV awareness programs, condom promotion does work. (See the reduction in birth rates across Africa as evidence of this.) While men were unlikely to stop having sex, there was acceptance and usage of condoms and that helped reduce the rate of transmission. Essentially, the empirical evidence supports my position.

Another point in favor of condom promotion is that a large percentage of HIV infection is through matrimonial sex. Husbands have sex with prostitutes (a common occurence) and then transfer the disease to their (often pregnant ) wives (meaning that they infect not just their wives, but also the next generation as well). It's just not reasonable to suggest that married couples should resort to abstinence and I believe that there are about 5,000 years of history to back up that point. While the idea of abstinence my have been culturally or politically palatable 50 years ago, all available evidence demonstrates the fallacy of that approach.

Moreover, I feel that it is nonsensical to put all the eggs in the proverbial basket, especially when their is scant evidence that abstinence only education actually works. We have to remember that we're talking about life and death issues here. This isn't just about a puritanical appeal to sexual morality. It's about whether people live or die or, more pointedly, whether disadvantaged African women will continue to be infected with HIV against their will by their unfaithful husbands or whether they will receive a minimum amount of protection. Condom promotion gives them a chance; it saves lives. Abstinence only doesn't; it kills.

That being said, the study reported in The Guardian revealed that HIV prevention, generally, isn't doing that well at the moment. In the US, for example, education and awareness has halted the increase of HIV, but not reduced those rates. The same was true in the UK, but not infection rates are increasing. In Africa, where the situation is the worst in the world, infection rates continue to climb, although not as rapidly as before.

The gains of the 1990's appear to be eroding. While no definitive conclusion is available, one possible explanation is "message fatigue". After hearing the same story, again and again, people do become numb to the significance of the message. Marketers and politicians fight this problem by changing their approaches, varying their campaigns, and highlighting issues. It is surprising that this same phenomena could be occuring with HIV prevention given the severity of the issue. But, when one remembers the significant number of uneducated in Africa and the rest of the world, it becomes somewhat understandable. To the relatively unsophisticated, HIV is just a name. Much like the Surgeon General's warning about smoking, it appears that people are ignoring the dangers in favor of a few moments of gratification.

This dynamic is likely compounded by better treatment for HIV/AIDs as well. It's now possible to live a relatively normal and healthy life when you have the disease. While treatment is a good thing, it appears at least possible that the sexually active public is less concerned about the risks as it is now less scary and something that can be "dealt with". The newest generation of sexually active adults, by the way, grew up with HIV/AIDs. They aren't scared of it like my generation was.

It is also possible that the average African is not overly concerned with HIV prevention because their average life expectancy doesn't go much beyond 50 years. Angolans, for example, can expect to live between 44 (men) and 48 (women) years. Even if they don't contract HIV, the average African is still not likely to enjoy a long life. One has to wonder if that reality instills a sense of listlessness or apathy in response to AIDs education and prevention programs.

My conclusion is that HIV prevention needs to be smarter. We need to combine a mixed message that explains the risks of unprotected sex along with the benefits of fidelity. We need to educate generations about effective prevention methods and we need to acknowledge that, as much as some wish, there is not only no stopping sex before marraige, the only room for morality in HIV prevention is in fullfilling our moral obligation to save lives.

Finally, we need to tailor these programs more specifically to the countries with the greatest need. A blanket "one size fits all" approach clearly won't work. Instead we need to find the appropriate mix of packages for each country. If we do this, I believe we can halt this terrible disease. But, if we continue "as is", I believe it likely that HIV infection rates will continue to rise.

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Things I'm thankful for this Thanksgiving:

1. My married life
2. My opportunity to live and grow in Colombia
3. My Spanish
4. The general health and well being of my friends and family
5. The absence of mayonnaise in my refrigerator

I hope everyone in the States enjoyed their Thanksgiving.