by Dorothy Brewster-Lee, MD

Coordinator, International Health Ministries, Presbyterian Church USA

E-mail: dbrewste@ctr.pcusa.org

Presented at the ABC Experts Technical Meeting

Convened by USAID, September 17, 2002

Introduction

I thank you for your invitation to participate in this discussion. This is a meeting long awaited by many Faith-Based Organizations (FBOs). While I don’t represent all FBOs, I believe that my comments on AIDS, which are drawn from personal experiences, do typify many, if not most, Muslim and Christian organizations in Sub-Saharan Africa. I’m not here to argue about what has actually happened or is happening in the field of AIDS prevention in Sub-Saharan Africa but simply to provide you with a sense of how that reality has been perceived by many FBOs over the past ten years. I will then follow those comments with suggestions on what “could happen” if we feel bold enough or frustrated enough with the past to work together on AIDS prevention. I will limit my comments to my experiences in three Sub-Saharan African countries: Malawi, Kenya and Cameroon. In each of these countries, Presbyterians, along with other FBOs, contribute substantially to health and educational services, particularly in the rural areas

Since I felt that most of the presenters today would be trying to determine what has “worked” in preventing AIDS in Africa, I decided that I would take an easier assignment and discuss what has “not worked”. If we consider the rapid spread of AIDS in Sub-Saharan Africa, I think that we can all agree that there has certainly been much more accumulated experience in this area. Then I will be able to share some helpful suggestions on what “might work” in turning around the AIDS epidemic in Sub-Saharan Africa.

Six Strategies that have NOT Proven Successful in Controlling AIDS

We need to reassess the following six strategies that, over the past 15 years, have not proven effective in controlling AIDS on Sub-Saharan Africa:

1.       Marginalizing the FBOs that refuse to engage in condom promotion. I will give an example from Cameroon since I lived there during the period when HIV rates went from 2% to 10% (1993-97). During that time I remember attending one of the early National Government Faith-Based Discussions on AIDS. At the conclusion of the meeting, the government reasonably concluded that FBOs were not going to be very useful in condom distribution. So, we were ceremonially dismissed, and the AIDS rate continued to climb. This was a very different scenario than that experienced by FBOs in Uganda over the same period, where the AIDS rates were falling.

2.       Attempts to “rubber stamp” on African communities the AIDS prevention program models that were successful in the US context.

3.       Social marketing that does not strengthen or support the “moral values” of the society. Instead, social marketing media campaigns used the society’s traditional symbols on condom posters in order to give value and legitimacy to foreign concepts such as “safe” recreational and casual sex.

4.       Giving only lip service support and token funding to “A” – Abstinence and “B” - Be Faithful strategies. The most recent example of this is found in the UNAIDS Report on the Global HIV/AIDS Epidemic 2002 in the chapter titled “Prevention: Applying Lessons Learned.” The text begins: “Condoms are key to preventing the spread of HIV/AIDS and sexually transmitted infections, together with sexual abstinence, postponement of sexual debut and mutual fidelity.” The next sentence cites the Ugandan experience with reduced sexual partners and postponement of sexual debut. This paragraph is followed by a four-page discussion of condoms. OK, we understand that condoms are an important component of the Global AIDS Strategy. So devoting four pages to a condom discussion makes sense. What we don’t understand is that in approximately 40 pages of the prevention discussion presented in this document, there is no further discussion of the role of “A” or “B” in AIDS control. Furthermore, in thumbing through this 250+ page UNAIDS document, I could only find one additional reference to “Abstinence” strategies. This was in the text on “AIDS and Young People,” which read, “Less successful outcomes were reported in school systems where abstinence was presented as the only appropriate option for teenagers outside of marriage…” This sums up the UNAIDS “balanced” discussion of the role of A and B in AIDS prevention.

5.       Exclusively focusing on the experiences and needs of sexually active youth. Again a good example of this is found in the recent 2002 UNAIDS Report cited above. The Report presents data discussing the experience of sexually active girls from South Africa and data on condom use in young males in  15 countries and then goes on to present data from 19 countries regarding youth reporting sexual activity prior to their 15th birthday. The Report, however, totally ignores the experiences and needs of millions of youth not sexually active, as if there are no lessons to be learned from those who abstain from sex. So, as a way of “Breaking the Silence” on this population, if we look at the flip side of the UNAIDS chart, we can see, for example, that in Cameroon, Kenya, Malawi and Zimbabwe, from 70% to over 95% of both boys and girls are NOT sexually active by their 15th birthday. I would like to challenge us to consider what we would need to do to replicate these same figures next year, but now this would be for youth reporting that they had not been sexually active upon reaching their 16^th birthday. But perhaps that concept is a bit too radical to be seriously considered.

6.       Pressuring governments in Sub-Saharan Africa to promote condoms through a set of global reporting requirements. As presently formulated by UNAIDS, the AIDS prevention target insists that they disclose outcomes of national condom promotion strategies, but there is no incentive for A and B promotion or reporting.

What Might Work

I have not come to tell you that I know with absolute certainty what will turn the global AIDS pandemic around. But I would like to challenge you to consider some different approaches. What do we have to lose by re-thinking our “condoms only” AIDS strategy and changing course? It would certainly be hard to come out with worse African AIDS statistics than those we have seen over the past 15 years. So here are suggested changes to consider:

1.       Incorporate A and B approaches as serious components of an overall AIDS prevention strategy.

 2.       Consider new partnerships with FBOs as one of the primary implementers of A and B strategies. This is particularly important in Sub-Saharan Africa as the epidemic spills into the rural communities, given the important role that FBOs already have in providing health and school services in rural communities. There are also some FBOs that might even want to implement “C” interventions, but not all FBOs should be forced by funding stipulations to implement all A, B and C interventions. We all do not need to be doing the same thing; what is important is that we all are doing something and are not undermining the efforts of those that are not doing what we have chosen to do. For their part, FBOs in Sub-Saharan Africa are changing their attitudes in regard to this epidemic. Over the past two years we have seen a consistent message in all the major Christian declarations coming out of the discussions at Dakar, Kampala, FBO UNGASS, Nairobi 2002 and Botswana 2002. They all say that there is a unique place for FBOs in combating AIDS, and they are committing to playing more active and constructive roles.

 3.       Help the FBOs, particularly those in sub-Saharan Africa, celebrate the Ugandan experience and other A and B success stories. Highlight the role of FBOs in these countries, and use their examples to challenge FBOs in other countries to become more actively involved in AIDS prevention. This would mean identifying and documenting the best A and B practices developed by FBOs. This would also mean more funding of opportunities for South-to-South exchange, where interested FBOs can learn from each other.

 4.       Provide more funding for FBOs to take leadership in A and B prevention. In Malawi I recently visited a regional Presbyterian AIDS prevention office. The staff of five was working out of a room a little bigger than my four-year-old son’s bedroom, sharing one computer and a refurbished ambulance for transport. This poorly resourced team had access to over 500,000 church youth and young adults in the rural area. In their office there were no UNAIDS pamphlets or glossy PSI condom promotion posters. There was, however, a simple sheet of paper signed by 65 of their pastors which read, “We Ministers of Nkhoma Synod CCAP, gathered here at Namoni Katengeza Church Lay Training Center{Chongoni} from 10^th to 11^th May, 2000, noting with great concern the Devastating effect of HIV infection and AIDS in Malawi, do hereby DECLARE that we as a Church confess and repent before the Almighty God that we have not obeyed His word, and that we have not been fully involved in addressing the HIV/AIDS crisis, and that we ask for God’s forgiveness, and from now onwards, we will take a preventive, care and support stand. SO HELP US GOD!!”

 Conclusion

 To conclude, I believe FBOs are the key to turning around the AIDS pandemic in Sub-Saharan Africa and that each day more FBOs are coming to the same conclusion. I believe that FBOs will rise up and play a key role in turning around this epidemic. But without strong international funding, that “turning around” will be a slower process, with many people becoming infected and dying in the interim. It is my hope that the international donor community will embrace FBOs as serious partners in AIDS prevention. We have seen too much death and dying, and we welcome the opportunity to help bring this epidemic to an end through the initiation of good A and B programs. We look forward to working with you in order to bring health and laughter back into our communities in Africa.