In response to:
God and the Fight Against AIDS from the April 28, 2005 issue
To the Editors:
Helen Epstein [“God and the Fight Against AIDS,” NYR, April 28] vividly and convincingly reveals how the theological agenda of the Bush administration is derailing a once-successful effort to limit the spread of HIV in Uganda. An old adage is that “science follows the money,” and, as Epstein shows, this applies not only to molecular biology but also to behavioral programs. In this vein, can countervailing financial incentives be brought to bear to ameliorate the current situation? Is the World Health Organization, or private philanthropies, like the Bill and Melinda Gates Foundation, able to intervene with resources to restore the earlier effective programs in that country? Or does the prevailing political party have an absolute stranglehold on public health measures?
Jerome E. Groopman, M.D.
Dina and Raphael Recanati Professor of Medicine
Harvard Medical School
Chief, Division of Experimental Medicine
Beth Israel Deaconess Medical Center
Helen Epstein replies:
Indeed, it would be great if the international public health community—the WHO, the UN AIDS Program, the large private charities like the Gates Foundation—began supporting programs like Uganda’s 1980s Zero Grazing campaign. However, these very institutions bear some responsibility for the fact that “partner reduction” programs—like Zero Grazing—are so thin on the ground in Africa today. Their policies and programs have overwhelmingly emphasized technical approaches to HIV prevention, including condoms, HIV testing, and research into as-yet-nonexistent vaccines and vaginal microbicides. All these approaches are important, but even those that are currently feasible, such as condoms and HIV tests, have so far failed to stem the tide of the epidemic, even where painstakingly implemented.
Partner reduction is virtually free, involves no equipment or commodities, and is easier to practice than wearing a condom during every single sex act—something very few people on the planet do. It is also a far more realistic recommendation than strict abstinence until marriage and perfect fidelity thereafter. It also seems to work. Everywhere that HIV infection rates have fallen—from Uganda, to Thailand, to the gay communities of the US*—partner reduction has played a crucial role in the decline.
See Warren Winkelstein Jr. et al., "The San Francisco Men's Health Study: Continued Decline in HIV Seroconversion Rates Among Homosexual/Bisexual Men," AJPH, Vol. 78 (November 1988), pp. 1472–1474; Martina Morris and Laura Dean, "Effect of Sexual Behavior Change on Long-Term Human Immunodeficiency Virus Prevalence Among Homosexual Men," American Journal of Epidemiology, Vol. 140, No. 3 (1994), pp. 217–232. For other cities see R.A. Coutinho et al., "Effects of Preventive Efforts Among Homosexual Men," AIDS, Vol. 3 (1989, Suppl. 1), pp. S53–S56, and references therein.↩
See Warren Winkelstein Jr. et al., “The San Francisco Men’s Health Study: Continued Decline in HIV Seroconversion Rates Among Homosexual/Bisexual Men,” AJPH, Vol. 78 (November 1988), pp. 1472–1474; Martina Morris and Laura Dean, “Effect of Sexual Behavior Change on Long-Term Human Immunodeficiency Virus Prevalence Among Homosexual Men,” American Journal of Epidemiology, Vol. 140, No. 3 (1994), pp. 217–232. For other cities see R.A. Coutinho et al., “Effects of Preventive Efforts Among Homosexual Men,” AIDS, Vol. 3 (1989, Suppl. 1), pp. S53–S56, and references therein.↩