June 15th, 2015
Abstinence, Be Faithful and Condoms: The ‘A,B,C’ of colonial legacies in Sub-Saharan HIV-AIDS prevention programmes | HART Prize for Human Rights
This essay, by Constantin Gouvy was shortlisted for the Senior Essay category of the HART Prize for Human Rights. Read more entries here.
As of 2013, sub-Saharan Africa (SSA) was home to more than two thirds of the world’s HIV-positive population, a figure which has not changed much over the past decade (Stillwaggon 2003 p.810). While this is true at the regional level, prevalence rates in certain countries have experienced much more fluctuation. In 2012, Uganda was home to 1.4 million people living with HIV – a 7.2% prevalence rate among adults, which represents a significant drop from the 15% prevalence rate of the year 1991 (Stoneburner & Low Beer 2004). The shift in numbers is largely attributed in the literature to the implementation of Uganda’s “Abstinence, Be Faithful, and Condoms” national policy also known as “A, B, C”, and its impact is indeed undeniable. The Ugandan case nonetheless calls for a more in-depth analysis of the influence the A, B, C policy had on prevalence rates and how its behavioural focus might be challenged while calls are put forth, advocating for a more comprehensive response to the underlying structural factors which support the daily reproduction and transmission of the illness.
The aim of this essay is to make explicit the limits of behaviour-focus policies, not only in Uganda but also in the wider SSA region, demonstrating they are influenced by prejudiced, Euro-centric appreciations of African sexuality, and raising awareness of the influence that the focal points set by the academic literature supporting the global AIDS response has on the creation of international and domestic public health policy. To understand the nature of the global AIDS responses and its shortcomings, it is first important to appreciate the context in which it took place. In the 1980s, the strikingly high rates of HIV/AIDS in SSA, contrasting with the rather contained epidemics in the United-States and Europe, participated in establishing a climate of urgency around the research concerned with the African continent’s AIDS epidemic (Epprecht 2009 pp.1268-1269).
This climate favoured the emergence of a behavioural narrative that subsisted well into the 2000s. This narrative gave rise to an uncritical transposition of the intellectual baggage of “nineteenth century racial science” (Stillwaggon 2003 p.814) into much of the literature then produced on the epidemic but also in the programmes designed by international bodies aiming to halt the spread of the virus (ibid p.810). After the origins of the virus and the “Haiti connection” / “monkey bite” narratives were discussed in the United-States (Packard & Epstein 1991 p.773), the “unusual” heterosexual mode of transmission of the disease in SSA gave rise to a renewed politicisation of the virus through a narrow focus of research on racial behaviour as the sole cause for the scale of the epidemic (Chirimuuta & Chirimuuta 1989). Indeed, the quasi-exclusive focus on the alleged peculiarities of African sexual behaviour (Packard & Epstein 1991 p.771) which emanated to a great extent from Western latent racial prejudices and perceptions (Stillwaggon 2003) had a critical influence on the shaping of the overall development of AIDS research in that it supported early on the narrowing of the scope of research questions to behavioural enquiries only (Packard & Epstein 1991 p.771; 776). It was as though the mid-1980s HIV pandemic had rejuvenated the western racism and bigotry of a colonial past, subverting reason and scientific logic (Chirimuuta & Chirimuuta 1989). AIDS and “African sexuality” seemed to represent one of the last bastions of scientific racism, as authors, journalists and scholars proved uncritical of their assumptions, which in most cases differed only little from popular and unenlightened visions of what “Africans” are (Stillwaggon 2003 p.810).
Such ahistorical depictions of Africans and of their sexuality have since been challenged by a Foucault-inspired discourse analysis literature that evidences the colonial-era over-simplifications and stereotypes made in regards to the continent (Epprecht 2009 p.1258), nonetheless the impact such colonial prejudices had on the AIDS literature at the time was remarkable in its reach, with the conclusions of certain papers, and those of the Caldwells serve as a great illustration, being quoted at length and held as scientific truths (Stillwaggon 2003 p.812). Africans, the reader is told, are “hysterical”, “anomalous”; their mental processes are “pre-logical” and constrained by the fear of “ancestral spirits” which they worship (Caldwell & Caldwell 1987 p.410). Their sexuality in particular is considered in the singular and with an implicitly timeless nature; it is found to be customary, tribal, native or pre-modern even (Epprecht 2009 p.1258); lacking guilt and sexual modesty, an argument often illustrated by references to naked breasts and “writhing dances” (Epprecht 2009 p.1262). Other claims pertaining to the exotic nature of African sexuality included mentions of particularly promiscuous sex or a prevalence of transactional relationships, pseudo-scientific data (Standing 1992 p.477-480 for an anthropological critique of “scientific” conclusions on prostitution in Africa) for which topic Diane Jeater exposed the foundational role of colonial narratives, eventually “discoursing” such claims into existence over time (Jeater 1993).
The behavioural focus of early research on AIDS has framed the relief programmes of international organisations so that they would be concerned with educating Africans to “modern” sexual practices and standards rather than addressing the socio-economic (Whiteside 2010; Poku 2001; Poku 2002) and biological factors (Stillwaggon 2002) – as well as their interrelation – that underlay particular sexual behaviours (Stillwaggon 2003). It is not disputed here that the “poverty cycle” dynamic that posits a strong inter-connection between poverty levels, biological vulnerability and prevalence in HIV/AIDs does not go completely unchallenged, and that more research is required to make sense of some diverging research results (Fox 2012). However, these discordant voices question some of the findings associated with Whiteside’s, Poku’s or Stillwagon’s research only to point towards inequality in wealth as an additional factor to be considered, without dismissing the original premises of the studies they seek to supplement, and leaving the overall burden of empirical (Tladi 2012; Booysen 2004 inter alia) data emphasising the key role of socio-economic factors in the spread of HIV in SSA mostly unaffected.
In Uganda, the dismissal of such socio-economic factors in favour of behaviour-only programmes (with a particular focus on abstinence) has been well documented, and openly linked with the financial influence of the conservative U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) (Human Rights Watch 2005). Although the A, B, C policy has proven effective to some measure, the emphasis PEPFAR has placed since 2003 on impacting sexual behaviour by promoting abstinence until marriage as the strongest means of fighting HIV-AIDS is misplaced. It simply fails to address the widespread poverty, wealth inequality and illnesses that strike too many in Uganda. The clearest example of this might be the evolution of the prevalence rates in the country: from 2006 onwards, the rate of the HIV-positive population witnessed its first rise after hitting an all-time low under regular A, B, C policy (Marco & Bernard 2006). In light of these developments, one can only hope that the necessity of programmes addressing the underlying dynamics of HIV transmission can be recognised and failing that, that PEPFAR reconsiders its dismissal of the key role of condom use in preventing HIV-infection.
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