1 December 2005

Africa's Condom Conundrum: Fighting HIV in Africa

guest column

Addis Ababa — A controversy about preventing HIV/Aids - the most profound strategic threat to Africa's future - has been raging over the past year in Uganda, a country that registered one of the early successes in the fight against the pandemic. Simply put, the debate is about the right mix between sexual abstinence and condom use to prevent and control the spread of AIDS.

In all of Africa, and not just in Uganda, the tension between these competing approaches is all too real, with the choice often presented as a dichotomy. Should condoms be promoted, along with an implicit endorsement of sexual freedom, or should they be discouraged in favor of advancing private morality as good public policy?

Call it the condom conundrum. The problem arises when, as is often the case, the debate is made into an ideological one that denies the evidence of the scientific benefits of condoms, on the one hand, or the importance of individual moral choices about premarital or extramarital sex as a legitimate response to the pandemic, on the other. Whatever one may think of the plastic contraption, the reality is that condoms play an important role in the fight against a disease that is spread in Africa mainly through heterosexual sex.

The condom conundrum confronts African societies at four main levels - culture, gender, political leadership and religion.

The issue of culture embraces technology and its impact on human behavior. Condoms have historically not been a part of sexual relations in African societies. Indigenous African technology never produced a device whose aim was to prevent pregnancy and sexually transmitted diseases at the same time.

Natural methods were used for birth control. This situation led to a culture in which condoms, ever since they became part of sexual mores in Africa, have remained an essentially urban phenomenon. Many people in rural Africa have never seen a condom, let alone used one.

At the same time, the gender dimension of the fight against Aids has not been accorded an importance equal to its impact as a cause of the pandemic's spread. The face of AIDS in Africa is mostly female. Sixty per cent of those living with the disease in Africa are women, and the disparity is often even greater among younger age groups.

Use of the "c-word" is circumscribed by the history and psychology of how men and women relate in the bedroom and is intrinsically bound in wider issues of gender relations. In many societies, including those of the industrialized global North, women have historically been disempowered - whether by denying them voting rights until well into the 20th century or control over their bodies. African and Islamic societies are not unique in the restrictions they have placed on women, although they have been slower to change. Thus many women, married or unmarried, cannot insist that a man use a condom against his will.

This female disempowerment is what has led to the invention of female condoms and microbicides that can help women protect themselves from the HIV virus. But again, few women in Africa know about these things or have access to them.

The lack of political leadership is a third factor limiting condom use. The fact that condoms are often seen as a social taboo means that political leaders in Africa do not want to be seen a mile near one - in public at least. As one African leader reportedly told UN Secretary-General Kofi Annan, "I can't utter the word condoms. I'm the father of the nation".

That aversion is not universal. When Alpha Konare, the current president of the African Union Commission, was President of Mali, he is reputed to have waved one in public - on television, no less - while talking about sex education and AIDS prevention. Such political leadership and mobilization at the grassroots level is essential if African countries are to have any chance against HIV/Aids. It should not be a matter of embarrassment. It is one of life and death.

Finally, the tension between religious and social morality and public policy is perhaps the most contentious issue when it comes to condoms. Abstinence, for reasons of spirituality or public health - or both - is a valid approach to fighting Aids.

Posters in Nigeria asking young men and women to "zip up" are not advocating a lifetime ban on close encounters of the intimate kind. They are asking young people to make a choice they can make - to reduce the chance of living with or dying from Aids by delaying sexual debut, preferably until marriage. Campaigns aimed at delaying sexual debut amongst youth have also emerged in countries like Zambia and South Africa. This campaign is gaining ground even in liberal societies like the United States, where stunningly pretty young women now pop up on television telling their future husbands out there that "you are worth waiting for".

What is wrong with this message? Nothing. When we consider that the majority of those living with Aids are young people in their prime, it becomes clear that their attitudes towards sex affect their health.

Many critics of the abstinence message are social libertarians who believe that individual freedom should not be restricted on moral grounds, as was argued among the free sex, marijuana-smoking youth culture of 1960s America. The Nigerian musician Femi Kuti, debunking the United States government's support for abstinence campaigns, recently argued in an interview with the American newsmagazine Newsweek that "we were born to have sex". He is entitled to his opinion, but I suspect that is not the advice many parents will be giving their daughters.

The political/ideological position that masquerades as a human rights campaign fails to recognize that the public space is often an aggregate of private actions. But the abstinence message runs into difficulties when it is presented as the only acceptable prevention method, especially on religious grounds.

The dilemma crops up in the positions of certain influential faiths towards condoms and Aids. The Catholic Church, for example, has launched a "Marshall Plan" to fight Aids in Africa, not by joining the condom-distribution chain - it says it will not) - but by treating Aids patients as part of the church's avowed mission to treat the sick.

Even here, however, the nagging dilemmas creep in. What of a case where one partner in a Catholic Christian marriage is living with the virus? Should that partner not use a condom to avoid passing it on to the other?

Whatever our personal or religious views about sex outside of marriage, the reality is that not all who wish to abstain succeed in doing so. To preserve their lives - and a chance for a possible latter-day spiritual conversion - they need condoms.

Expecting all faith-based organizations to actively encourage the use of condoms may be asking too much. But public health is a legitimate concern and responsibility of governments. They cannot - and should not - discourage or prevent condom use to promote religious doctrine.

This is why the "ABC" approach - abstinence, be faithful, and condoms - is the best approach to preventing the spread of HIV/Aids. Emphasizing one of these three components to the exclusion of the others is not good public health policy. Let the churches and mosques play their role in prevention and treatment. And let the public authorities do their duty to safeguard public health. Neither should stand in the way of the other.

But all these methods together have no hope of success in Africa without effective public education about HIV/Aids. Education, which informs effective prevention, holds the key to breaking the back of Aids in Africa. When the uninformed man or woman in rural Africa gets to know what this potent virus is, how it is acquired, how to prevent it, and how to live with it when the all-important prevention fails, then he or she will know that the "wasting disease" is often a consequence of preventable behavior. It is not "witchcraft".

Kingsley Moghalu, Ph.D. is head of global partnerships at the Global Fund to Fight AIDS, Tuberculosis and Malaria in Geneva, Switzerland. This column reflects his personal views.


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