Simon Duffy: Global Aids war has many fronts

COMMENT

The International Aids conference in Bangkok last week saw an old controversy rise from the ashes: should Aids prevention programmes promote condoms or abstinence?

It always amazes me that people sitting in comfortable chairs in the developed world think it is up to them to make decisions about what sexual behaviour is appropriate for people thousands of kilometres away in vastly different cultural contexts.

But it's more insidious than that. This debate is a damaging distraction from the real issues. Aids is an immensely complex global problem that requires urgent action in a huge range of areas. Controversies such as this are like a giant handbrake.

It is very important to have respect for the cultural context and values of the community with which you are dealing. If you cannot do that, it does not matter what you say - no one is going to listen.

Good Aids education programmes teach people about the dynamics of the disease. They warn about high-risk behaviour, and give people realistic options for keeping safe. One of the best strategies - and this is an area where the New Zealand Aids Foundation has been very strong in its work with the gay community - is to spread the word via peer networks, rather than having outsiders telling people what to do with their sex lives.

So if you are dealing with sex workers, you build up trusting relationships with some of the older ones who have status in their community. They get alongside younger ones and new recruits, who tend to be more careless about condom use and control of other sexually transmitted infections.

This way you actually create a new social expectation among that community. And you don't talk about abstinence to sex workers unless you can also offer them a realistic alternative way of making a living.

Using the same logic, you don't ask a commercial sex worker to talk about Aids to a conservative church congregation. You build up relationships with respected church leaders. You talk about faithfulness in marriage and respect for the rights of women, and gently challenge the attitudes that lead to stigma and discrimination. You encourage them to set up groups to help orphans and visit the sick, which churches across Africa are doing to great effect.

And you take a softly-softly approach when discussing condoms, or you don't get to discuss anything at all.

In a country with low HIV prevalence, like New Zealand, the epidemic is largely confined to a few high-risk groups, although none of us can afford to be complacent. In high-prevalence countries, the entire population is a high-risk group. This makes churches and other faith groups, which have a huge ability to influence communities, a very strategic ally for Aids awareness and education.

But Aids prevention is about so much more than just education. A Herald article last week emphasised the limitations of the ABC model - abstinence, be faithful and use condoms. It doesn't matter how many Aids billboards you've seen, if you're a woman, and especially a young woman in parts of Africa, you may not be in a position to act on what you know.

This has led World Vision to start research in Tanzania and Zambia to discover why global efforts to prevent Aids are failing women and girls. In Tanzania, the HIV infection rate for girls aged 15 to 19 is 4.8 per cent, compared with 1.5 per cent of boys. In Zambia the rate for girls in the same age group is 6.6 per cent, compared with less than 2 per cent for boys.

Girls in these communities were subject to violence, including sexual abuse in the home, sexual abuse by teachers, rape, premature sexual activity, commercial sexual exploitation, and sexual harassment in homes, schools, and the community. They were also put at risk by harmful traditional practices including early marriage, female genital mutilation (in Tanzania) and initiation ceremonies (in Zambia).

Where women and girls are largely monogamous, but men and boys are not, and where girls have little to no sexual agency, sole reliance on condoms is not sufficient for reducing girls' vulnerability.

Some of the most important Aids prevention work is about building relationships with communities and community leaders, including men and women, boys and girls, to change gender attitudes and customs.

A good example is property rights for women. Last year I met a group of six commercial sex workers in Zambia. Three had been married, but their husbands had died or left. Their husbands' families had laid claim to their homes, land and all their resources. They had children to care for. With no other options they ended up in the sex industry.

The long-term solution is to ensure communities are aware of, and abide by, the law, which in Zambia protects women's rights to own land and makes property grabbing illegal. World Vision has had some successes in this area, but it is going to take time, and long-term commitment.

The rest of the group of sex workers were orphans. This is another key issue: Aids kills people in their reproductive prime, leaving millions of children without parents. It is estimated there will be at least 25 million Aids orphans by 2010. If they are not cared for, and do not get an adequate education, many will end up in high-risk situations and will contract HIV.

Unicef has taken the lead in producing an excellent framework for orphans and other children made vulnerable by Aids, and this deserves support and funding from donor countries like New Zealand.

One of its main strategies is to strengthen communities' ability to care for orphans, by building networks of caring people who keep an eye out for children at risk, making sure they are in good homes, in school and being looked after.

The global war against Aids has to be tackled on many fronts. I have never encountered an issue so complicated, so multi-sectoral, interdisciplinary, and international. So I don't have much time for the condoms v abstinence debate.

The world's response to Aids has been littered with pointless controversies. What's really needed, as Kofi Annan was at pains to say last week, is commitment, co-ordination, and hard work.

* Simon Duffy is World Vision New Zealand's policy analyst.