The ABCs of AIDS Prevention

The Jeito campaign has sent condoms and condom advertising into far-flung parts of Mozambique

MAPUTO—As night falls along the highways of rural Mozambique, lights come on in the barracas, open-air roadside bars. Some are cane huts lit by kerosene lamps; others are concrete, with metal roofs, spinning lights, and blaring music. Truckers heading from Mozambique’s ports along the Indian Ocean to landlocked countries in southern Africa pull to the side of the road. It doesn’t take long for a few girls to wander over and strike up a conversation, then a negotiation: How much for sex? And where? The woman may ask the trucker to use a Jeito, a brand of condom widely available at these way stations. But he may offer a little more money to keep the condom in its wrapper.

These women are rarely full-time sex workers. They come out to the barracas when they need cash for school fees or clothing. And part-time prostitution is not the only unorthodox sex practice that’s common in Mozambique. To prove their virility, men often take a second or third wife. Women spend years scarring their legs and stomachs to make themselves sexually attractive. Migrant workers often return to their families from jobs, and sexual liaisons, abroad. And in some regions, when a man dies, his wife must sleep with one of her husband’s male relatives, a practice known as sexual cleansing. This mix of sexual economy and cultural practice is a petri dish in which HIV grows and spreads with speed and ease. About 1.4 million of Mozambique’s 19 million people are believed to be infected.

Into this scene comes a flood of money from President Bush’s Emergency Plan for AIDS Relief and its “ABC” approach. ABC stands for “Abstinence, Be faithful, use Condoms,” the three-pronged strategy generally agreed to be the most effective way of preventing the spread of HIV. Mozambique is one of 15 countries selected to receive the bulk of the money in a five-year plan to spend $15 billion. But the money comes with strings attached, including rules that encourage abstinence-only education and de-emphasize condoms. The people fighting AIDS agree that the politicization of this aid, and ignorance of local practices, threaten to undermine its effectiveness.

In Washington, the United States has become adept at smooth talk about the ABC approach, mentioning just enough science and just enough religion. “Abstinence works, being faithful works, condoms work. They all have a role in the important mix,” Randall Tobias, the head of Bush’s plan, told Congress in March. Tobias makes it sound like all three are deployed equally, which is far from the case. Last year, for example, the United States gave $100 million in grants for abstinence-only education to the 15 countries, with the great bulk going to faith-based groups. (Science does not back up the effectiveness of these programs. A recent report from the American Foundation for AIDS Research said that “evidence does not support” the abstinence-only emphasis as a way to stop HIV in young people and that comprehensive sex education would be more effective.)

New internal guidelines for implementing ABC say that abstinence and partner reduction (A and B) strategies can be used ad hoc, but any approach involving condoms must also include messages about A and B. The rules list seven points that condom programs must mention, only one of which actually deals with the use of condoms. The rest involve abstinence, condoms’ limited effectiveness, and ways to reduce the risk of transmission. What’s more, the Bush AIDS initiative restricts distribution of condoms to “high-risk” groups such as sex workers, members of the military, and migrant laborers. It forbids discussing condoms with people under age 14. The result pits the letters of ABC against one another, dissolving the three-prong approach, while often making it hard to talk about condoms at all.

On the ground, nearly every independent group disagrees with that strategy. “We promote condom use,” said an official at the World Bank, which gives millions of dollars to Mozambique to fight AIDS. “We don’t have a moral angle, because we’re not a moral institution. We can fund as many condoms as the government of Mozambique is willing to buy and can distribute effectively.” The United States enters the scene as the 800-pound gorilla, pushing its agenda along with its vast quantities of money, thereby shifting how the issue is addressed. That shift is beginning to confound groups with long-standing experience in Mozambique.

Take Júlio Pacca, head of the Mozambique office of Pathfinder International, which operates more than 100 youth centers doing AIDS education all across the country. “When you are talking about the fight against HIV transmission, you must talk about condoms,” he said. In the tiny town of Buzi, a Pathfinder organizer regularly gathers teens from area schools for peer counseling and lessons on reproductive health. The information the teens take home helps overcome myths about HIV, including the rumor that it’s contained in condoms. Pathfinder did not bother to ask for money from the U.S. initiative, though they may apply in the future.

Nonetheless, U.S. money is slowly transforming the lay of the land. Some organizations with U.S. funding chafe at the rules but say they comply. “They want us to do capital A, capital B, little c,” said an official at a group in Mozambique that gets U.S. money and asked not to be named. “We see condoms as an essential part of the array. [Bush’s plan] was forced to kowtow to this right-wing lobby that really wants to see the A-B portion only. They’ve really downplayed the C portion.” Kevin Novotny, head of the Mozambican office of the group Project HOPE, a new recipient of U.S. money under this initiative, said the rules had a chilling effect on condom education. “I didn’t even put condoms in my budget,” he said referring to his funding application, which aims to raise money to form youth groups to promote abstinence and educate girls about how to negotiate safe sex.

Condoms or no condoms, the need for such negotiating skills, as well as talk about fidelity, should not be downplayed. The average age of sexual debut in Mozambique is about 16, and activists peg sex between older men and younger women as another way the virus spreads. U.S. rules say condoms can be given only to high-risk groups, and not to youth. With infection rates around 15 percent in the cities and above 35 percent along the transportation corridors, and with so many infected people, it seems fair to argue that all Mozambican youths are high-risk.

“They want to experiment,” said Filipe Charles, who runs a range of AIDS programs in northern Mozambique for the international aid group CARE. “Sex is good, but it has to be responsible sex.” Charles uses U.S. money to teach all three parts of ABC and says the United States has taken a hands-off attitude.

The United States does fund condom promotion in Mozambique, mostly through a group called Population Services International, which is well known for condom advertising and distribution around the world. PSI had to change its accounting practices to play within the new guidelines. The group bought about 21 million condoms for Mozambique last year, using money from Britain. Its U.S. funds go to promoting condom use, not purchasing prophylactics.

If truckers use condoms, it’s probably thanks to PSI. PSI runs the Jeito campaign, which distributes the condoms nationwide, sells them below cost, and promotes safe sex on bright green and yellow billboards, often showing couples in humorous situations. PSI’s agents sell Jeitos even in remote areas, so most barracas have them for sale alongside the food and drink. The United States gave PSI $1.2 million for this effort in Mozambique in 2004, most of the $1.54 million allocated for non-AB prevention activities. Abstinence and fidelity programs got just over $2 million. The United States also buys condoms for free distribution at all the country’s public health centers.

The United States often stresses the involvement of faith-based groups in its abstinence-promotion work, but Christian organizations are the most conflicted about how to mix messages about condoms, abstinence, and fidelity. While some would like a Western moral message to come to the fore, they also acknowledge it’s not realistic, given local beliefs. “To say that everybody’s going to be abstinent is crazy,” Darcy DeLeon, head of the Adventist Development and Relief Agency in Mozambique, told me. “From a Christian standpoint that’s what we’d like to see, but we recognize we can’t force people to live to that standard, especially in the fight against AIDS.” ADRA gets money for abstinence-only education, but not for work in Mozambique, according to DeLeon. Each ADRA mission can determine its own philosophy, and in Mozambique that means talking—very carefully—about condoms.

Care for Life, a small Mormon organization, is far less subtle: “If you’re involved in sex very early, you will die,” says the group’s director, Augusto Cherequejanhe. Care For Life carries that message into hundreds of schools in central Mozambique without any reproductive health education or information about how HIV is transmitted. The group gets money indirectly from the United States for work on literacy and care for AIDS orphans, but not for its sex education program.

Perhaps information disseminated at several Catholic boarding schools in the same province offset Care for Life’s harsh, unscientific program. “Condoms do not mean you can fool around. It’s immoral,” Sister Palmeira told me at a rural school, where abstinence and fidelity are taught in the classroom. Kids who come to the adjoining clinic—run by the same nuns—after school can get their hands on condoms. “We should advise them that condoms exist and tell them how they work. If you can’t abstain, please try to use prevention methods such as condoms.”

Groups in every province take a different approach. The government of Mozambique envisions a complex ABC program that adapts to each region’s cultural differences, such as polygamy and sexual cleansing. Of course, that’s at odds with the United States’ more blanket focus on A and B, and it doesn’t jibe so well with local practice either. The result is a piecemeal effort when a comprehensive, countrywide approach is needed to curb the disease. In a country as geographically and linguistically diverse as California but twice as big, the barracas are the only thing the entire nation seems to have in common.