In most countries trying to combat the HIV pandemic, prevention strategies have adopted the ABC approach. That is Abstain, Be faithful, or Condomise. Sometimes, D is added for ‘you Decide’. This is not so popular in more conservative countries where it is felt that abstinence should come first and condoms should only be for high-risk groups such as sex workers. In Chipata, where the HIV infection rate is around 26% its difficult to see who isn’t a high-risk group. Something I’ve been puzzling about is whether the Zambian preference for abstinence-focused prevention campaigns comes from the country’s tendency towards conservatism, or whether it comes from following the money donated from the USA through PEPFAR (the Presidents Emergency Plan For AIDS Relief). PEPFAR is a massive donor, and has saved lives particularly through the provision of anti-retroviral drugs, but its funding is also controversial as this recent exert from a Zambian HIV/AIDS newsletter shows:
Treatment Advocacy and Literacy Campaign (TALC) activist Paul Kasonkomona is alive today because of PEPFAR support. He receives his supply of life-prolonging ARV drugs through the PEPFAR-funded CIDRZ program. This is what he has to say about PEPFAR and US Government funding in Zambia:

“The drugs keeping me alive are provided through PEPFAR, and that is good. My genuine feeling is they are doing the right thing when it comes to treatment, but there are some issues that we need to look at. When the US Government came in, the first thing they did was fund the treatment programme and said we buy the treatment from the US pharmaceutical companies, which sell drugs that are around 10 times more expensive than those from Indian and Brazilian companies”.

“While things have since changed, that US monopoly led to less Zambians receiving treatment. So while the US Government is trying to do the right thing, there is also selfishness there. We need to look at treatment for discordant couples (where one partner is HIV positive and the other is HIV negative) and when they say we shouldn’t talk about condoms with PEPFAR money.”

“What about when we have a HIV positive person in a committed relationship who is receiving ARV treatment? If they do not know about using condoms and do not have access to them then they will continue to have unprotected sex and risk re-infecting themselves, or infecting their partner, with a new strain of HIV. There is also the reality of women in relationships where they do not have the power to say ‘no’ to sex with their husbands, despite knowing that HIV is present in the relationship and that the risk of re-infection is real. Programmes that preach abstinence are not relevant to such women, and in fact do more to disempower them, and leave them more vulnerable to increased risk of AIDS.”

“Being re-infected with HIV makes you resistant to treatment, ultimately undoing much of the usefulness of the US Government supplying the treatment in the first place. It seems PEPFAR cares about treating HIV, but not about avoiding resistant strains of HIV.

“I’m not saying that abstinence is bad, but let us balance this campaign. Let those who choose abstinence have it, but let us still help those who have sex and teach them to take responsibility and use protection.

“The impact is also evident on the youth when we are made to say the youth should practice abstinence. I was asking a youth worker just this week how they relate to youth who have tested HIV positive.

“When you talk about HIV infection, the youth are the most at risk and so many are obviously sexually active already. So what use is an abstinence message to them? It pushes HIV positive away from treatment, care and support.

“What is needed from the US Government is funding choices that are left in the hands of Zambians. They have got to give Zambia a platform and say, “We have this amount of money, what are your priority areas?’ and then let us as Zambians be the one’s to decide.” (originally published in Partners Zambia newsletter, 25th July)

In Zambia, American Christian Fundamentalists have found fertile ground for their abstinence-only messages. Zambia is already a deeply conservative country, or at least people express conservative, moral sentiments at the public level. What happens in reality, unsurprisingly, is that a majority of people do have sex before marriage. This is the same as what happens in the USA, but Bush and the Christian right are not willing to promote condoms there either.

Abstinence-only funding can be even more inappropriate in countries such as Thailand where many people are infected through sharing of needles in intravenous drug use.The Global Fund, supported by Britain and many other countries is not free of error either. While in my view it has the right intentions, the gaps between the donors, the co-ordinating body in Zambia and the community organisations implementing activities lead to skewed and often ineffective results.No New Money Logo


Many activists, and now the US Congress are pushing for changes so that each country can determine how money can best be spent there. But as I said I’m not sure that the prominence of abstinence-only messages in Zambia is entirely the fault of PEPFAR. If the Zambian people are given control of how the money is spent, might there be an even greater degree of moralising and condemnation of those who have sex? The Zambian government has kept a ban on condom distribution in schools because it is suggested it will promote promiscuity among young people, despite evidence to the contrary.

Whether this moralising first came from US AIDS money, British Christian missionaries or the Zambian people long before this doesn’t really matter. What does matter now is that the international community ensure money is spent on evidence-based ways of tackling HIV/AIDS.

More information:

AVERT UK based AIDS information service

PEPFAR-watch US based organisation promoting accountability of US Global AIDS programmes through Information and Advocacy

No New Money US based organisation fighting against abstinence-only programmes in the US



July 23, 2007

Working in Zambia has been a bit of an eye-opener for me. In the UK I was involved in campaigning for ‘global justice’ with several organisations. These organisations portray the poverty in Africa and suggest how individuals can help either by campaigning for changes from governments and companies, or by donating to relief and development projects. While this simplified message is understandable given the short attention span of the public, the reality has left me a bit disillusioned. Most Zambians I know are not remotely interested in global justice. They want cars and iPods. But because of donor money available they do set up organisations which claim to fight poverty.

There are over 10,000 NGOs registered with the Zambian government. Almost all have a mission, vision, moto, logo, constitution and strategic plan. My experience is that only about 1 in 10 are implementing activities at any one time. In a country with over 50% unemployment, people seek the easiest route to employment. This is often starting a non-governmental organisation as Zambia is one of the countries which has received the most aid since independence.

In Chipata, the fourth largest town, the UN are represented by the World Food Programme and UNAIDS volunteers. There are several large international development NGOs, World Vision, Care International, Plan and Africare. There are perhaps 50 medium-sized organisations with staff, premises and activities, and several hundred smaller organisations. Most upwardly mobile young people I speak to are trying to set up NGOs not businesses because of the easy money that comes with it.

There is a great deal of learnt dependency. People are used to getting money from willing donors so have tired of coming up with ways in which they can work themselves out of poverty. Of course I am working in an urban setting, and many rural Zambians would never have even seen a white person, never mind accepted donations. And its wrong to suggest that Zambians are lazy. They work incredibly hard tilling fields and cycling the produce to market.

In a bid to avoid corruption, donors will often only fund projects, rather than overheads and staff. This is understandable given the lack activities carried out by organisations. However it also leads to organisations collapsing, reforming, and failing to develop over a number of years. Inactive organisations are labelled ‘briefcase’ organisations, and are usually characterised as being run by inexperienced people. But the problem I have run into is organisations run by ill-intentioned people who are very experienced in fiddling money from donors, what I call PreteNdGOs. Given the poverty levels, most people are not willing to volunteer. This coupled with the corruption is confusing coming for people coming from Britain where people who are not willing to volunteer are seen as selfish and those who steal from charities as the spawn of the devil. These concepts don’t hold here, which is a big reason why in my opinion aid doesn’t work as well as it could.

However I would not want to understate the poverty here. There are many people who do not eat enough, die unnecessarily and have few if any material possessions. But this is not because their is a lack of food, or a lack of money to solve these problems. Its because this food is not distributed fairly, and people do not have either the power or will to solve their problems. The lowest rank of Zambian society, often illiterate and malnourished, can not challenge the government because they do not know how. But the organisations that are supposed to help them do this are staffed by people who have managed to create a comfortable existence for themselves by Zambian standards and do not seem particularly intent on changing the status quo.

I don’t know if the solution is to cut all aid to Zambia as this would almost certainly make things worse, but cutting it a bit and making sure people have to work hard to gain it again wouldn’t hurt. One thing I am surer of is that if development is to happen it has to come from the people affected, or its likely to be pointless and misdirected.