Abstinence, abstinence-only, faith-based, and the psychology of stigma.

The June 23 talk by President Bush in Philadelphia (see "President Bush on AIDS: More Questions Than Answers" in this issue) raised deeper issues that need attention.

* There is common ground on abstinence; the problem is with abstinence-only (a phrase Bush did not use in his talk). Everyone agrees that not having sex is the most certain way to prevent sexual HIV transmission--and few if any object to teaching that. But it certainly does not follow that abstinence-only prevention programs are best--since many clients will not remain permanently abstinent, and the issue is what happens when they do not. Marriage is no magic answer, and in fact is a serious HIV risk factor for women in some societies. And the dynamics leading to sex vs. those leading to marriage can be very different--especially in today's world where sexual maturity comes earlier, while the ability to support a family comes increasingly late in life, if ever.

Maybe we should remind the public that everyone alive today is here because every single one of his or her direct ancestors, throughout all of human history, had sex. In thousands of human generations not a single ancestor of anyone alive maintained sexual abstinence 100% (with a few exceptions in the last decades only, through modern fertility technologies). Those who believe in evolution will understand that so compelling a record will be hard to override by some organization's abstinence-only program. Yes, most people can be abstinent at critical times, reducing the risk of HIV infection, and this should be encouraged. But we cannot expect abstinence-only programs to work 100%. Nor should we use HIV as a weapon to force people to conform, or as a means of execution when they do not.

* While the term "faith based" became prominent in the year 2000, religious organizations have been an integral part of the AIDS movement for many years. Organizations like Siloam (praised by President Bush), Catholic Charities, The Balm in Gilead, AIDS Interfaith Network, and many others have done excellent work. But unfortunately most churches have been unwilling to help--a problem by no means limited to religious organizations.

Over the years I have found that most "AIDS stigma" (in the U.S. at least) stems from men's fears that if they get involved or help in AIDS, people may think that they secretly have AIDS or are gay. That suspicion can be a problem whether it is true or false (except of course for those who are already open about being gay and H1Vpositive). This simple psychological dynamic explains the continuing difficulty of mobilizing churches, governments, and others to take obvious steps to prevent the worldwide catastrophe that has occurred. Compare the speed of mobilization against AIDS with that against legionnaires disease or SARS when they had killed thousands of times fewer people. Those diseases could get effective cooperation immediately, without first having to start thousands of new organizations and build them to the point that they could move governments and other institutions.

Now some religious conservatives are thinking that with more than 60,000,000 people who have been infected with HIV and more than 20,000,000 of them dead, maybe their churches should respond. Their help is welcome. If they want to focus on abstinence and fidelity, while leaving condoms and harm-reduction to others, that is fine.

The problem is the increasingly unmistakable efforts from a minority of religious conservatives to sabotage and destroy existing AIDS organizations, and replace them with programs intended to control the epidemic almost exclusively by stopping people from having sex. This problem should be addressed before right-wing politicians transfer funding and control of Federal and other AIDS programs from those who have cared for people with AIDS for the last 20 years to those who have not.