What the rest of Africa could learn about AIDS

KOLDA, Senegal -- The open-air classroom, buffeted by a stiff, dusty wind, rang with the sound of children's laughter and excited chatter as their teacher paced in front of the blackboard, brandishing colored chalk. He raised his hand, and the room fell silent.
He pointed to a poster with an illustration of a man in a bar, leaning suggestively toward a woman holding a condom in her hand. "What do we think is happening here?" he asked.

The 12- and 13-year-olds raised their hands eagerly, some bouncing up and down in their seats. The teacher called on a girl sitting in the back of the room.
"He wants to have sex with her," she said.
"And what will she say to him?" asked the teacher.
There was some mumbling, and then a boy raised his hand.
"Not without a condom."
This is a scene I witnessed recently in the West African country of Senegal, one of the continent's success stories in the fight against HIV/AIDS. The infection rate in Senegal is 0.9 percent -- similar to the rate in the U.S. (0.6 percent), and far lower than the soaring tolls in African countries such as Namibia (19.6 percent), South Africa (18.8 percent) and Botswana (24.1 percent).
What is Senegal doing right, I wondered, and could those practices be replicated in other countries?
I arrived in Senegal with plenty of questions and, like most Americans, a few misconceptions about Islamic West Africa. As far as AIDS in Senegal was concerned, I knew there were a few factors to consider: government involvement, religious attitudes and the country's long-standing legalization and regulation of prostitution.
The Senegalese government has taken a remarkably active role in the sex education of its citizens. In 1986, immediately after the first case of AIDS was confirmed in Senegal, the government launched a massive prevention program, pouring resources into AIDS education.
The Senegalese brand of Islam dictates a certain social conservatism, and there is little opportunity for teenagers to be alone together. The lack of alcohol certainly plays a role in disease prevention; drunken sex is statistically far less likely to involve condom use than sober sex. And Senegal's sex worker registration system, in place since 1969, provides prostitutes with weekly health care and free condoms. In a recent academic report, 100 percent of Senegalese sex workers surveyed (all of whom had taken part in government-sponsored classes on AIDS and sexually transmitted disease prevention) said they use condoms with every customer.
But there are plenty of other reasons for the country's low AIDS rate, including the early and intensive efforts by the country's powerful imams, some of whom use Friday services to educate their congregations about AIDS. This growing trend is a powerful indicator of the partnership between the medical community and religious leaders: While imams limit their sermons to discussions of abstinence and fidelity, doctors are often on hand to handle practical instruction and clinical questions.
One particularly warm day during my trip, I went to speak with the imam who presides over the Grand Mosque in Kolda, a city in Senegal's Casamance region, where the AIDS rate is six times higher (3 percent) than it is in the capital of Dakar (0.5 percent). I took note of the imam's kind eyes, grizzled hair and easy smile and asked him, through a translator, whether he had any hesitation incorporating AIDS into his sermons, which reach about 3,000 people each week. "We treat this like any other disease," he replied. "If someone is sick, we want to help them."
And when it comes to talking about condoms? "Teaching people to use condoms is a contradiction of Islamic law," he said. "We teach fidelity in marriage and abstinence before marriage." Outside the mosque, he said, he can discuss HIV and AIDS more directly and, like many Senegalese imams, he refers congregants to a local clinic or doctor where practical advice about contraception is readily available.
Imams enjoy enormous political and cultural power in Senegal. In involving its religious leaders -- a process that has taken patience, time and government funding -- Senegal's anti-AIDS strategy provides a useful blueprint for other countries struggling to contain the spread of the disease.
Another of Senegal's successful HIV/AIDS prevention techniques should also be duplicated and exported: Frank, open and comprehensive sex education beginning at age 12, and AIDS awareness training starting as early as 1st grade.
The emphasis on education is deeply ingrained. In 1994, Senegal's Ministry of Education requested -- and received -- funding from UNFPA (the United Nations Population Fund) to begin the Group for the Study and Teaching of Population Issues, or GEEP. GEEP's mandate: to bring information about sex, contraception, health and family planning to children in Senegal's schools.
Over 13 years, GEEP has expanded; it now provides peer counselors to students and sponsors family life education clubs in schools. Since GEEP's inception, Senegalese girls have delayed sex three years longer than their mothers' generation, and a recent survey shows that condom use has risen threefold from 10 years ago, to nearly 70 percent.
The message is clear: Comprehensive sex education -- including information about condoms and how to use them -- is one of the most important weapons in the fight against AIDS.

Teaching kids about condoms doesn't promote sex. (Anyone who's been a high school student knows this makes some sense: If there's anything less romantic than unrolling condoms in front of your classmates, it's seeing graphic photographs of STD-infected genitals -- available at any Senegalese health kiosk.) But the Bush administration exports a restrictive, abstinence-only agenda used in many American schools.
PEPFAR, the United States President's Emergency Plan for AIDS Relief, has made funding of sex education projects contingent on the use of extremely limited language when talking about contraception and sex. To receive PEPFAR funding, countries must severely constrain teaching about condoms in favor of abstinence-based lessons.

In Senegal and in Uganda, where the HIV infection rate has fallen from 15 percent to about 6 percent, the governments were quick to implement the "ABC" approach, which advocates "Abstinence, Be Faithful and Use Condoms." This trifecta is consistent with the teaching I saw in Senegal, where middle school pupils were told that abstinence and monogamy were the best choices -- though if they were unable to maintain either, they should always use a condom.
That doesn't jibe with PEPFAR's logic, which hinges on "targeted" messaging. By their calculations, only sex workers and other "high risk" populations should receive information about condoms. And even then, PEPFAR policy dictates that the message has to include an abstinence component.
Many African nations, including AIDS-ravaged Botswana and South Africa, continue to receive PEPFAR money, a dependency that stifles the free exchange of information and could cost more lives than it saves. Senegal's policy of legalized prostitution means the country is ineligible for PEPFAR funding, so it relies instead on donations from the UNFPA and the Global Fund, an independent grant-making consortium of governmental, non-governmental and private-sector groups. That means Senegal's teachers and community leaders are free to discuss condom use as part of a larger prevention message -- a message, it must be noted, that has been far more successful than what is offered in any of the PEPFAR recipient countries.
The hot March day when I visited a classroom in Kolda, I was struck, as the kids answered their teacher's questions without embarrassment, by their sophisticated understanding of AIDS and of the ways, including abstinence until marriage and condom use, they could prevent the disease from spreading.
As the class period ended and the kids filed out of the room, the girls whispering and giggling and the boys whooping on their way to the dirt field for a game of soccer, their teacher suddenly let out an exclamation.
"I forgot the condom demonstration," he said, shaking his head ruefully. "I got so wrapped up in the lesson I forgot to bring out the condoms."
"Oh, well," he said, sitting down at his desk to rewrite the next day's lesson plans. "We'll tackle that tomorrow."

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