The bulk of transmissions in rich countries, such as the US, are still accounted for by male to male sex, with a far smaller proportion being a result of injected drug use. But in poor countries, especially sub-Saharan African countries, where the majority of HIV transmissions occurred and continue to occur, most people infected are not men who have sex with men, nor injected drug users.
The ruling assumption behind HIV ‘strategies’ in high prevalence African countries became ‘promiscuity’. UNAIDS and the HIV industry grew up around claims that 80-90% of HIV transmission in African countries is a result of ‘unsafe’ heterosexual sex. Given the low probability of transmission during heterosexual sex, long-held notions about ‘African’ sexuality were dusted off, and spawned the behavior change industry.
Sex (among Africans, of course) came to be presented as an addiction, a pathological condition. Predictably, one of the most popular approaches to addiction, The Twelve Steps, was adapted for the behavior change sector. Billions of dollars were wasted on programs that were shaped by familiar assumptions about what ‘African’ men do to ‘African’ women, and how frequently.
It’s not clear how much George W Bush himself was involved in earlier versions of behavior change and abstinence only programs, claimed to reduce HIV transmission (and, eventually, eradicate it altogether). But he is likely to have been familiar with the Alcoholics Anonymous program, given his own experience with drink (and evangelical religion).
It would be tedious to go through every step individually, but it’s worth broadly comparing the 12 steps with received views about HIV in ‘Africa’. Aside from connections with a ‘higher power’, confessions, testimonials, evangelism and notions of ‘rescue’ or being ‘saved’, there’s also the oppressive emphasis on ‘abstinence only’ that has been the downfall of all 12 step programs, whatever they aimed to remedy.
It’s like the line in the movie ‘Burn Before Reading’: “Fuck you, Peck! You're a Mormon! Next to you, we all have a drinking problem!” All sex (in ‘Africa’) is ‘unsafe’ sex, all sex is wrong, all sexually active people are ‘promiscuous’, all HIV is either a result of ‘unsafe’ sex, or of contact with someone who engaged in ‘unsafe’ sex.
Why is the HIV industry so firmly wedded to abstinence only programs? They have failed for drink, drugs, sex, gambling, eating, smoking, etc; abstinence-only just doesn’t work. Since all the serious HIV epidemics in sub-Saharan African countries peaked and started to decline, mostly before these behavior change programs had been deified, many millions of people have been newly infected.
If sex were the only risk for HIV, almost everyone would be able to protect themselves, and most would do so. There would only be a minority for whom sex is an addiction, an occupational hazard or unavoidable risk that exposes them to HIV, STIs and other hazards. Most sexually active people are not ‘promiscuous’, and recognizing this is key to reducing HIV transmission in sub-Saharan Africa.