And some guys were like, “Abstinence is an illusion, it doesn’t happen.” The guy who spoke before me, Dr. Steven Sinding [who represented] Planned Parenthood,42 and then a girl from India. And I was like, “Guys, am I an illusion? I made a decision to wait! And I’ve been waiting, and it helped me!” So this was really eye-opening for me. There were four people presenting, but 80 percent of the questions came to me. But I kept the story. Some guys came and said, “Thank you very much for sharing the story.” Then I talked to [prominent American evangelical minister] Rick Warren’s son, shared with him some personal things, kept him in prayer, and then we kind of kept in touch.
Andrew had been prepared to “testify” in a mode of speaking common to evangelical and born-again Christians the world over. Testimonies are narratives of personal transformation shepherded by faith. In Andrew’s eyes his faith had helped him abstain from sex, which had enabled his transformation from a sinful youth to a principled young man. For him this was a positive story, one laced with allusions to his own aspirations and personal achievements: nearing completion of his college degree and planning for marriage. This was a message central to the teachings in Andrew’s church—that abstinence could be a strategy of upward mobility and social achievement—and it was one now being sanctioned by the U.S. government. Andrew and his peers’ experience with abstinence is a topic I will return to at length in later chapters, but the story he tells here is about the controversy that surrounded abstinence, and the sense of division within the world of AIDS activism that PEPFAR had seemed to generate. Andrew had been dropped into a struggle over public health policy that was animated by a broader conflict rooted in the U.S. religious and political landscape. In Bangkok, the first major international AIDS conference following PEPFAR’s introduction, an American conservative coalition had, to an uncertain reception, thrust itself into the world of AIDS research and programming. Andrew’s offhand mention of Rick Warren highlights the way in which PEPFAR and abstinence had emerged as a key arena for this American struggle, and the ways in which American politics and American religion had come to have an impact in even seemingly remote African communities. In fact, these African communities were placed at the very center of these debates.
Harnessing the Story of Uganda’s Success: Defining Behavior Change
It was also at the Bangkok conference that the Ugandan story of declining HIV prevalence rates took center stage, in large part because the Bush administration had cited the country as evidence for why abstinence and faithfulness-only programs had been earmarked for special funding. Ugandan president Yoweri Museveni was a featured speaker at the conference, and he delivered a wholesale celebration of individual responsibility and self-control as frontline defenses against the epidemic:
Eighteen years ago, as we emerged from a two decades protracted peoples’ war of liberation against the dictatorial regimes of [Idi] Amin and [Milton] Obote, Uganda was once again under the shroud of a devastating mysterious ailment called “Slim,” later to be known as AIDS. Two decades of civil war, state mismanagement and inappropriate monetary policies had left the Ugandan economy and social infrastructure in tatters with extreme levels of household poverty. The medical infrastructure, especially the hospitals, were in a sorry state with many of the medical profession living in exile, and the total per capita expenditure on health at less than $1 per annum. By 1985, Uganda was among the ten poorest countries in the world.
We had to transmit to our people the conviction that behavior change and therefore control of the epidemic was an individual responsibility and a patriotic duty and within their individual means. In our fighting corner was a resilient population and a committed leadership with years of fire-tested experience in mobilizing our people to overcome obstacles at great odds and with minimal resources.
Our only weapon at the time [was] the message: “Abstain from sex or delay having sex if you are young and not married, Be faithful to your sexual partner (zero grazing), after testing, or use a Condom properly and consistently if you are going to move around. This has now been globally popularized as the ABC strategy.” With no medical vaccine in sight, behavioral change had to be our social vaccine and this was within our modest means.43
By the late 1990s, HIV/AIDS had become increasingly important to Museveni’s profile on the international scene, bolstering his image as a “new African statesman” intent on supporting political reforms and terms for economic growth that were supported by his allies in the West. Uganda’s government, like others across Africa, had become heavily dependent on foreign donor aid during the 1980s and 1990s; by necessity Museveni had embraced economic restructuring in 1987, opening Uganda to international donors who had avoided the country under the Amin dictatorship of the 1970s, a period that had been characterized by intense xenophobia and economic isolation in Uganda. While Museveni had come to power in the mid-1980s as a leader espousing “revolutionary” politics with an antielitist and broadly socialist ideology of rural uplift, by the 1990s the locus of his power was clearly situated in and through the economic and political relationships he fostered with the West.44 The state’s reliance on international aid expanded significantly during the first two decades of his rule.45 And, as was the case in other parts of the world during this period, there were changes in the manner in which that aid was distributed. The aid world had become radically decentralized during the 1980s and 1990s, with direct state-to-state aid becoming a less popular model for donors.46 Nongovernmental organizations (NGOs) and faith-based organizations emerged as critical players in the local management of donor funds.47 These trends redefined the landscape of AIDS care and treatment in Uganda, a sector that has seen the expansion of medical research projects fueled by donor funds.
Museveni’s speech in Bangkok highlights many of these trends, especially in the way he links economic restructuring to a successful HIV prevention strategy he calls “behavioral change.” In the years just prior to the Bangkok conference, behavior change emerged as a popular term highlighting individual accountability in health care choices. In Museveni’s speech, avoiding disease risk by delaying sex and by promising faithfulness within monogamous relationships were celebrated as choices that buttressed other economic and political changes in Uganda. As Ugandans became more accountable, empowered, and self-reliant citizens, their nation supposedly also became more economically viable, more democratic, and better able to manage the epidemic that had ravaged its populace. In Museveni’s words, control of the epidemic was an “individual responsibility” and within “individual means.”
In fact, this language of self-sufficiency in many ways obscured the heavily community-based approach that Ugandans had embraced in the early years of the epidemic—strategies that emphasized accountability not only to one’s self but to others, including those infected and at risk. Early prevention education emphasized peer-to-peer counseling rather than any top-down centralized curricula. Women’s groups, newly empowered in the early years of the Museveni government, had organized themselves to address the impact of the epidemic on communities and families. But in a global context that emphasized neoliberal structural reforms, behavior change came to stand for liberal democratic ideals steeped in the rational, autonomous individual. One Ugandan public health student I interviewed in 2010 succinctly characterized the shifts from the 1980s to early years of the twenty-first century in Uganda when she said, “In the eighties there was a sense of communal vigilance [about HIV]. Communities became vigilant and aware of each other. It is not the case anymore. It is more about individual aid. [Prevention], now it’s your call.” By Museveni’s calculation, behavior change seemed to represent these broader shifts in global sources of power and influence as well as the changing Ugandan economic and political context that marked early twenty-first-century life. Behavior change was a “technology of citizenship,” to use Barbara Cruikshank’s term, a mode of governance that has proliferated in the neoliberal era and “work[s] on and through the capacities of citizens to act on their own.”48
What is most remarkable about the global adoption of behavior change is the way it came to replace earlier Ugandan strategies that focused more on community transformation than individual accountability. Long before there was widespread international focus on AIDS in Africa, Ugandans had in fact changed their behavior in ways that helped reduce HIV, but by the years of the new century the term behavior change had come to stand for something more particular than changing