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The Bill and Melinda Gates Foundation held a July 11 summit designed to raise an estimated $4 billion to promote contraception in the developing world.
The Gates campaign comes amid new research suggesting that use of hormonal contraception doubles the risk of both transmission and acquisition of HIV in regions like sub-Saharan Africa. Register senior editor Joan Frawley Desmond turned to HIV/AIDS expert Dr. Timothy Flanigan to explain how this research is likely to transform family-planning campaigns.
Flanigan offers insight into how big global health organizations and foundations approach these issues and how they perceive natural family planning. He also answers a few burning questions: Why is pregnancy presented as a dangerous medical condition? Are there new opportunities to promote natural family planning?
Flanigan is a professor of medicine and infectious diseases at Brown University Medical School and practices at Miriam and Rhode Island Hospitals in Providence, R.I. He has been caring for patients with HIV/AIDS for 25 years, and his research on HIV prevention and treatment has been funded by the National Institutes of Health and the Centers for Disease Control and Prevention. He is the father of five and is enrolled in the deacon program for the Providence Diocese.
You’re an authority on HIV/AIDS who has published hundreds of peer-reviewed studies on HIV/AIDS transmission, participated in global conferences and cared for patients with HIV/AIDS near your home in Rhode Island. What are your concerns about the promotion of contraception in Africa and other parts of the developing world?
New research raises serious concerns about whether hormonal contraception — Depo-Provera and oral contraception pills (OCT) — actually doubles the risk of a woman acquiring HIV if she is exposed. And if an HIV positive woman is on oral contraception, it may double the risk that she can transmit it to her partner.
How was the study conducted?
It was a very large study that involved seven African countries. The researchers looked at couples with one HIV-positive spouse and one HIV-negative spouse.
The study was designed to look at whether suppressing the herpes virus would decrease HIV transmission. They enrolled well over 3,000 couples, mostly from sub-Saharan Africa.
Since hormonal contraceptives, especially Depo-Provera, are widely promoted in sub-Saharan Africa, the study provided an opportunity to see whether oral or injectable contraception would increase or decrease the risk of HIV transmission. What they found was very concerning: The hormonal contraception widely touted and promoted doubles the risk of acquisition and transmission of HIV.
The study was very well done, coordinated by the University of Washington in Seattle. The results are alarming and have significant implications for programs that actively promote the use of hormonal contraception.
The study was presented at the International AIDS Society in Rome last summer and was then published in the October issue of Lancet Infectious Diseases, a premier medical journal.
Since the study was published, the National Institutes of Health (NIH), UNAIDS and the World Health Organization (WHO) have convened panels to review the research about how hormonal contraception increases the risk of heterosexual transmission of HIV.
How will the study’s conclusion likely affect large-scale contraception promotion campaigns like the Gates Foundation’s global program?
There is great concern, because hormonal contraception has been seen as the solution for reproductive-health challenges. This alarming data must lead to a reconsideration of the whole reproductive-health agenda, which has relied on the promotion of hormonal contraception.
How long will it take for this research to result in a broader reassessment of the present strategy?
The data have been rapidly disseminated, but the change in practice takes a long time. The field is confused, in disarray and uncertain about how to proceed.
In the broader family-planning field, there has been an attempt to assert that post-conception drugs designed to prevent pregnancy do not work as abortifacients.
There is a whole separate issue going on in this field: An effort is being made to say that post-conception contraception does not work as an abortifacient. The reason for this aggressive effort is to normalize it.
This is on the cutting edge of the HHS [Health and Human Services] mandate controversy. People are sympathetic to the Catholic Church’s position that it should be able to deny coverage for abortifacients in its employee health plan. When you poll Americans on this issue, you get very different responses if you explain that abortifacients are covered.
Many who oppose artificial contraception on moral or health grounds wonder why global public-health organizations and foundations focus so heavily on contraception promotion and provide fewer resources for other health needs. Is this a fair assessment?
There is an underlying philosophy that the root of almost all problems is too many people and that the way to solve these problems is through population control. That philosophy promotes contraception as the centerpiece of its effort.
Authentic development should not rely on contraception, but on economic, social and community development. When that takes place, families plan their children, and population decreases at a level consistent with improved development.
The other problem with this approach is that women and families want children. Recently, I read an article that reported that women on contraception were still getting pregnant, and they needed to be taught to take their birth-control pills. But one reason they don’t take their birth-control pills is because they desire children.
Why are experts in the field so unwilling to consider natural family planning?
Natural family planning (NFP) is wrongly associated with the “rhythm method” promoted many decades ago, an approach that is not effective. NFP has evolved, and today it relies on excellent science and is used by couples to space children and to enhance fertility when a woman wants to be pregnant.
Second, many in the field assume that it can only be used or understood by individuals who have advanced education.
That is not the case. But NFP does require that a woman develops an understanding of her cycle and that a couple together make decisions regarding their sexual relations during the appropriate time in the cycle, as interpreted by the NFP program they use. If the couple is not committed, it doesn’t work.
NFP is relatively complicated and isn’t easy to “dispense.” It’s easier to give a shot once a month than to take the time to educate and then discuss a woman’s questions about her cycle.
Finally, public-health organizations want a family-planning approach that can be adopted by women in vulnerable, abusive circumstances, where sexual relationships are harmful or exploitative, such as commercial sex workers and prostitutes. In that context, the spousal consultation that makes NFP a gift for married couples isn’t possible.
So because NFP is more of a challenge in non-marital relationships, it is ignored by global health programs. Sounds like they have adopted a one-size-fits-all approach.
Yes, that is true.
But there are programs being tested in resource-limited areas. For example, the World Youth Alliance is working throughout the island of St. Lucia to develop a knowledge-based reproductive-health program. There, FEMM or “Fertility, Education and Medical Management” is doing very promising work. It’s an example of the promotion of new forms of reproductive health in an atypical setting. It is getting a lot of positive response from the women and teenagers of St. Lucia, along with the Ministry of Health.
Are you suggesting that educating people about NFP, along with other promising reproductive-health programs, is still a work in progress?
It’s always a work in progress, because it’s an intimate, complex issue; and that’s true whenever you are doing work that involves human relationships. No reproductive-health program can be applied in all circumstances, but natural family planning is a beautiful gift that should be promoted. And now that we know hormonal contraceptives carry serious risks, a more holistic approach that includes natural family planning may get consideration.
Many pro-life activists view the term “reproductive rights” with suspicion because it is often linked to an abortion-rights agenda.
Reproductive health should be a top priority. And “reproductive rights” should mean that a woman deserves the best health care possible for her, her family and her children.
But reproductive rights have been hijacked. The term now emphasizes the need for “safe abortion.” An “unsafe” abortion takes the life of a child and risks the life of the mother as well. But the answer is not to promote safe abortion, but to understand and support women so that abortion is unthinkable.
A new study funded by the Gates Foundation concluded that effective contraception could save the lives of the “358,000 women ... [who] die each year because of complications related to pregnancy and childbirth.” Clearly, the Gates Foundation is basing its campaign goals on this study. If you had a chance to advise Melinda Gates, what would you tell her?
Pregnancy can be an enormous challenge to women’s health, and they can develop life-threatening problems. In the developing world, you address the risks associated with pregnancy by providing trained health-care providers such as midwives and providing access to Caesarean section for extended labor.
It’s important to understand that the risk of pregnancy doesn’t mean that women don’t want children. Look at China: Look at what challenges women will overcome to have their children.
The Gates Foundation has been extraordinarily generous, but the idea that the promotion of oral contraception is the No. 1 answer to maternal health needs is misplaced.
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Thank you for interviewing Dr. Flanigan. I want the wider world to know about his research. But this interview needs to do a better job explaining the link, otherwise they will just not listen to you. Here’s some questions we should be able to answer: Just what is it about the use of hormonal contraceptives that “may double the risk of transmission”? How exactly do the hormones promote transmission? Or is it more likely that couples think they are “safe” because the woman is on the Pill, so they engage in sex more often and the man doesn’t use a condom…hence greater transmission rates. Was there another group to control for the differences? If it was just couples (HIV+/-)couples using just the Pill and (HIV +/-) couples using nothing at all, what are the hypotheses about *why* the hormonal contraception increased the risk of acquisition and transmission?
If anyone’s read the full article and can tell us in layman’s terms, that’d be much appreciated!
anonymous ,
Oral contraceptive use lowers a woman’s immune response which increases the possibility of STD infection including HIV.
If you search on the internet you can find more information on the link between oral contraception & STD’s.The process is kind of lengthy to explain here.
The study in Africa which Dr. Flanigan mentions was covered in the BBC news as well.
What we must bare in mind when weighing in this person’s policies and perspectives on the female body is that she sees all female bodies as though they were her sole property; judges all women’s reproductive behaviors from her own shoes. If you step outside of the prurient narcissism, nothing she says really adds up either economically, morally or scientifically. That she has access to this level of influence over the reproductive lives of other women on any level never mind that she professes to speak on behalf of our institution of faith is nothing short of scandalous.
What we must bare in mind when weighing in this person’s policies and perspectives on the female body is that she sees all female bodies as though they were her sole property; judges all women’s reproductive behaviors from her own shoes. If you step outside of the prurient narcissism, nothing she says really adds up either economically, morally or scientifically. That she has access to this level of influence over the reproductive lives of other women on any level never mind that she professes to speak on behalf of our institution of faith is nothing short of scandalous. That she gets this scale of media coverage with no focus on her own personal reproductive background while others are run through the mud; lifelong careers destroyed for having one extra marital affair, is nothing short madness. People have a right to know if, say, Jeffrey Dahmer opened a meat pie shop around the corner…
Shall we endeavor to raise the glooming spectre of sodomy as it pertains to Biblical teachings? Because this woman is an enthusiastic pusher of this sexual behavior as a mainstream activity and thus she aggressively forces circumcision on everyone around her including young children. I think it’s clear as day what the political motives are behind this agenda when we see how HIV transmits much more easily in this manner.
Education always seems to be the key to solving most problems…Common sense tells us the ‘smarter’ we become the more like God we get since He is ALL KNOWING…My fear is that there is so much propaganda out there to obstruct true learning that it becomes harder and harder to get at THE TRUTH…!!! Of course, JESUS IS THE TRUTH…It can be that simple…!!!
Kathleen says on Wednesday, Jul 18, 2012 8:27 AM (EST):
“anonymous ,
Oral contraceptive use lowers a woman’s immune response which increases the possibility of STD infection including HIV.”
However the article says:
“New research raises serious concerns about whether hormonal contraception — Depo-Provera and oral contraception pills (OCT) — actually doubles the risk of a woman acquiring HIV if she is exposed. And if an HIV positive woman is on oral contraception, it may double the risk that she can transmit it to her partner.”
A lowered immune response due to hormonal contraception in the infected woman does not explain why her male partner is more likely to be infected than the male partner of a woman who is not using hormonal contraception. A much more likely explanation is that couples who were not using hormonal contraception used condoms. Did the study control for this variable? The true result of this study could be that the use of condoms by heterosexual couples reduces the rate of HIV transmission by half.
Considering that the successful use NFP requires an excellent marriage relationship between a woman and a man who regards her as an equal partner, I doubt that NFP will be the answer for the majority of couples across the globe in the near future. The information should certainly be put out there, but other methods have to be made available.
Here is a case of eugenics in a flimsy disguise—The Bill and Melinda Gates Foundation held a July 11 summit designed to raise an estimated $4 billion to promote contraception in the developing world.
(quote from article): A new study funded by the Gates Foundation concluded that effective contraception could save the lives of the “358,000 women ... [who] die each year because of complications related to pregnancy and childbirth.”
Were all 358,000 of these pregnancies unwanted? Was birth control unavailable to all 358,000 of these women?
Bill Gates is a member of the Bilderberg group, which is promoting Agenda 21 (Sustainable Development) In 1991, at a Bilderberg meeting in Germany, David Rockefeller thanked the NY Times, The Washington Post, and other media, for keeping silent for over forty years their plans for a one world government by the “intellectual elite and world bankers”
Agenda 21 calls for plans to reduce the surplus population by whatever means necessary. Bill Gates supports research into a sterilization vaccine and an ultra-sound device to render males sterile for six months at a time.
In addition, Agenda 21 calls for the confiscation of private farms and property, with people being squashed into small living spaces and high rise apartment buildings. Consider the recent efforts of Mayor Bloomberg of New York City, praising the development of tiny apartments.
Consider the building of many “ghost cities” in China. Satellites revealed the existence of many of these sites in China - fully functional cities that are waiting for the occupants.
The plans of the elites have been proceeding for many years, with the mainstream press keeping the information from the public. Check out some of the conservative websites and find out what is going on.
cowalker ,
Could be, but it could also be that the hormones allow the virus to become more virulent & more infective.
I think there are different components being considered here.My explanation was about why women are more susceptible to HIV infection & other STD’s, but that might also affect how they can infect others.
Good questions to ponder.
Who can fathom the number of souls lost through the attempted preservation of promiscuity and licentiousness? No wonder Blessed Anna Maria Taighi said those who will be saved will be very few, but those who will be condemned will be as numerous as the snowflakes in a blizzard.
This is one of the most unprofessional researches I have ever read! In fact the research methodology is so flawed, unprofessional and negates the whole idea of professional ethics that I call here for the immediate arrest of the organizers of this research and their principals. And subsequently they should be charged for the international criminal act of crimes against humanity. Just listen to the warped argument of this research: that the use of oral/parenteral contraceptive increased the risk of acquisition of the HIV/AIDS virus from an infected person to a negative person; and that such contraceptive use also increased the risk of transmission of the virus from an infected person to a previously negative person! It is trite knowledge, it is an already known knowledge in the public domain that engaging in unprotected sex invariably leads to an acquisition of the HIV/AIDS or transmission of the deadly virus amongst human beings. In that context, a risk has been established. So what was the motive of this research looking for a greater risk??? Such an aim, objective and justification is not only dubious; it is very devilish, devious and mischievous. In case my reader doesn’t understand the argument I put up here, just see what I mean: a doctor/researcher who, ab initio, knows that a research subject/patient has a disease of public health importance has no justification whatsoever in allowing this risky patient act in such a way during the study to transmit the disease to a healthy person. Similarly, such a doctor/researcher has no justification whatsoever in allowing a healthy person act knowingly or unknowingly in order to make this healthy person contract such a disease. This is the crux of the matter! This is why I stated above that the whole experimental exercise was flawed, dubious, immoral, unlawful and is an infringement of professional ethics of the highest order. Then come to think of it, what is the function of a contraceptive, whether oral or parenteral? In essence such a contraceptive contains a synthetic sex hormone (estrogen or progesterone basically)that gets to the woman’s blood stream and increases the overall level of these hormones. The resultant effect is that the increased hormone level creates what is called a negative inhibitory action on the pituitary, thus shutting off secretions from this higher centre and finally leading to a temporary barrenness in the woman. This barrenness is reversed on withdrawal from this external hormone (contraceptive). Yes, it is true that these hormones could have carcinogenic (cancer-causing) effect because of their effect on growth of cells but saying that such hormones compromise the immune system is suspect. But if it did, why must such compromise only be with respect to contracting the HIV/AIDS? There are other conditions that could be precipitated by a compromised immune system; but has the use of these contraceptives been associated with those? But let us not put the cart before the horse in this argument: the job of the HIV/AIDS is to compromise and reduce drastically the victim’s immune system and thus leads to the opportunistic infections associated with AIDS. So how could one argue that contraceptives would first compromise the immune system prior to HIV/AIDS infection? That is an argument that is non sequitur. The HIV/AIDS infects people of normal and even strong immune system and these people have not or have not necessarily used contraceptives! In concluding I categorically state that it is only in Africa can people go to conduct such suspect and dubious experiments; Africa where the people and their governments don’t care about their own welfare, including their lives and well-being. And then we people from the Western society cash in to exploit the situation when we want to sastisfy our own whims and caprices; whims and caprices that are now crying to Heaven for vengeance. What these researchers have done in full knowledge and thinking is planned mass murder because the victims that have now been recruited into the AIDS status would inexorably and invariably die from such a disease or lead a life whose quality would be abysmally compromised before they eventually die, all the same, from the disease. What these researchers had done is tantamount to testing deadly diseases on otherwise healthy subjects! And history is replete with such contumelous, dastardly and horrible acts. It is on these bases that I declare such researchers suspects of international criminal acts of crime against humanity. And I hope America would not kick against the arrest of such individuals and trying them for genocide, crimes against human torture, etc, at the International Criminal Court at The Hague. In the alternative a separate International Tribunal should be set up to try these researchers. And, finally, the seven African countries where this dastardly research was carried out can apply to try them under the universal jurisdiction principle. Before I sign off, it is funny also to read that pregnancy is looked upon as a disease! Pregnancy is no disease because it is the only way Nature has ordained for procreation; and this has been ongoing from the beginning of humans on this planet. Yes, there could be complications of pregnancy but such complications are only collateral to pregnancy; and with good medical facilities the effects of such complications could be handled. And complications of pregnancy are of universal occurrence; they have no predilection for any part of the world.
Kathleen,
So how do we increase respect for women? Isn’t that the root of the evil? In Humane Vitae, it says that birth control will decrease respect for women in society, and I think we’ve seen that. We can throw condoms at these women, but how will we change society so that they will be treated better? Birth control keeps them down- they continue to be a “warm place” for men to put “it.” Educating women- the whole woman, is the answer to these problems. A woman who has power over her WHOLE life will be able to make better choices.
It’s easy for the uneducated among us to scream, “JESUS!!!” when the subject of education arises. This woman would have us all live in a police state with no rights over our own bodies, young children earning their right to education through child pornography and anyone earning less than 3 figures enslaved to her agenda. Lock her up and throw away the key if you can find a police chief who’s not complicit with this disgraceful woman’s ideal of what society ought to be. Never mind the priests— look to the misogynist police chiefs she uses to enforce this sickness. They rape their own women with no repercussions and Melinda encourages the behavior.
cowalker says:
“A lowered immune response due to hormonal contraception in the infected woman does not explain why her male partner is more likely to be infected than the male partner of a woman who is not using hormonal contraception.”
Actually it does. A lowered immune response would mean that the viral load in her body would remain unchecked. More virus = more chance she can spread it to her partner.
drea916,
I don’t disagree with you or Humanae Vitae.
This is from The Lancet back in 1997, but might be part of the explanation re transmission.Probably more info than most readers want to see….sorry about that.
The Lancet, Volume 350, Issue 9082, Pages 922 - 927, 27 September 1997
Findings:
“HIV-1 infected cells were detected in 51% of endocervical and 14% of vaginal-swab specimens. Both cervical and vaginal shedding of HIV-1 infected cells were highly associated with CD4 lymphocyte depletion (p=0·00001 and p=0·003, respectively). After adjustment for CD4 count, cervical proviral shedding was significantly associated with use of depot medroxyprogesterone acetate (odds ratio 2·9, 95% Cl 1·5—5·7), and with use of low-dose and high-dose oral contraceptive pills (3·8, 1·4—9·9 and 12·3, 1·5—101, respectively). Vitamin A deficiency was highly predictive of vaginal HIV-1 DNA shedding. After adjustment for CD4 count, severe vitamin A deficiency, moderate deficiency, and low normal vitamin A status were associated with 12·9, 8·0, and 4·9-fold increased odds of vaginal shedding, respectively. Gonococcal cervicitis (3·1, 1·1—9·8) and vaginal candidiasis (2·6, 1·2—5·4) were also correlated with significant increases in HIV-1 DNA detection, but Chlamydia trachomatis and Trichomonas vaginalis were not.
Interpretation
Our study documents several novel correlates of HIV-1 shedding in cervical and vaginal secretions, most notably hormonal contraceptive use and vitamin A deficiency. These factors may be important determinants of sexual or vertical transmission of HIV-1 and are of public health importance because they are easily modified by simple interventions.”
Hello—It just might be possible that HIV is being transmitted because of the Pope/Catholic/Christian policy against condoms, which have been proven to be effective in reducing the transfer of HIV.
Also, the study sample was in seven African countries. Not to mention the very important variable—ONE OF THE PARTNERS IN EACH COUPLE TESTED WAS ALREADY HIV POSITIVE!
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This obviously flawed study also does not mention if any of the couples used condoms, or even if they were educated about methods of safe sex.
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But then, bloggers on this site get their exercise from jumping to conclusions without fact-checking.
Gloria, check out the Medical Institute’s website’s information on how “effective” condom use is anyway. Shocking. Talk about fact-checking. You should do the same.
Besides, how many people do you know are 100% faithful to the use of condoms??? For EVERY sexual encounter???
Mrs. Baker:
I will check out the site—do you have a link or web-path on which article you are referring to?
Tell me: what does “‘faith’ in the use of condoms” have anything to do with science? What does “faith” in anything have to do with evidence-based medicine?
It doesn’t surprise me that the results of my Google search of “faith in condoms” turned up numerous Christian/Catholic publications.
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Why do people think “faith” in something has any influence on facts?
I think we all know that condoms rip and many do suffer from painful latex allergies and also allergies to the spermicidal jelly they contain… there’s a reason so many band-aid packages read, “LATEX FREE” these days. By the time you factor in reduced nerve sensation from circumcision in addition to the 2-layers of condoms advocated by AIDS groups, you may as well be practicing abstinence for all the pleasure you derive!
Interesting that Dr. Flanigan ignores the main recommendation of the authors of the study, which is that couples use both condoms and contraceptives.
@Gloria: Since HIV/AIDS is spread primarily through behavior which violates Church teaching on the sacredness of human sexuality, it defies common sense to assert the same people change their behavior to obey the Church on condom use.
Posted by Kathleen on Wednesday, Jul 18, 2012 1:48 PM (EST):
“This is from The Lancet back in 1997, but might be part of the explanation re transmission.”
Kathleen, thank you very much for the effort you made to find information that explains the results of this study. I suspect you devoted more research time than the author of the article. I followed up on terms suggested by your reference, and was impressed with the results. There are even more possibilities than the study you quoted gave to suppose that the rate of HIV transmission would increase between heterosexuals using hormonal birth control alone when the woman was HIV positive.
I would still like to know if the study controlled for the possibility of the use of condoms by couples who were not using hormonal contraceptives. This could still be very important in interpreting the results of the study.
Clearly almost any method of contraception would be preferable to hormonal contraception for couples where one was already HIV positive. Luckily I think that the Melinda Gates initiative is aware of this information.
http://www.gatesfoundation.org/familyplanning/Pages/overview.aspx#
@cowalker: I saw no mention in there about HIV but I did see a photo of twins and something about “renewed commitment” to family planning strategies…
Posted by Chris Halasz on Thursday, Jul 19, 2012 10:46 AM (EST):
“@cowalker: I saw no mention in there about HIV but I did see a photo of twins and something about “renewed commitment” to family planning strategies…”
Sorry. There’s a second tab on the link labeled “Our Approach,” but the address is the same. You would need to click on that tab. There isn’t much, but the foundation is aware that diverse clients require diverse approaches.
“We support culturally-sensitive efforts to conduct intensive research to identify the best approaches to increase access to contraception among diverse clients, including HIV-positive men and women.”
They’re not just shipping mass quantities of HBT to Africa. They’re also going to sponsor research into new methods of birth control.
Their view of others as little more than human guinea pigs is certainly no news to us…
The reason women on any hormonal birth control contract HIV more easily is because these methods or devices dramatically deplete the women of basic nutrients, exposing her not only to HIV more easily, but also other venereal diseases. WHO already exposed hormonal birth control methods as the main cause of breast cancer and even liver cancer. Why continue poisoning women with chemicals when the Ovulation Method of Natural Family Planning is 99% effective in postponing pregnancy, lowers the divorce rate to 3% and lower, couples of all cultural levels have been successful regardless of level of education of the couple. The promotion of morals and values together with NFP is the only answer for families all over the world. The leadership of the Catholic Church needs to address the lack of formation of parents and their children to set the best example for the future.
Okay, either this guy is working off of incomplete information (in which case he really needs to improve his research methods) or he is being disingenuous. While it is true that one type of hormonal contraceptive injection MAY cause an increased risk of HIV transmission, the half dozen studies on the risk have been inconclusive. In the study he is referencing, both condom use and contraceptive use were self reported, increasing the risk of inaccuracy and incomplete data. Recently both WHO and the CDC released updated recommendations based on all the studies done, and basically they cound that there is no proof one way or another.
You can find a good general summary of the situation here: http://www.hivaidsguide.com/2012/07/hiv-and-contraceptives/
And the CDC’s recommendation here: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6124a4.htm
Three possible mechanisms in addition to depressed immune response by which hormonal contraception may increase transmission of HIV/AIDS
1. Thinning of vaginal mucosa (Depo-Provera)
2. Increased area of ectropion at squamocolumnar junction of cervix/ vulnerable delicate skin (Oral contraceptives)
3. Risk compensation - increased risky sexual activity causing HIV by those who feel “protected” by their contraception (See Affirming Love, Avoiding AIDS: What Africa can Teach the West by Hanley and Irala)
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