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Randy Tobias, Risky Sexual Behavior, and AIDS

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The news that Randall Tobias, the former Lilly executive and chief of the Bush Administration's global AIDS programs, was using the services of call girls, led to this reaction from one AIDS activist:

Oh my God. Mr. Married Abstinence only used an ESCORT service!!!!!! The anti-prostitution pledge promoter?

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The press coverage about this has predictably focused on the apparent hypocrisy of the leader of a government agency that to fight AIDS in Africa and other developing countries, promotes "abstinence only" and derides sex workers, and then is caught doing exactly the opposite.

AIDS is a terrible health crisis, and no one would deny the importance of discouraging risky sexual behavior, particularly in countries and populations with extremely high infection rates. The problem with the Bush Administration's "abstinence only" efforts was the word, "only," since prevention should include other strategies, including the use of condoms.

I asked friends who would know, "How much of the 'abstinence only' efforts at USAID were the fault of Tobias, and how much from the White House." The push for this policy, which is actually mandated by a Congressional requirement, came from Republicans in Congress, the White House and the religious right.

Activists give Tobias much more blame for efforts to protect big drug companies from competition from generic manufacturers of AIDS drugs, for example, by undermining the World Health Organization's program to certify generic AIDS drugs (the WHO pre-qualification program) and forcing U.S. taxpayers to unnecessarily pay top dollar for brand name AIDS drugs in PEPFAR treatment efforts. This policy has been poorly covered in the press, but it is far more consequential than Tobias' sex habits.

That said, the Tobias case illustrates just how difficult it is to persuade people to give up risky sexual behavior. This, and plenty of other evidence leads many experts to believe that the "abstinence only" programs pushed by the Bush Administration are costly wasted opportunities to reduce the harm of AIDS.