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Rethinking AIDS in Africa: Why prevention is now more important than ever
Media Global, NJ
By Emily Geminder

3 November 2008 [MediaGlobal]: Prevention is a word that draws considerable controversy among AIDS experts. Billions of dollars have been poured into treatment programs and vaccine research, but prevention strategies – things like condoms, education, and clean needle exchanges – rarely receive comparable attention. Prevention does not require vast research capabilities. Its success is not dependent on feats of technical ingenuity such as refrigeration in remote, off-grid villages. But in Africa, prevention has nonetheless baffled the medical establishment. Meanwhile, the most recent in a long string of research disappointments have caused scientists to forecast a long wait for a vaccine breakthrough. In its absence, it is increasingly apparent that prevention will have to be at the forefront of any HIV/AIDS response.

The year 2003 saw the beginning of a new wave of political and financial capital invested in AIDS treatment across Africa, as the United Nations and the international community called the epidemic a global health emergency. While the number of Africans receiving life-extending antiretroviral therapy increased significantly, studies show that the disease is spreading as quickly as ever, with new HIV infections outpacing the numbers of patients going on treatment. Hence the inconvenient paradox of AIDS treatment. As epidemiologist and AIDS expert Elizabeth Pisani puts it, “The more effective our prevention programs are, the less treatment we need. But the more effective our treatment programs are, the longer people live with their infections, the healthier and more sexually active they are, the more prevention we will need.”

But prevention is not popular. For one thing, unlike treatment programs that yield tangible results, the fruits of prevention efforts are notoriously difficult to qualify. For another, while promises of treatment provoke surges of optimism and general good feeling, doling out condoms and clean needles does little to help politicians win votes

It is also clear that those prevention programs that have been deployed in Africa have largely failed. Many argue that it all comes down to an issue of funding: which programs receive funding and how much. In 2003, President Bush announced an unprecedented financial commitment – $15 billion over a five-year period – to fighting HIV/AIDS. While the President’s Emergency Program for AIDS Relief (PEPFAR) has dramatically increased the number of people receiving antiretroviral treatment, its record on stemming the tide of new infections has been questionable. Critics have said PEPFAR’s promise has been undermined by its morally-driven standards for funding. In order for an organization to receive prevention funding, it must sign an agreement saying it will not work with sex workers or provide clean exchange programs. Over PEPFAR’s first four years, a third of its prevention funds were channeled into abstinence-until-marriage programs.

But while PEPFAR may be the starkest illustration of a moral agenda edging its way into public health policy, the prevention efforts of the broader international community are similarly shaped by a chorus of concerns that can essentially be distilled to a single question: to whom do we want to give our money? It’s far easier to convince donors to fund programs for vulnerable women and children than for the fringe groups who are highest at risk – sex workers, drug users, and men who have sex with men. Not only are these groups at higher risk of infection, they are in turn at higher risk for infecting other parts of the general population.

In the movement to tie HIV/AIDS funding to broader development issues, policymakers have sometimes lost sight of what HIV is first and foremost: an infectious disease. There are many reasons – and mostly good ones – why AIDS has been framed as a development issue. For one thing, in countries where HIV runs rampant – countries like Swaziland, for instance, where almost 40 percent of adults are infected – the country’s work force is decimated, precisely among the demographic at the height of its productivity. Staggering death rates leave children orphaned and families strained. They divert huge portions of government funds to healthcare. The United Nations agricultural agency estimates that in the 25 most-affected African countries, AIDS has killed seven million agricultural workers since 1985 and could kill as many as 16 million more within the next 20 years.

While HIV/AIDS is an epidemic of complex social dimensions, the response of the international health establishment has been criticized for being both too broad and too narrow. Too broad because the refrain “AIDS is a development problem” allows the disease to get lost amidst a flurry of programs on gender, human rights, poverty, and agriculture – all issues that reckon with huge swaths of the fabric of society. The HIV/AIDS response has also been called too narrow because it fails to contextualize the epidemic within the larger crisis of healthcare. Some point to the many cheaply preventable and treatable diseases that together incur far greater death tolls in developing countries than AIDS. The larger healthcare system suffers, they say, because of the exceptionalism with which AIDS is treated, an exceptionalism that is not justified by the cost effectiveness of its interventions.

Speaking in Zambia in 2006, UNAIDS Executive Director Peter Piot stressed the social aspects of the epidemic. “It is patently clear that we need to make real headway against the fundamental drivers of this epidemic, especially gender inequality, stigma and discrimination, deprivation and the failure to protect and realize human rights. This challenge is perhaps the greatest of all those facing the AIDS response. And there can never be a technological fix for these social issues. We need positive social change – and all of us in the AIDS effort must be willing to back this. I am increasingly convinced that just expanding programs, doing more, even much more, is not going to stop this epidemic. To reach universal access to HIV prevention and treatment care and support, we need to pay attention to the drivers.” Few would argue that issues such as gender inequality and poverty have largely shaped the particularities of AIDS in Africa. But there is a cost of focusing on the social dimensions of AIDS to the exclusion of its immediate health implications.

“I think there are a lot of misconceptions about AIDS in Africa – including misconceptions among the agencies of the United Nations,” says Susan Watkins, a research scientist and sociologist who has long studied the response to AIDS in rural sub-Saharan Africa. Too often, she told MediaGlobal, “depictions of gender and HIV in international and national policy documents do not reflect the reality on the ground.”

Watkins, whose latest work is a long-term study on HIV prevention in rural Malawi that questions much of the conventional wisdom on gender and AIDS, cited a Johns Hopkins project in rural Malawi that aimed to give women a safe space to talk about AIDS. She noted, “Our data show that women have lots of safe spaces to talk about AIDS – the borehole getting water, walking together to cut wood. It’s simply not a problem.”

A great deal of Watkins’ anecdotal material comes from extensive records kept by Malawian participants over a number of years. Watkins calls them “conversation diaries” and says the only instructions given were to record from memory any conversation witnessed about HIV/AIDS. The logic is that, in conventional studies, informants often give answers they believe the questioner wants to hear, which may differ greatly from how they talk about AIDS in everyday life. In one diary, a woman called A. recorded the conversations of an informal women’s group to which she belonged. The group of neighbors gathered weekly to discuss everything from parenting and divorce to ways of supporting themselves to local gossip. In one entry, A. recounts the history of Mrs. M., who was twice divorced and is now single. Like many women, she sells firewood to make a living, but with the recent rises in the price of food, she is now finding it difficult to sustain herself and her children. The group offers advice – one says it is better to try a new business than to fail in the old one, but another woman warns that, unlike selling firewood, other businesses require capital to start. The conversation then turns to the issue of sleeping with men for monetary or material gain:

These days are very dangerous. They are not the days which one can depend on having a sexual partner because of the AIDS disease. You cannot sleep with a man for several times before you get infected with AIDS… It is better to stay [as we are] though we are poor than buying death. Miss J. said that it is better to die of hunger than to die of AIDS. If it is hunger, maybe you can die all of you, but if it is AIDS, you die alone and leave your children suffering.

But Mrs. T. said that things are just happening. It is better to get married and be faithful in your marriage. [But] there are some people who were born sexy – those people who cannot stay without men. It does not mean that they have partners because they need them to help them. What they want is sex. Therefore if the marriage is not found, let us use the condoms for the protection. But we should not take sex as our business because of hunger, we shall put ourselves in trouble. But Mrs. M. said that she heard from her religion at the Roman Catholic that condoms are forbidden to the Christians. They encourage people to be having sex with those who are not their spouses, which is committing adultery. What we should just stop having sex with outside marriages.

What becomes clear from this and the many other conversations recounted is that women in rural Malawi know very well that they can protect themselves from AIDS by using condoms. They talk openly about sex within and outside of marriage. And perhaps most significantly, they also cannot talk long without coming back to AIDS; it is the persistent refrain in the conversation, the point that must always be taken into account.

It’s difficult to come to any quantitative conclusions about the efficacy of women’s empowerment trainings in terms of HIV, mostly because there is very little data. The vast majority of these programs do not test for HIV. A few have tested for indicators of safe sexual practices such as sexually transmitted disease rates, but those that did have largely found that sexually transmitted diseases either stayed constant or increased. Putting aside all undertones of cultural hegemony inherent in outsiders coming to “empower” women – sometimes in as quickly as a few days – or the unaddressed question of the men who are presumably doing the disempowering, these programs do not seem to be listening to whether or not they are succeeding. In a sort of dual blindness, or perhaps hubris, not only are these programs conceptualized by people other than those impacted, but they are not attuned to their own implementation. Catherine Campbell, who has studied prevention strategies in South Africa, notes, “HIV prevention strategies are informed by the assumptions of Western science and policy, with insufficient assessment of whether these are appropriate for local conditions. Proposals for projects funded by overseas bodies may be written by external consultants and presented to local groups for implementation. Local people may therefore have little sense of ‘ownership’ of the proposals.”

In many ways, it’s the archetypal tale of modern times. Western interventions fail to accommodate the nuances and complexities of local topographies. Too often, they rely on outdated conceptions and over-simplified conclusions. Out-of-place values get in the way of real solutions.

Thailand has been hailed as a rare success story among developing nations attempting to curb their HIV/AIDS epidemics. A large part of its success had to do with the groups to which Thai funding and programming were aimed: drug users, sex workers, and the men who visited sex workers – all the demographics, in other words, that are not in vogue with UNAIDS. But Thailand differed from most African countries in a crucial way: it had the resources and governmental infrastructure to tackle AIDS on its own terms. Likewise, in 2005, Brazil made headlines when it rejected $40 million in U.S. funding due to the Bush administration’s prohibitions on sex workers and clean needle programs.

Sometimes the larger “truths” about AIDS get in the way of seemingly small but significant discoveries. Economist Emily Oster, who has studied routes of HIV transmission in Africa, believes the continent’s high rates of other sexually transmitted diseases – it is estimated, for instance, that roughly half the population has the herpes virus – play a much larger role in the spread of HIV than previously thought. “Because many of these infections cause open sores on the genitals, transmission of the HIV virus is much more efficient,” she says. Treating other sexually transmitted diseases would cost about $3.50 per person each year. Providing an individual with AIDS treatment is an annual $300.

Of course, that would require a healthcare system with the capacity to treat half of Africa’s population. And no less importantly, it would require that the international community start listening with its ear to the ground.