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How, and How Not, to Stop AIDS in Africa

For many reasons, concurrent, long-term sexual relationships are much more dangerous for the spread of AIDS than serial monogamy. When both men and women have concurrent relationships, they are part of a huge web of sexual partners by which the HIV virus moves through the population. Long-term relationships are much more likely to spread AIDS than one-night stands because of the low probability of a single sex act spreading the virus. Since the HIV-positive are most contagious soon after they themselves become infected, a long-term partner who has just become infected in another relationship poses much more risk than a prostitute who has been infected for a long time. Serial monogamy in the West kept the virus largely trapped within single relationships, a fact Epstein nicely illustrates with some clever graphs. Her explanation based on concurrent relationships has gained broad acceptance and has been confirmed by mathematical modeling and by surveys of sexual habits in various countries; but one still wishes the evidence was a little more extensive for such a critical issue. At this point, however, it looks like much stigma, denial, and inaction took place simply because of lack of understanding of African sexual behavior.

We have since emerged from the Age of Inaction to the Age of Ineffective Action. In Africa, AIDS is now a multibillion-dollar industry, with the US President’s Emergency Plan For AIDS Relief (PEPFAR), the Global Fund for AIDS, Tuberculosis, and Malaria (GFATM), the United Nations’ AIDS consortium, UNAIDS, and major efforts by the World Bank, the World Health Organization, the Gates Foundation, and national aid agencies. Unfortunately, these well-meaning efforts are badly weakened by political agendas, misdirected priorities, ignorance, and plain incompetence.

To illustrate the role of political agendas, Epstein discusses the famous success story by which AIDS infection rates in Uganda decreased as a result of the ABC campaign—“Abstain, Be Faithful, and Use Condoms.” Epstein damns both the Western right and left for their misuse of the lessons of Uganda. The religious right played up the “Abstain” part because it happened to fit their particular moral preferences. People on the left, who had different sexual morals, said just use condoms. The “Be Faithful” message, precisely the one in Epstein’s story that was critical in Uganda (led by Ugandan President Yoweri Museveni, who called for “Zero Grazing”), was a political orphan, disdained by both left and right.

The response of the aid industry to AIDS has its own ABC, much less effective than its Ugandan counterpart: antiretroviral drugs, bureaucracy, and consultants. A huge part of the Western response has been concentrated on getting antiretrovirals to those in Africa with full-blown AIDS. There is nothing wrong with the urge to treat the sick, but in practice it has crowded out nearly every other response to the epidemic. ARVs are now reaching only a tiny minority of those in need and it will never be feasible to treat everyone. Even if you avoid the Scylla of insufficient money to pay for the expensive treatments, you run into the Charybdis of Africa’s dysfunctional health care systems. And even if you did treat everyone who has AIDS with ARVs, which add a few years—four or five, Epstein notes, according to current UN estimates—to the lives of people who remain terminally ill, that would still ignore the omnipotent question: How do you stop AIDS from spreading further through this generation and into the next generation?6 Alas, the glory that people get from sponsoring AIDS treatment so blinds the politicians and celebrities involved in AIDS causes that they can’t keep elementary medical math straight. So not only did the most relevant part of prevention strategies—“Be Faithful”—lack political sponsorship. But prevention itself has been badly neglected in favor of the privileged method of treatment.

For example, take the World Health Organization/UNAIDS April 2007 publication, Towards Universal Access: Scaling Up Priority HIV/AIDS Interventions in the Health Sector. Somehow prevention did not make the cut as an intervention deserving priority in this document, which is all about treatment. (There is one mention of “counseling” that hints prevention may have briefly crossed the minds of the authors.) To promise “universal access” to treatment—a promise that cannot be kept and that nobody is held accountable for keeping anyway—while saying nothing about the prevention that would stop the epidemic itself is so irresponsible that even a hardened student of UN evasions is left gasping. The UN’s lack of accountability perhaps explains such flagrant irresponsibility.

President Bush’s PEPFAR doesn’t fare much better in Epstein’s account. In fiscal year 2006, by design, less than a quarter of PEPFAR’s budget was spent on prevention, and a hefty chunk of that went for the useless abstinence campaigns. In a revealing incident earlier this year, the American ambassador to South Africa sent a letter to PEPFAR contractors telling them to cut back on prevention—but not treatment—activities for the next year because of a budget squeeze. He said: “Our priority must be delivery of treatment services.”7

The neglect of prevention is bipartisan. Former President Bill Clinton has been admirably active in fighting AIDS in Africa. The issue that occupies him is of course treatment (specifically, negotiating cuts in drug prices). In his speech to the International Aids Conference in 2006, he went into great detail about what the Clinton Foundation had accomplished in making treatment available; but he talked of prevention only in a kind of ritual incantation with no details, except to mention quick technical fixes like microbicides and AIDS vaccines—which at this point don’t exist—or the magic bullet of HIV testing, although there is little evidence that it is effective in preventing the disease.

When well-conceived efforts to improve prevention do exist, they often run afoul of the aid industry. Epstein observes that there was already a huge international bureaucracy devoted to combating population growth by distributing condoms. When suddenly condoms became marketable for preventing AIDS as well as pregnancy, this presented a huge new growth opportunity for family-planning organizations (which had been losing foreign aid market share as people realized that population growth was not as scary as originally thought). The condom bureaucracy did what it does best, which is flood countries with condoms. Alas, supply does not create its own demand. Condom-saturated countries like Botswana have made little progress in reducing new AIDS infections, since people there don’t like to use condoms and are not yet convinced that they are at risk of HIV infection if they don’t. Meanwhile, the “Be Faithful” message was neglected because it was not of interest to the bureaucracy concerned with AIDS. As Epstein muses acidly: “Zero Grazing” had “no multimillion-dollar bureaucracy to support it.”

Then there is the bureaucracy’s bean-counting approach to problem-solving. Epstein describes how the measurement of “results,” such as the number of people counseled to practice safe sex, defeated its own purposes. The “results,” as is common in foreign aid, were really inputs rather than outputs—what was being measured was the numbers of people counseled, not the behaviors actually changed by counseling. Moreover, the emphasis on quantities had the predictable effect of diminishing the quality of the aid being given. As one frustrated counselor quoted by Epstein said:

If you have to do one thousand people by the end of the month, you end up not doing good counseling…. They’re not asking “are we really meeting the needs of these people.”

Alas, even these efforts look like models of bureaucratic efficiency compared to some of the other activities of the UN agencies and the World Bank. Plans, strategies, and frameworks are favored activities in foreign aid—this is what aid bureaucracy does. Then the bureaucracies “coordinate” their respective strategies with the others. One bureaucracy’s output serves as another bureaucracy’s input, with the output of the second bureaucracy then feeding back as an input into the first bureaucracy’s output.

For example, the World Bank announces that its plan to fight AIDS is to produce more plans. It advocates

strengthening national HIV/AIDS strategies, to ensure they are truly prioritized and strategic, integrated into development planning…. The World Bank will focus intensively on improving national HIV/AIDS strategies and annual action plans. … Support for a network of country practitioners will be provided to help countries to develop strategic, prioritized national plans…. Enhanced Country Assistance Strategy (CAS) and Poverty Reduction Strategy (PRSP) guidelines and assessment criteria will aim to support better integration of HIV/ AIDS into national development planning and better aligned national AIDS responses…. The Bank will continue to provide financial and technical support…to enhance country capacity and systems to implement national HIV/AIDS plans…[and] work with countries and Bank project teams to further improve planning.8

This repetitive exposition on how strategies should be strategic is to be found in the short version, or executive summary, of a seventy-eight-page report. Those who can, act; those who can’t, produce plans.

The World Bank will do all this through “partnerships across Bank units, working closely with client countries, UNAIDS co-sponsors, GFATM and other development partners.” As for UNAIDS, it is “monitoring the progress on the UNGASS [the apt acronym for the UN General Assembly] Declaration of Commitment on HIV/AIDS.” It was one of these progress reports that ignored the need for prevention. UNAIDS issues such documents when it is not busy engaging “diverse partners and stakeholders, including inter-governmental bodies, governments, other key partners, UNAIDS and the broader UN system.” This Kafkaesque maze of the AIDS bureaucracy would be comic, except for the millions of nonbureaucrats who are dying of AIDS.

The C in the aid industry’s ABC is for the consultants from the West who implement AIDS programs, often slighting homegrown efforts. Epstein gives an example of how a decent homegrown organization that cares for AIDS orphans, called Sizanani, was starved of funds in South Africa. Meanwhile, high-powered, foreign-sponsored organizations like one called Hope Worldwide (founded by American fundamentalists) skillfully captured PEPFAR dollars. Hope Worldwide offered Sizanani a “memorandum of understanding” in which it would provide advice but no money. Apparently it wanted to count Sizanani’s orphans toward its target of “orphans helped” in order to meet PEPFAR’s demand for results. Elizabeth Rapuleng, an elderly African woman who founded Sizanani, said, “When the Americans come, we sing, we dance, they take our picture, and they go back and show everyone how they helping the poor black people. But then all they do is hijack our projects and count our children.”

Other firms engage in Madison Avenue marketing campaigns to spread sexy messages about safe sex. Epstein dissects one such Western-funded campaign called loveLife, whose leader describes it as “a brand of positive lifestyle.” Throughout South Africa, the campaign has built recreation centers (loveLife Y-Centers) for young people, where they can hear American motivational speakers tell them to believe in themselves, all of which has shown no sign of working to halt the spread of AIDS. Why would it? As Epstein describes a bitter saying in Uganda, there is Slim AIDS and Fat AIDS. Slim AIDS is what happens to the emaciated victims of HIV. Fat AIDS is what happens to the consulting companies who win contracts from International AIDS Inc.

Epstein argues that it violates both common sense and the evidence to put much faith in vague, happy-sounding messages about self-esteem and safe sex. During visits to Africa I have often seen the ubiquitous donor-funded “AIDS prevention” billboards, featuring beautiful young couples who are meant to convey—well, what exactly? Epstein (backed up by an epidemiological study of the Uganda prevention success story) argues that the prevention campaigns could use less sexiness and more fearfulness. What worked in Uganda, she writes, was the “ordinary, but frank, conversations people had with their family, friends, and neighbors—not about sex—but about the frightening, calamitous effects of AIDS itself.”

This is Epstein’s “Invisible Cure.” Ugandans had enough social cohesion in their densely settled agricultural country so that the discussions about the calamity of AIDS and the urgent need to change behavior could well up from the bottom of society, rather than resulting from any bureaucratic action plan or consultants’ marketing campaign. What was crucial was open and active recognition of the danger, and community encouragement of families to avoid risk. By contrast, in the more dislocated and anonymous environments of southern African cities and mining camps, denial of the AIDS problem behind a wall of silence was the dominant attitude (undeterred by the efforts of Western AIDS bureaucrats, who didn’t even understand the problem). One still wishes that the evidence for what works was a little more substantial than one Ugandan success story that lasted a few years, but Epstein is such a persuasive storyteller that she earns a serious hearing. To illustrate what’s needed, Epstein draws an analogy to the medical activism of women’s groups in nineteenth-century America. Once they understood the germ theory of disease, they were able to spread habits of hand washing, covering your mouth while coughing, not spitting in public, etc. This successfully reduced disease even before the invention of antibiotics.

The Ugandan AIDS activist Beatrice Were told Epstein:

As a woman living with HIV, I am often asked whether there will ever be a cure for HIV/AIDS, and my answer is that there is already a cure. It lies in the strength of women, families and communities who support and empower each other to break the silence around AIDS and take control of their sexual lives.

In Epstein’s words, “When it comes to fighting AIDS, our greatest mistake may have been to overlook the fact that, in spite of everything, African people often know best how to solve their own problems.”

Alas, as Epstein notes, this “Invisible Cure” is unlikely to commend itself either to big-budget Western AIDS programs or to the bureaucrats and consultants who are committed to them. The cure Epstein describes can’t be carried out by a World Bank strategy; it can’t be bought by aid dollars, or put on a billboard. But perhaps, by reading her book, AIDS International will learn a lot about what not to do. Maybe Epstein’s account of the dangers of multiple long-term partners will be more widely understood and decrease some of the stigma and denial that have hampered frank discussion of AIDS in Africa. Maybe some politicians and citizen activists in both the West and Africa will dare to challenge the wall of silence surrounding the spread of AIDS. And maybe, through research and experiment, some well-meaning Westerners will find a way to reinforce the homegrown “Invisible Cure,” and to make it more likely to happen sooner rather than later.

Just read The Invisible Cure. If you do, you will be mortified that such an epic tragedy has found so few heroes and so many opportunists and bumblers. And you’ll hope that someone will do better next time. Except that this particular next time is already here.

  1. 6

    Some treatment advocates claim that HIV testing and treatment themselves have preventative effects, but Epstein notes that there is little evidence to support this politically convenient claim.

  2. 7

    Letter to PEPFAR partners from Ambassador Eric M. Bost, Embassy of the United States of America, Pretoria, South Africa, January 26, 2007.

  3. 8

    The World Bank’s Global HIV/AIDS Program of Action, December 2005.

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