How, and How Not, to Stop AIDS in Africa

One of the classic works of journalism of the last couple of decades was Randy Shilts’s And the Band Played On¹ about the sluggish response to AIDS in the 1980s in the United States, which indicted both the Reagan administration and the leaders of the gay community. I still remember the sense of outrage I felt when reading Shilts’s book; it struck just the right note, leaving one both horrified about the tragic incompetence of so many and yet also hopeful that someone, somewhere could do things better next time.

Yet after reading Helen Epstein’s masterful new book, the response to AIDS in America now looks in retrospect like a model of courage, speed, and efficiency by comparison with the response in Africa. In the US, the government publicized the threat and funded research, the gay community reduced its infection rates by encouraging less risky sexual behavior, the dreaded breakout into the heterosexual population never happened, and AIDS receded to become a disease that, while still tragic, could in most cases be kept under control with expensive new antiretroviral drugs (ARVs).

The opposite is true in every respect of AIDS in Africa, which was anticipated as a looming crisis already in the 1980s, yet governments, foreign aid agencies, and even activists reacted with denials and evasion. The disease rampaged through the heterosexual population and is still rampaging, ARVs were too late, too costly, and available to too few, and Africa is still in the midst of an epic disaster without a solution in sight. As of the latest figures in 2006, 25 million Africans are HIV-positive, 2.1 million die from AIDS every year, and 2.8 million are newly infected each year.²

Epstein’s book lays all this out in courageous and thought-provoking detail, describing the maddening complexity of the AIDS crisis in Africa, and the reprehensible and simplistic evasions of nearly everyone involved. It is not only a book that should be required reading for people concerned in the least with AIDS or with Africa; it is also compulsively readable.

It is not without some flaws. Epstein’s discussion of the economics of African poverty is overly simple—it sometimes sounds more like flat statements about corporate and official power than deep analysis. More seriously, for some of her key points, the evidence base—the numbers of studies and of people and the different groups whose experience she draws on—seems a little thin, although I found her points plausible and largely convincing. Perhaps the fact that there is insufficient evidence about so many aspects of AIDS in Africa is itself a symptom of the skewed priorities that the book describes as afflicting the international AIDS effort.

The history of the response to African AIDS can be divided into two phases: (1) fiddling while Rome burns, and then (2) trying to use the fiddles to put out the fire.

Phase I began long ago, undermining any claims of any of those involved to ignorance of the problem. An article published in the London Times on October 27, 1986, said:

A catastrophic epidemic of AIDS is sweeping across Africa…. The disease has already infected several millions of Africans, posing colossal health problems to more than 20 countries…. “Aids has become a major health threat to all Africans and prevention and control of infection…must become an immediate public health priority for all African countries,” says a report published in a leading American scientific journal.

Signs of the coming epidemic had appeared even earlier. A sample of prostitutes in Butare, Rwanda, in 1983 found that 75 percent were infected with HIV. A later study reporting this statistic dated the general awareness that Central Africa was at risk for the spread of AIDS back to 1983 as well.³ An article in 1991 in the World Bank/ International Monetary Fund quarterly magazine predicted that 30 million people would be infected worldwide by the year 2000 if nothing were done.⁴ This was not far off the actual outcome in 2000, so sixteen years ago many knew that a catastrophic epidemic was underway.

One of the lead organizations for fighting the African epidemic was the World Bank, which says today on its AIDS Web site that it is “the largest long-term investor in prevention and mitigation of HIV/AIDS in developing countries.” In its first AIDS strategy report in 1988, the World Bank said the crisis was urgent. It presciently detected “an environment highly conducive to the spread of HIV” in many African countries. It noted that the epidemic was far from reaching its full potential and that “the AIDS epidemic in Africa is an emergency situation and appropriate action must be undertaken now.”⁵

Yet the World Bank’s effort at the time was pitiful: it made a grant of $1 million to the World Health Organization (WHO) in the 1988–1989 fiscal year to fight AIDS. The World Bank sponsored only one project dedicated to AIDS before 1993 (an $8 million loan to President Mobutu of Zaire in 1988). Over the entire period between 1988 and 1999, it spent $15 million a year on all AIDS projects in Africa. In 1992, another World Bank report noted that it “has done little to initiate prevention in countries in which the risk of spread is high.” Yet the 1992 report closed with the inexplicable admonition that “AIDS should not be allowed to dominate the Bank’s agenda on population, health, and nutrition issues in Africa.”

Other aid organizations did little better. What explains such fateful inaction? There was a failure of courage on the part of both Western aid agencies and African leaders, and misinformation that made both parties reluctant to press the issue. As Epstein explains, Western scientists had identified the continent as the source of the worldwide epidemic, and pinpointed a virus in monkeys that had somehow jumped to humans as having initiated it. There were still plenty of mysteries: How had the jump happened? When did it happen and why? Why did the virus not spread before the 1980s and then why did it spread so rapidly in Africa afterward? Epstein discusses what is known and unknown about these questions, which makes fascinating reading. Perhaps what is even more relevant than the right answers to the questions, however, is the way that the wrong answers inhibited the response to the epidemic.

Western scientists flew into Africa, collected blood samples, and flew out, seemingly much more interested in getting recognition in the Western press than in communicating useful and sensitive knowledge to African leaders and the public. Scientists carelessly put forward hypotheses about African promiscuity without considering how important it was to avoid any unnecessary stigma that would provide an excuse for denial by African leaders. The press and television portrayed (and still does portray) Africans as being almost universally HIV-positive. Would African AIDS become less of a tragedy if the press reported accurately that HIV-positive individuals make up just 3 percent of the population of sub-Saharan Africa? Of course, being accused of promiscuity and having Africans labeled as the equivalents of Typhoid Mary did not make their leaders or the general population all that receptive to messages from Western scientists on how to confront the epidemic.

Many Africans reacted with a mixture of denial and conspiracy theories. Maybe the CIA had targeted Africans during the cold war with a scientifically engineered virus, perhaps spread through vaccination campaigns. In South Africa, there was a claim that the apartheid government had targeted black South Africans for decimation through the HIV virus (a conspiracy theory that may not have seemed so far-fetched in view of the evil deeds of the South African secret service under apartheid). As Epstein chronicles, South African President Thabo Mbeki and Health Minister Dr. M.E. Tshabalala-Msimang also consorted with AIDS quacks who doubted that HIV caused AIDS. Few in Africa or the aid agencies lending to Africa wanted to talk about AIDS with these ideas in the air.

A more mainstream but also damaging view of the Western AIDS experts was that the spread of AIDS in Africa was driven by “core transmitters,” such as prostitutes and the truck drivers and migrant workers who patronized them. This was a theory favored by the World Health Organization and World Bank, as set out in the bank’s 1997 AIDS report. This new theory added yet more layers of stigma and denial. If AIDS victims were prostitutes or patrons of prostitutes, who was going to admit being HIV-positive? Or that their late relatives died of AIDS? This could explain some of the astonishing wall of silence surrounding AIDS that Epstein documents and that still prevails among both the African public and politicians.

Of course, such theories may well have been true—maybe AIDS was the result of the sex trade and promiscuity. So some Westerners advised Africans: just try to overcome the stigma as best you can. Treat the problem at its source by getting prostitutes to force condoms on their customers. The rest of the population could breathe easy as long as they did not use prostitutes or sleep promiscuously with men who did.

Epstein’s contribution is to say loudly that this conventional wisdom is wrong. The stigma attached to the HIV-positive, and the implied general stigma for Africa, were tragically misguided. According to survey evidence Epstein provides, Africans are no more promiscuous than most other people, as measured by numbers of sexual partners in a lifetime, casual sexual encounters, and visits to prostitutes. As she says, sexual behavior in Africa is governed by strict rules; they are just different rules from those prevailing elsewhere. She argues that in many African countries the large numbers of people willing to follow those rules have a great deal to fear from AIDS; and they must know they cannot dismiss the problem of infection as one of a whoring minority. The international aid agencies and Western governments are only now belatedly coming around to Epstein’s perspective (which is based on the findings of a number of independent researchers), over two decades after the start of the epidemic, and they still don’t know quite how to handle it.

Epstein’s view is that the cause of the AIDS crisis in Africa is what has now become known in AIDS jargon as “concurrent” relationships. Africans have about the same number of sexual partners as anyone else; they are just more likely to have more than one long-term partner at a time. Crucially, both men and women have multiple partners, in contrast to other poor societies where men may often stray but women’s monogamy is jealously guarded. Western men and women are more likely to practice serial monogamy or engage in one-night stands. To oversimplify a little, Africa’s AIDS tragedy is that it combines greater Western-style sexual equality for women with social norms that permit simultaneous long-term sexual relationships for both partners.

Multiple long-term relationships are prevalent in Africa for many reasons. In southern Africa (where the epidemic is concentrated), one of the few opportunities for gainful work open to men is to become long-distance migrants to the mines. Both husbands and wives may have other long-term partners during the months when they are separated. The African tradition of polygamy (described by historians like John Iliffe as a cultural response to maximize fertility in what used to be a lightly settled continent) has given way to modern relationships between older, well-to-do, gift-bestowing men and multiple young girlfriends. This is not so different from the successive trophy wives of American fat cats, but much more widespread since Africa’s poverty often makes it a matter of survival for African young women to have a rich (older) boyfriend. The desire of young women for young boyfriends can be accommodated on the side.

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.