Think Again: AIDS

Two decades and billions of dollars into the fight against AIDS, the world still has a long way to go in arresting the epidemic. The cash that donor governments roll out with much fanfare won't make a dent so long as misperceptions persist about how we are winning and losing the battle against the disease.

"The World Now Recognizes the Severity of the AIDS Crisis"

"The World Now Recognizes the Severity of the AIDS Crisis"

No. For years, activists around the world have clamored for wealthy countries to offer greater financial help in the fight against AIDS. That help has started to arrive. In 2003, the world spent $4.7 billion to combat the epidemic in poor countries. The United Nations in 2002 helped create the Global Fund to Fight AIDS, Tuberculosis and Malaria, which will give out between $1.4 and $2 billion in 2005. The World Bank is now spending $1 billion to stem the epidemic in Africa. And, in his 2003 State of the Union Address, U.S. President George W. Bush announced a $15 billion, five-year initiative to increase prevention programs, care for AIDS orphans, and bring antiretroviral treatment to 14 of the world’s hardest-hit nations.

These sums, large as they are, would have been enough to staunch the AIDS epidemic in 1996, not 2005. In 1996, $4.7 billion would have provided new antiretroviral drugs for most people who needed them and paid for effective prevention campaigns so that AIDS might have been a minor disease today rather than a global catastrophe. That kind of spending would have been one of the most brilliant investments imaginable, eventually saving hundreds of billions of dollars and tens of millions, perhaps hundreds of millions, of lives.

Unfortunately, the epidemic has not abated. Today’s spending is 15 times what it was in 1996, but it is insufficient to turn the course of AIDS today. In fact, it doesn’t even tread water: The Joint United Nations Programme on HIV/AIDS (UNAIDS) estimates that the developing world needs $12 billion in 2005 alone, which doesn’t even include the billions required to build working healthcare systems in dozens of the poorest countries.

"Lack of Money Is the Biggest Obstacle to Beating AIDS"

Wrong. Actually, it’s a lack of people. The single biggest obstacle to fighting AIDS in Africa, the region most laid waste by the epidemic today, is not a shortage of cash, but of personnel — doctors, nurses, pharmacists, counselors, and trained lay workers in the community. Without these people, Africa cannot even provide AIDS testing and counseling, much less antiretroviral therapy. But the only way to build up a network of health workers is to spend money — lots of it.

At the hospital in Addis Ababa, Ethiopia, that serves the bulk of the country’s patients on antiretroviral therapy, two doctors and two nurses care for roughly 2,000 people. By contrast, the United States employs about 15 nurses for the same number of patients. Malawi, to give another typical example from Africa, employs one nurse for every 4,000 citizens. Many countries have no doctors outside major cities and district capitals.

AIDS has intensified Africa’s preexisting healthcare crisis by killing off doctors and nurses and filling hospital wards, stretching healthcare even thinner. But another reason for the shortage of health professionals is that tens of thousands have emigrated. Rich countries, unwilling to pay to attract doctors to rural areas or solve a nursing shortage, instead loot doctors and nurses from English-speaking areas of Africa. Three quarters of all doctors in Ghana emigrate to developed countries such as Britain, Canada, Australia, and the United States within 10 years of completing medical school. Only 360 of the 1,200 physicians trained in Zimbabwe during the 1990s were still practicing in the country in 2001. Such poaching by the very countries that purport to be concerned about AIDS in developing countries is unconscionable. The South African Medical Journal should not be full of ads touting the joys of practicing medicine in rural Canada.

African nations must drastically improve working conditions for their health workers. This will mean substantial wage increases across the board, in addition to bonuses for rural service. They also need to give thousands of health professionals short courses in AIDS-related skills, and recruit tens of thousands more into clinical and health management jobs. This capacity building could consume all the money rich countries can muster.

"Poor Patients Don’t Follow Drug Regimens”

False. Misuse of AIDS drugs is a serious worry, as the rise of resistant strains of AIDS makes the disease more dangerous for everyone. Andrew Natsios, who runs the U.S. Agency for International Development, told the Boston Globe in 2001 that Africans couldn’t take AIDS drugs correctly because they lack a Western concept of time. Natsios couldn’t have been more wrong. Africans have proven responsible pill-takers — far more responsible, in fact, than patients in the United States and Europe, where only about 70 percent take their medicines on time.

In a Malawi clinic run by Médicins Sans Frontières (MSF), or Doctors Without Borders, only four of 800 patients have defaulted on their drug regimens. In MSF’s community clinics outside Cape Town, South Africa, nearly 90 percent of patients adhere to their prescribed schedules. Government programs have shown similar results: Recent studies of combination pills produced by generic manufacturers found adherence rates of 99 percent and 97 percent in Cameroon and Uganda, respectively. And it’s not just Africa; at the medical centers run by the Boston-based group Partners In Health in central Haiti, nearly 100 percent of patients take their medicines on time, helped by a system of accompagnateurs — community workers paid to make daily visits to watch people swallow pills and spot problems that might affect their health.

Compliance in poor countries can reach these levels partly because most people have watched family and friends die or stared at death themselves, whereas young people with AIDS in Europe and the United States may not know anyone who has died of the disease. Africans also tend to have more community and group support for their treatment, often with a family member recruited to help the patient take his or her pills.

Another reason AIDS patients in the developing world are more faithful pill-swallowers is that many of these people have the great advantage of taking generic drugs, the same pills the Bush administration has been reluctant to finance. Brand-name versions of the drugs in antiretroviral cocktails are made by different companies, so those who use them must take six pills a day from different bottles. But, because patents aren’t an issue for generic manufacturers, they can combine all the necessary drugs into one dose — creating an easy-to-follow schedule of one pill at sunup, one at sundown. Combination pills additionally simplify management of the drug-supply chain, thus helping to assure a steady availability of medicines. And because they are cheaper than brand-name versions, they can save four times as many lives for the same amount of money.

"The Advent of AIDS Treatment Will Encourage Risky Behaviors"

Possibly, but the reverse is more likely. The availability of AIDS treatment has indeed made people careless in rich countries: Both the United States and Europe have seen an increase in risky behavior since treatment became available. Rates of infection for HIV and other sexually transmitted diseases (STDs) are rising among high-risk groups, especially young gay men.

But, more significant, AIDS treatment has made governments careless. The U.S. budget for AIDS prevention has been fairly flat for the last four years, despite a 5 percent rise in infection rates from 1999 to 2002 and a 17 percent rise among gay men. This trend is not only true for rich countries: Take Thailand, one of the world’s signal successes in AIDS prevention. Thailand brought its number of new infections down from 143,000 in 1991 to 21,000 in 2003. But HIV incidence is now rising again. The percentage of infected intravenous drug users rose from 30 to 50 percent in the past decade, and 1 in 50 pregnant women is infected in the country’s south — double the rate of three years ago. Although Thailand increasingly offers widespread AIDS treatment, it did get lazy about prevention, cutting its budget by two thirds after the 1997 Asian financial crisis.

In fact, the availability of AIDS treatment is more likely to boost prevention in poor countries. Individuals who successfully take antiretrovirals — greatly reducing the amount of virus in their bodies — are far less contagious. Also, the clamor for antiretrovirals has brought new financing to such nations, money that will allow them to increase dramatically their AIDS prevention efforts.

Medical experts also know that those who get tested and counseled reduce risky sexual behaviors. The problem is that only a tiny percentage of people in the developing world have been tested. Treatment will change that, because it finally offers them a good reason to find out their HIV status. Only 450 people turned up for tests at the MSF clinics outside Cape Town in 1998, before treatment was available; the clinics now conduct 17,000 HIV tests each year. Similar demands for testing have followed the introduction of antiretrovirals almost everywhere. For example, once the Partners In Health clinics in Haiti made treatment available and boosted staffing, locals turned up for testing in much greater numbers.

Treatment also reduces the stigma of AIDS. One of the biggest reasons people don’t change their sexual behavior is because AIDS is just too scary to contemplate. Where AIDS is always fatal, it is shrouded in denial. This phenomenon changes when AIDS becomes a manageable chronic illness, like diabetes. Countries that emphasize both prevention and treatment, such as Brazil, are successful with both. The Brazilians tell everyone that they could not have kept the percentage of adults infected at only 0.7 without their free universal antiretroviral program. As long as nations do not neglect prevention, offering treatment will not make the epidemic worse.

"Socially Conservative Nations Don’t Have to Worry About AIDS"

No. Leaders of countries where religion or other conservative traditions dominate society frequently argue that they enjoy a sort of cultural immunity to AIDS. It is true that in countries where citizens have fewer sex partners, virus transmission rates are likely to be lower. Other factors, such as strictures against drinking alcohol or near-universal male circumcision in Islamic nations, help as well.

But traditional societies have other disadvantages that make them as vulnerable to the disease as less conservative countries. Power imbalances between the genders have helped spread AIDS all over the globe — by hindering, for example, wives’ ability to persuade their husbands to use a condom. Women tend to be especially powerless in conservative societies. Prohibitions against extramarital sex that might protect a couple are of little help, as they often apply only to women. Prostitution, drug use, and homosexuality exist in traditional societies. But, because they are criminalized and driven underground, people at high risk for AIDS are rarely informed about the disease. And traditional societies with autocratic governments usually have an aversion to working with nongovernmental organizations — cooperation that has proven vital to combating AIDS elsewhere.

AIDS infection rates are indeed low in most traditional Islamic countries — at least health experts think so, as these countries do not conduct the surveillance of high-risk groups that would allow them to track the early stages of an AIDS epidemic. But World Bank researchers believe that Middle Eastern countries have many key risk factors, including a young population, rising drug use, and high levels of migration. In countries such as Algeria, there is evidence that AIDS is increasing sharply in high-risk groups and spreading into the general population. Middle Eastern countries are singularly ill-prepared. Condom promotion is nonexistent, and few governments openly address the issue of AIDS.

The poster child for a responsive, socially conservative country is Senegal. Its population is 94 percent Muslim and it has one of the lowest rates of AIDS infection in Africa, at 1.4 percent. But Senegal is not a typical Muslim country. Prostitution has been legal since 1966, and prostitutes get free condoms and mandatory medical exams. Muslim clergy encourage open discussion about sex and have led AIDS prevention campaigns. The fact that Senegal took AIDS seriously from the disease’s first appearance in 1986 is as important to the country’s success as its traditional mores.

"Asia Will Be the Next Africa"

No. There is a tendency — even among otherwise responsible people who work on AIDS — to imply that southern Africa is the future of Asia. Last year’s AIDS conference was held in Bangkok to highlight the dangers of the disease in Asia, and the meeting was filled with predictions that Asia would dwarf Africa’s epidemic.

It is indeed likely that Asia, especially China and India, will have large numbers of AIDS infections and deaths as their epidemics break out from high-risk groups into the general population. Big countries can equal big epidemics — even the infection of a small percentage of the population means an avalanche of cases. But the 30 to 40 percent adult infection rates in southern Africa are not Asia’s future. That scenario assumes that rates of infection will always rise to southern Africa’s level as epidemics mature, which is untrue. The AIDS epidemic is older in many places than in southern Africa. In the late 1980s, an estimated 40 percent of Argentina’s gay men were HIV-positive, even as that number was near zero in southern Africa. Yet, today in Argentina, the overall adult infection rate is less than 1 percent. Urban Botswana and Mumbai had similar HIV-infection rates among men with STDs in the late 1980s. After 10 years, only 2.5 percent of women in Mumbai’s prenatal clinics were HIV-positive. However, in Botswana’s two largest cities, Gaborone and Francistown, 45.6 and 48.5 percent of women were infected, respectively. Clearly, AIDS in southern Africa exploded into the general population with a special virulence.

"Poverty Explains Southern Africa’s Crisis"

False. If ability to pay continues to determine who receives antiretrovirals, then indeed, the poor will die. But AIDS is not naturally a poor person’s disease. Poverty, curiously enough, does not affect how likely HIV is to spread in a population, nor how long you are likely to live before your HIV infection develops into full-blown AIDS.

Compared to the rest of sub-Saharan Africa, southern Africa is relatively rich. So why is its AIDS problem especially severe? The most important factors appear to be low rates of circumcision — a protective barrier against HIV transmission that is only now beginning to be understood — and the physical dislocation affecting families. Yes, you can partially blame apartheid. South Africa built a system that housed blacks in scattered settlements and forced them to travel huge distances to work and spend long periods away from home. The government built a relatively good transport network that allowed people to move easily from city to village, as did Botswana. Hence, disease goes home to the village quite easily.

South Africa and Botswana also depend heavily on mining, an industry that forces men to live away from home. Men living without their wives turn to commercial sex more often. Women without their husbands also probably have higher numbers of sexual partners, and they are more likely to solve their economic problems through sexual relationships with older local men. Infections in sex workers move easily into the general population, and women infected by their husbands are more likely to pass on the disease rather than allow the infection to dead-end. A mix of factors may cause other countries to experience a similar explosion in the general population. But so far, the percentage of adults with AIDS in most African countries does not approach the nearly 40 percent found in southern Africa; 5 percent or less is typical.

That news, of course, is still terrifying. If 5 percent of adults in China and India contract the virus, that means at least 65 million infections. But the direst scenario also assumes that the world learns nothing. The successful prevention campaigns of Thailand, Uganda, Brazil, and other countries show that AIDS epidemics are created by humans. Russia, in fact, could contain its budding epidemic if it only offered drug users needle-exchange programs. The grace for China, India, Russia, and other countries poised on the edge of today’s epidemics is that the world is realizing that the prevention of millions of deaths is wholly within its power.

<p> Tina Rosenberg is co-writer of the Fixes column on and author, most recently, of Join the Club: How Peer Pressure Can Transform the World. </p>

More from Foreign Policy

Russian President Vladimir Putin and Chinese President Xi Jinping give a toast during a reception following their talks at the Kremlin in Moscow on March 21.
Russian President Vladimir Putin and Chinese President Xi Jinping give a toast during a reception following their talks at the Kremlin in Moscow on March 21.

Can Russia Get Used to Being China’s Little Brother?

The power dynamic between Beijing and Moscow has switched dramatically.

Xi and Putin shake hands while carrying red folders.
Xi and Putin shake hands while carrying red folders.

Xi and Putin Have the Most Consequential Undeclared Alliance in the World

It’s become more important than Washington’s official alliances today.

Russian President Vladimir Putin greets Kazakh President Kassym-Jomart Tokayev.
Russian President Vladimir Putin greets Kazakh President Kassym-Jomart Tokayev.

It’s a New Great Game. Again.

Across Central Asia, Russia’s brand is tainted by Ukraine, China’s got challenges, and Washington senses another opening.

Kurdish military officers take part in a graduation ceremony in Erbil, the capital of Iraq’s Kurdistan Region, on Jan. 15.
Kurdish military officers take part in a graduation ceremony in Erbil, the capital of Iraq’s Kurdistan Region, on Jan. 15.

Iraqi Kurdistan’s House of Cards Is Collapsing

The region once seemed a bright spot in the disorder unleashed by U.S. regime change. Today, things look bleak.