HIV-AIDS IN SOUTHERN AFRICA:

THE WORLD’S HIGHEST INFECTION RATES

By Nick Gier, Professor Emeritus, University of Idaho (ngier@uidaho.edu)

Go to www.class.uidaho.edu/ngier/AIDSday.htm to execute image below

          As we commemorate World AIDS Day on December 1, we should celebrate the fact that fewer people are dying from this dreaded disease.  The number of deaths in the world peaked at 2.2 million in 2007, but the 2 million people who died in 2008 are still a great tragedy.  The number of those newly infected has also dropped: from a high of 3.5 million in 1996 to 2.7 million in 2008.  The totals, however, are really grim: 25 million dead since the early 1980s and 60 million infected.

           We should also praise President Bush for reauthorizing the Emergency Plan for AIDS Relief on July 30, 2008.  Although the bill has been criticized for focusing on abstinence rather than condom use, it will provide $39 billion (up from $15 billion the previous 5 years) over the next five years.

            The other good news is the dramatic increase in antiretroviral therapy in the Third World, which has been supported by agencies such as the U.S. government, the Clinton Foundation, the Gates Foundation, and the Global Fund.  Over the past five years the use of antiretroviral drugs (ARVs) has increased 10-fold, reaching 4 million people in the Third World. AIDS patients on ARVs experience a dramatic reduction of the virus in their systems, especially in the male semen. Unfortunately, the ARVs used in the Third World are first generation varieties that have serious side effects, unlike the new drugs available in the U.S. and Europe.

            During my six-week tour through four countries in Southern Africa in August, I encountered friendly and outwardly healthy people everywhere I went.  I was especially impressed with the high morale of these proud citizens, especially in Namibia and Botswana.    Our tour group visited a medical clinic in rural Namibia.  The nurse there said that she saw very few AIDS cases, and she showed us the condoms that she handed out free.  I was impressed with the graphic posters indicating the horrid results of the major sexually transmitted diseases.  Among the condoms was the female version, which is being promoted as a way of protecting women from males who refuse to wear condoms.

I did not visit any AIDS clinics, but if I had done so, I would have witnessed what I knew only as statistics: these countries have the highest AIDS infection rates in the world, averaging 18 percent of the adult population. By comparison the infection rate in the U.S. is .6 percent and some European countries are the lowest at .1 percent.

In Swaziland one in four adults have AIDS, which has brought life expectancy to a low of 32 years.  Over 60 percent of the deaths in Swaziland are due to AIDS, outstripping every other cause of death.  Nearly 40 percent of pregnant women are infected, and their infants will be born with the virus.  According to the Economist, young women in Africa are “three times more likely to have HIV than males,” primarily because of “poor education, having multiple sexual partners, or having sex with older men,” in most cases without their full consent and usually without a condom.

The next highest rate is found in Botswana where 23 percent of the adult population is HIV-positive.  This fact comes as a surprise for those who know Botswana as one of the best-governed and most prosperous African countries.  In 1966 Botswana gained independence from Britain without war or bloodshed, and it did not suffer the indignities of apartheid.

As I traveled through the northern part of Botswana, I was struck by two things: gigantic equipment used in the diamond mines and large billboards strongly recommending male circumcision.  Tests have shown that circumcision may prevent HIV infection by 60 percent.  As the Economist reports: “Foreskin tissue is rich in a particular cell that HIV likes very much.” A doctor friend in Zimbabwe told me that clinics run by Population Services International pay men to have their foreskins cut off, and many are eagerly lining up for the procedure.  There is fear, however, that these men will think that they are now completely immune.  The greatest danger is that promiscuous men who are already infected will spread the virus, circumcised or not. 

For this reason Uganda’s president Yoweri Museveni, with strong support from right-wing Congressmen, has come out against the circumcision program.  Even though the virus is spread overwhelmingly by heterosexual sexual relations, Musenveni has also supported a bill that calls for the execution of HIV-positive gay men. This is unfortunate because Uganda is one of the great AIDS success stories in Africa. 

A national program emphasizing marital fidelity and condom use, plus local leadership by those infected with AIDS, has reduced Uganda’s infection rate from 30 percent to 5 percent over 30 years.  Recently the rate has risen about one percent, and this coincides with infusion of U.S. money with the condition that abstinence, not condoms, should be the main policy.

When our tour group visited a school in Zimbabwe, we were impressed with the strongly worded posters that appeared in elementary grade classrooms.  The most compelling aspect of one poster was the picture of a man in a clerical collar who says: “I’m an HIV-positive pastor. It can happen to anyone.”  The removal of the stigma of AIDS--that is only a gay or prostitute disease--is the one of the most effective elements of successful AIDS education.

A public relations campaign in Zimbabwe featuring billboards such as “Anyone can contract HIV-AIDS and everyone can prevent it”; and “What smart guys are wearing” (a condom) appears to have had good effect. Although some critics dispute the claim, the government reported that the infection rate has dropped from 24.6 percent in 2003 to 15.3 percent in 2007.  Namibia has had similar success in the same period: down from 21.3 percent to 15.3 percent.

In 2008 5.7 million people were living with HIV-AIDS in South Africa, more than any other nation and 17 percent of the world’s total.  The country has an 18 percent infection rate and  lost 350,000 to the disease in 2008 alone.  On a positive note, the percentage of people are using condoms in their first sexual encounters rose from 31.3 in 2002 to 64.8 in 2008.

South Africa could have been well ahead of neighboring countries if it had not been for the disastrous policies of former president Thabo Mbeki. Early in his presidency Mbeki came under the influence of Peter Duesberg from the University of California at Berkeley.  Duesberg is a maverick scientist who, along with other some distinguished researchers, did not believe that HIV caused AIDS. Mbeki refused offers from drug companies to provide ARVs free or at little cost, and insisted that AIDS was caused by poverty and general poor health.  A 2008 Harvard study estimated that Mbeki’s stubbornness caused 330,000 unnecessary deaths.

The new president Jacob Zuma has removed Mbeki’s health minister, and he is moving forward with a plan to offer ARVs to every infected South African by 2011.  (By contrast Botswana met this goal already in 2006.) For this effort the U.S. will add $120 million to the $560 million that it has already pledged for South Africa in 2010.

My doctor friend in Zimbabwe said that prevention education, rather than using ARVs to treat symptoms, is the best way to fight this disease. Even more effective than billboards is the deterrent effect of seeing your friends and family die in droves.  Public health officials in Southern Africa are heartened by behavioral changes in sexual relations that will, slowly but surely, bring these high infection rates down.

There is another important lesson to be drawn from the AIDS disaster in South Africa. In life and death matters, such as AIDS and climate change, policy makers have an obligation to go with broad-based scientific consensus, not with a few scientists no matter how distinguished they might be.