Another Approach to AIDS in Africa

Another Approach to AIDS in Africa



New York Times


DURBAN, South Africa, July 15 --

When the former South African president Nelson Mandela issued his

forceful call for action to stop the AIDS epidemic that is ravaging his country and

much of the continent, it was a great relief to the 12,500 participants at the 13th

international AIDS conference, which ended here on Friday.


Meeting in the most-infected province of the most-infected country on

the most-infected continent, they were bitterly disappointed when the current South

African president, Thabo Mbeki, did not acknowledge forthrightly that H.I.V.

causes AIDS, emphasizing instead social factors like poverty as a major force

behind the epidemic. In a way, however, Mr. Mandela's call for immediate

action and Mr. Mbeki's emphasis on poverty were making similar points.


For while a virus causes AIDS, social conditions feed the epidemic.

Patterns of behavior -- fed by poverty, ignorance and despair -- have

resulted in a disease so widespread that it has left millions of orphans and

threatens to destroy much of Africa's economy and to wipe out a

generation of young people.


But what is implicit in the remarks of both Mr. Mbeki and Mr. Mandela

is the idea that some AIDS problems can be attacked now, even without

the vaccines and cures that have yet to emerge from laboratories in the

developed world.


Just 10 miles from the plush surroundings of the conference center, many

South Africans live in squatter camps and earn meager incomes as

migrant workers. As they have traveled seeking jobs in mines and other

industries, they have brought H.I.V. home to their families to fuel what

has become an explosive epidemic.


Mr. Mandela cited two African countries, Uganda and Senegal. The first

turned around a major epidemic of AIDS. The second prevented a small

one from becoming larger. Those successes, using relatively inexpensive

public health tools like education, suggest that other countries severely

affected by H.I.V. might do as well, if they can only muster the political

will to act.


Mr. Mandela challenged the world to focus on what health workers

know works in preventing AIDS. Though the use of drugs to prevent

transmission of the virus from mothers to infants is mandatory in any

H.I.V. control plan, Mr. Mandela said, "Promoting abstinence, safe sex

and the use of condoms and ensuring the early treatment of sexually

transmitted diseases are some of the steps needed and about which there

can be no dispute."


These are steps that could be carried out immediately and at a relatively

low cost.


Throughout the conference, other participants stressed similar steps, the

kind of old-fashioned public health work that has shown good, if not

spectacular, results.


For example, Dr. Hoosen M. Coovadia, a leading AIDS expert in

Durban and the conference chairman, cited the way political and religious

leaders from diverse parts of Uganda and Senegal spoke out about

AIDS, both to reduce the stigma of the disease and to encourage

counseling, testing and the aggressive promotion of condom use.


The results have been encouraging. Uganda's infection rates have

dropped to 8 percent from 14 percent in the early 1990's, according to

United Nations statistics for the most recent years available. Rates in

Senegal, where the country's then-president, Abdou Diouf, began

speaking out forcefully more than a decade ago, have stayed below 2



In a country where prostitution is legal, Senegalese health officials have

set up free clinics to treat sexually transmitted infections, and have

organized a vigorous education campaign on the virus.


Mr. Mandela also pointed to Thailand, which acted relatively quickly to

set up an aggressive program to offer condoms and treat sexually

transmitted diseases, which enhance the spread of the AIDS virus.


Thailand was one of the first countries to commit its own resources to

fight the epidemic, said Dr. Helene Gayle, who directs the H.I.V.

program for the United States Centers for Disease Control and



The C.D.C. has worked with Thailand to set up sophisticated infection

surveillance systems that allowed it to track the path of its epidemic.

Thailand has used the systems to respond quickly when it spotted rising

H.I.V. rates in specific areas.


By contrast, South Africa, which at the start of the epidemic had a

relatively low infection rate, is now seeking ways to help an estimated 20

percent of adults infected with the virus. Because few have access to

tests for the virus, most are ignorant of their condition. And almost none

have access to the drugs that have helped control the infection in richer



The AIDS epidemic is "depleting health services and robbing schools of

both students and teachers" as it undermines the country's economy, Mr.

Mandela said.


And Zola Skweyiya, the South African minister of welfare and population

development, was quoted in the nation's newspapers as offering an even

more drastic assessment: if the AIDS trend goes unabated, South Africa

could eventually have a white majority.


In South Africa, H.I.V. rates rose slowly during apartheid and surged late

in Mr. Mandela's presidency and during Mr. Mbeki's first year in office.

In the last two years, they have risen by more than 50 percent.


Mr. Mandela acknowledged that H.I.V. flourished when it could have

been prevented. Now, he said he is instructing his private foundation to

consult experts about the best way to conduct anti-H.I.V. campaigns.


Though the meeting was held in Africa to encourage the world's AIDS

experts and government leaders to focus on the dire conditions here,

participants looked beyond the continent, repeatedly calling on leaders of

countries elsewhere to show the political will to beat AIDS.


They cited the rapidly worsening epidemic of H.I.V. in Russia and voiced

particular concern about the threat to the world's most populous

countries, India and China.


Much of the emphasis on public health efforts stems from the belief that

the drugs that have greatly improved life for AIDS patients in the

developed world are out of reach of the third world's poor.


But Unaids, a joint United Nations agency, and five drug companies are

negotiating steep drops in the price of AIDS drugs for Africa and other

poor regions afflicted by the disease. For example, the German company

Behringer-Ingelheim announced that it would offer an anti-H.I.V. drug,

nevirapine, free of charge for five years for the prevention of

mother-to-child transmission in developing countries.


Still, health officials at the conference stressed that lowering prices is only

part of the battle. For example, the combination drug therapies used

extensively in rich countries require testing for H.I.V., measuring the level

of the virus in the blood, and preventing and dealing with the

complications that often occur with such therapy -- much of which is

beyond the health care infrastructure in the third world.


Dr. Stefan Vella, the president of the group that organizes the AIDS

conferences, warned of "the dangers of parachuting drugs" into countries

that have no health infrastructure because "you may do more harm than



In education efforts about the basic facts of AIDS, a major goal will be

to destroy widespread myths in Africa. One is that having sex with a

virgin will cure AIDS, a belief that often leads to violence and rape, said

Dr. Zweli Mkhize, the health minister of KwaZulu/Natal province.


But the educational programs will not be effective unless they focus on

men, said Dr. William M. Makgoba, the head of the South African

equivalent of the United States National Institutes of Health.


"We always target young females," Dr. Makgoba said. Instead, he urged,

efforts must be made to educate men about how risky sexual practices

spread the virus and that, over all, men have done more than women to

spread the disease.


Dr. Coovadia said that the meeting he led provided a range of options for

governments to make decisions about how to combat AIDS, but that it

was up to them to carry those policies out.


But that will not be easy. "Anybody who claims they have a simple

solution for such a complex problem is either nave or a liar," said Dr.

Peter Piot, the director of Unaids.