Another Approach to AIDS in Africa
By LAWRENCE K. ALTMAN
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
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
Throughout the conference, other participants stressed similar steps, the
kind of old-fashioned public health work that has shown good, if not
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.
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 naïve or a liar," said Dr.
Peter Piot, the director of Unaids.