Thursday, June 14, 2007

Health In Africa

"28 Stories of AIDS in Africa:"
About 5,500 people died in sub-Saharan Africa yesterday—about one and a half times the number of American troops killed since the invasion of Iraq—and few people in the United States noticed.
The killer wasn’t a war or famine or natural disaster but rather a virus the shape of a spiky basketball which hijacked its victims’ DNA, replicated itself and then destroyed the host’s immune system.
The killer was AIDS, and it will kill 5,500 more Africans today. And tomorrow. And every day for the foreseeable future. The scourge of the disease and its precursor virus, HIV, is destroying lives, families, communities and countries. The disease’s effect on everyday people is the subject of Stephanie Nolen’s book, 28 Stories of AIDS in Africa, a group of profiles written by the reporter for Toronto’s Globe and Mail newspaper.
The pandemic has all but disappeared from today’s media. One reason seems to be the so-called “AIDS fatigue”—simply put, Americans are tired of reading about the disease. Dying with AIDS is a gruesome way to die, and it doesn’t make good reading or fun watching.
Also, living with HIV/AIDS in the West has become not much different than living with a chronic disease. The development of antiretroviral drugs—which can arrest the spread of HIV or AIDS but don’t cure it—is one of the most underappreciated and remarkable breakthroughs in medicine in decades.
Many countries are offering free or subsidized ARVs—but the drugs are hard to come by in the area with the highest rates of infection: sub-Saharan Africa.
The decreasing interest abroad and a sense of horror after witnessing a group of Tanzanian men wasting away with the virus is why Nolen chose to focus her efforts on reporting HIV/AIDS.
And why 28 stories? According to the United Nations’ AIDS organization, 28 million of the estimated 39.5 million people in the world living with the disease live in Africa.
The book’s profiles can be heartbreaking or inspiring—or sometimes both at the same time. One such case is Lefa Khoele, a 12-year-old Basotho boy born with HIV who has been too sick to take his year-end school exams, so he’s stuck in a class with 7-year-olds. Still, he makes the best of things—he’s learning gardening, and his ambition isn’t dimmed by the disease.
There’s Mohammed Ali, a Kenyan trucker who frequently purchased the services of prostitutes on his routes. After testing positive, he changed his behavior: no sex with his wife (who is HIV-negative) or prostitutes. No more cigarettes or drinking. He believes the disease will kill him, “but everybody dies one day,” he said.
And there’s Cynthia Leshomo, who won the Miss HIV Stigma-Free beauty contest in Gabarone, Botswana, and is trying to break social taboos.
The most famous person profiled in this book is Nelson Mandela. South Africa’s first post-apartheid president announced two years ago that his final surviving son, Makgatho Mandela, had died of AIDS-related diseases.
The power of the announcement can’t be overstated. Mandela was the glue that kept the “Rainbow Nation” from fracturing into race-based warfare after the first all-race elections in 1994. He’s the only politician respected among almost all races, classes and political affiliations. And then he announced AIDS had affected the Mandela family, too.
“The admission that AIDS had touched them, too, made it all a bit more normal, a bit less shameful,” Nolen writes.
It’s difficult to figure out if the war on HIV/AIDS is being won. Various groups give mixed signals. One example: Siphiwe Hlophe founded a successful grass-roots AIDS awareness and treatment group in Swaziland, but the country’s King Mswati III, Africa’s last ruling monarch, is a polygamist who chooses a new wife each year. He’s up to 13 wives.
South Africa transmits the most conflicting messages. Mandela, now a vocal advocate for increased HIV/AIDS funding and treatment, was largely silent about the disease while in office.
Mandela’s successor, Thabo Mbeki, has called AIDS a disease of the poor and defended a group of scientists who allege HIV does not cause AIDS. He’s criticized the West for its portrayal of the pandemic in Africa, saying reporters buy into the stereotype that Africans are savage and unable to control their bodies.
His health minister, Manto Tshabalala-Msimang, has promoted a diet rich in vegetables as a traditional cure for the virus. After much domestic and international fury over her statements, she’s modified it—now she says the best cure is a diet and antiretroviral drugs.
Yet despite this sharp rise in boneheadedness at the top of Africa’s richest and most industrialized nation, there are positive signs. Mbeki’s Cabinet forced the president to accept South Africa’s use of antiretroviral drugs, and it commanded Tshabalala-Msimang to develop a way to distribute them free to those who can’t afford them. The president has backed off his previous comments, and his health minister is fading away from the political scene because of health concerns.
The drug rollout program is under way, but only reaches 250,000 of the 5 million infected in South Africa. Within five years, Pretoria hopes ARVs will reach 80 percent. But the stigma remains: Most people do not want to be tested or acknowledge the disease.
These are the obstacles in Africa’s richest nation. Cross the borders into some of its neighbors—Lesotho, Swaziland, Mozambique, Zimbabwe, Namibia—and suddenly the poverty rate skyrockets and the infection rate increases.
These countries often can’t afford to give away ARVs.
Every day, Nolen reminds us at the end of her book, 5,500 people in Africa die of AIDS-related diseases. More are infected every day. Therefore, she writes, “we have twenty-eight million reasons to act.”
"Africa wants DDT:"
Sam Zaramba, head of health services in Uganda, in an op-ed (subscription required) campaigns for a wider use of Dichloro-Diphenyl-Trichloroethane (DDT) as a preventative against malaria:
The United States and Europe eradicated malaria by 1960, largely with the use of DDT. At the time, Uganda tested the pesticide in the Kanungu district and reduced malaria by 98%. Despite this success, we lacked the resources to sustain the program. Rather than partner with us to improve our public health infrastructure, however, foreign donors blanched. They used Africa's lack of infrastructure to justify not investing in it.
The exercise pays for itself. With 90% fewer people requiring anti-malarial medication and other public-health resources, more healthy adults work and more children attend school.
Although Uganda's National Environmental management Authority has approved DDT for malaria control, Western environmentalists continue to undermine our efforts and discourage G-8 governments from supporting us.
The World Health Organization officially endorsed the practice last year.
"Bringing Back the Sex into HIV/AIDS Work in Africa:"
It's not a revealing discovery that sexual engagement with multiple partners increases the likelihood of getting some kind of an infection, HIV included. But this is increasingly getting attention as HIV/AIDS workers and researchers grapple with a ballooning epidemic in sub-Saharan Africa, where just 12 percent of men and 10 percent of women know their HIV status. More than anything else, it shows the lack of integration of HIV/AIDS and sexual reproductive health that is characteristic of many programs in Africa.
For example, over the past few years the term "small house" has gained currency in Zimbabwe, a country with 18 percent HIV prevalence rate among the 15 to 49 age group. Small house simply refers to the extra-marital affairs that married men or women have in secret.
"Small houses are a form of concurrent relationship in which a person is having regular sexual relations with another person, while at the same time continuing to have sex with their current primary sexual partner," says Lois Chingandu, Executive Director of Southern Africa HIV and AIDS Information Dissemination Service (SAfAIDS) in an ongoing electronic forum discussion on accelerating-prevention measures in Zimbabwe.
Usually, such relationships often include a powerful element of sexual-economic exchange. Because of women's subordinate economic status, they often enter into the relationships for financial gain, making themselves vulnerable to HIV infection. Also, in many African countries, cultural and traditional practices encourage multiple partnerships for men. Like in many societies around the world, men's sense of masculinity is often associated with sexual prowess.
"Researchers increasingly attribute the resilience of HIV in Botswana—and in southern Africa generally—to the high incidence of multiple sexual relationships," reports The Washington Post. "Europeans and Americans often have more partners over their lives, studies show, but sub-Saharan Africans average more at the same time."
While it's clearly a fallacy to say such partnerships are unique to sub-Saharan Africa, they do indeed facilitate the transmission of HIV because of other reasons.
"The fact is that concurrent sex or small houses are a key driver of the epidemic for a number of reasons: people do not know their status when they engage in sex; condom use is zero in these relationships, despite high HIV awareness levels; mutual fidelity is very rare; small houses are themselves driven by other drivers like power dynamics and gender inequality, which make it difficult for women on both sides of the relationship to demand protection, even when they know they are at risk," says Chingandu.
The World Health Organization (WHO) estimates that sub-Saharan Africa alone accounts for 65 percent of all new HIV infections. The primary transmission of HIV is through heterosexual contact.
The catch, however, is that most of the people who are infected, do not know that they are HIV-positive. Reducing the number of partners is key to HIV prevention, but must be promoted alongside the provision of other services—such as HIV testing, stigma reduction, access to treatment, and correct and consistent use of existing prevention methods.
In many parts of sub-Sahara Africa, HIV/AIDS lives in the shadow of silence, fear and death, and many people prefer not to know their status.
The UN estimates that nearly 80 percent of the people with HIV in poor and developing countries do not know they have it. In Africa alone, nearly 20 million people with HIV are not aware they have the virus.
The stigma associated with HIV/AIDS causes many people to shun HIV testing services.
And when people enter into a sexual relationship, they trust each other after a period of time to forgo protective measures, putting themselves at risk. The rate of the spread of the disease increases in the event of multiple concurrent sexual relationships.
Unfortunately, the AIDS response in Africa has largely steered away from matters of sex and sexuality. While there's a large amount of printed material on HIV and AIDS, it often ignores the heart of the matter: sex. NGOs, government and AIDS funders have concentrated efforts on alleviating the social manifestations of the disease. There's every justification to provide services to the affected populations, but equally important is the need to tackle often-taboo subjects associated with sex in wide-scale campaigns.
"Africans are overwhelmed with information on AIDS but not nearly enough that is useful," said The Washington Post's Craig Timberg, in a recent online chat with his readers.
If heterosexual contact is the main cause of the spread of the epidemic, it is imperative for African societies to start exploring the cultural, traditional, social, economic and political dynamics that define sexual behaviour, especially between men and women.
There's need to bring the sex back into HIV/AIDS work. Programs that promote safe sexual relations, even in multiple partnerships, need to be emphasized to harness the high rates of new infections.
"Good news about HIV at last?"
Until recently, the best estimates for the number of HIV+ Indians was 5.7 million, although estimates ranged from 3.4 million to 9.4 million. However, a new study puts the number of Indians with HIV/AIDS at roughly half of the previous estimate:
Early analysis of the figures suggests that India really has between two and three million victims, according to several sources, including American epidemiologists who know the data and the Health Ministry here.
The lower figure for India would imply that India has managed to keep its epidemic more like that of the United States, in that the virus circulates mostly within high-risk groups. In India’s case, these are prostitutes and their clients — especially truckers; men who have sex with men; and people who inject drugs, especially in the northeast, on the borders with Myanmar.
The big improvement in the quality of the numbers comes from the third National Family Health Survey:
The third National Family Health Survey was a gigantic exercise in logistics. Research organizations had to interview 124,385 women and 74,369 men in 3,849 villages and urban centers across India…. NFHS-3 was the first large scale nationwide survey to collect dried blood samples for HIV testing. Nearly 110,000 women and men were tested for HIV and more than 200,000 adults and young children were tested for anemia.
One surprise result of the new numbers- infection rates are much higher in the South than in the North:
But Ashok Alexander, director of Avahan, the Indian AIDS program of the Gates Foundation, says that while “it’s good news that overall the numbers are down, the real danger of this is it masks the real prevalence in one third of India: the south.” The study … found that infection rates in southern India are significantly higher than in the north of the country.
Two side points. First, HIV/AIDS advocacy groups are accused of having previously overstated the numbers in order to increase their own clout. I can see how they might have erred on the side of over-estimation, but the Gates Foundation was one of the groups that previously argued that the numbers were high and that the Indian government wasn’t doing enough, and which underwrote the comprehensive survey. That makes me think that the previous numbers were not just the result of projection by activists.
Second, I worry that people will make too much of Indian sexual fidelity and assume away the possibility that AIDS might still pose a serious threat:
Indians do not have the same kind of sexual networks that are common in southern and eastern Africa, in which both men and women often have two or more occasional but regular sexual partners over long periods of time. Also, outside of prostitution, “transactional sex” between teenage girls and older men in return for money, food or clothes is much less common in Asia than in Africa.
This is in fact true - Indians stress female virginity and there is little privacy, so it is harder for most people to have sex before or outside of marriage. Men do stray somewhat, but according to a friend who is an AIDS researcher, sexual double standards serve to limit spread of diseases in the population.
Over-stressing sexual behavior ignores other more important factors such as women’s sexual health. Emily Oster’s research argues that women’s poor sexual health is at the root of the epidemic in Africa:
… Africa has very high HIV transmission rates, likely due to high rates of other untreated sexually transmitted infections, while transmission rates in the United States are low. The difference in transmission rates is large enough to explain the observed difference in prevalence between the United States and Sub-Saharan Africa.
Oster argues strongly that differences between the US and Africa are caused by the fact that transmission rates are far higher in Africa and the epidemic started sooner. It’s really not about the number of sexual partners that Africans have. To make this point, she demonstrates that if Africa had transmission rates as low as the US, it would take superhuman levels of sexual activity to explain the epidemic. Basically, everybody would have to have far tremendously more sex than they do:
The results demonstrate that extremely large increases in sexual behavior would be necessary to produce the rate seen in Africa with the transmission rates from the developed world. One possible mechanism includes everyone having nonmarital sex (everyone has both premarital sex and extramarital sex in all periods), all women having an average of four nonmarital partners, and all men having an average of five nonmarital partners per year. Such a scenario involves sexual behavior that would have to be many times higher than in the reported DHS data.
If correct, then India should invest in female sexual health to keep rates of transmission low, rather than just relying on continued social pressures, especially since sexual mores are gradually changing. [If you’re interested, see Emily Oster’s webpage, she’s one of the top young economists today, and the author of the study I cited. Here’s a shorter less technical version of the paper cited above

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