A Better Understanding of African AIDS
and What to Do About it

Edward C. Green

Since the early- to mid-1980s we have all been hearing how AIDS is decimating Africa, how HIV infection rates are exploding beyond the direst predictions and it seems nothing can prevent the death of the continent where Homo sapiens first appeared. So it was a surprise to see a front page article in the Washington Post called ?How AIDS in Africa Was Overstated: Reliance on Data From Urban Prenatal Clinics Skewed Early Projections (Craig Timberg, Washington Post Foreign Service, Thursday, April 6, 2006; Page A01).

The article began with observations about Rwanda:

?KIGALI, Rwanda -- Researchers said nearly two decades ago that this tiny country was part of an AIDS Belt stretching across the midsection of Africa, a place so infected with a new, incurable disease that, in the hardest-hit places, one in three working-age adults were already doomed to die of it. But AIDS deaths on the predicted scale never arrived here, government health officials say. A new national study illustrates why: The rate of HIV infection among Rwandans ages 15 to 49 is 3 percent, according to the study, enough to qualify as a major health problem but not nearly the national catastrophe once predicted.

The new data suggest the rate never reached the 30 percent estimated by some early researchers, nor the nearly 13 percent given by the United Nations in 1998.

The study and similar ones in 15 other countries have shed new light on the disease across Africa.?

I had actually written an op-ed in Uganda?s daily paper, New Vision, a couple of weeks earlier. I did not submit this to an American newspaper (Although I have previously published op-eds in the New York Times, Washington Post, etc) because I felt sure it would not be published. Calling attention to lower HIV infection rates in Africa can get one in trouble. One can be accused of not caring about Africans, about being in denial, or, in extreme form, being a holocaust denier.

In most reporting on African AIDS, there seems to be competition over who can paint the most catastrophic picture.

The Washington Post article was about HIV infection rates being considerably lower than previously estimated. HIV infection rates are also declining slowly, as an article in The Lancet by Shelton et al recently showed evidence for, and as I argued earlier in my controversial book Rethinking AIDS Prevention (Praeger, 2003).

This news, to the extant it has even gotten out, has been greeted not with joy and relief, as might be expected, but with skepticism and disbelief. Part of the reason for Western disbelief about lower-than-we-thought and declining HIV infection rates is, frankly, a deeply imbedded Western stereotype about African sexual behavior. Americans and Europeans, including those who ought to know better, believe that Africans start to have sex at a very early age (11 or 12 is usually suggested) after which they continue to have numerous sex partners, even after being HIV-infected.

When Uganda rocked the world of AIDS prevention by promoting ?sticking to one partner? and delaying the age of first sex, Western experts smugly though ?How na?ve. Well, they?ll soon learn.?

Instead, national HIV prevalence declined by an unprecedented 66%. And why should this not result? HIV epidemics are driven by significant proportions of people having multiple, concurrent sex partners. So having fewer partners would mean greatly reduced opportunities for exposure to HIV. In fact, if HIV-negative partners remain mutually faithful, there is zero percent chance of sexually transmitted HIV infection.

Other countries in Africa began to wonder if they too might put emphasis on promoting fidelity and delayed age of sex, not necessarily instead of condoms, treating STDs and being testing?but in addition to these ?risk reduction? interventions. Such interest led to instant backlash. There were dark hints about right wing plots to force everyone into total abstinence. Rarely was reduction in numbers of sex partners actually discussed; the easier target was always ?abstinence only.? But lest anyone think partner reduction was even feasible, many Western AIDS experts clamed that, ?African men cannot be faithful,? ?Africans are polygamous by nature,? ?African women might abstain only to be infected by their husbands,? ?not everyone can be faithful so it would be stigmatizing to expect anyone to be faithful,? etc, etc. Fidelity and abstinence programs were and are routinely dismissed as unrealistic, while condom programs are said to deal with people "as they actually are" rather than how we might wish them to be. Yet the best current biological and survey data simply do not support the popular image of the promiscuous African. According to UNAIDS, Sub-Saharan Africa now has an average HIV prevalence rate of 7.2%, down from 7.3% in 2004 and 7.5% a year earlier. This means that about 93% of Africans ages 15-49 are not HIV infected. If we consider all ages and include both the sexual inactive and North Africans as well, we can say that about 97% of all Africans are HIV-free. If this is so contrary to everything we have heard, we can also calculate simple numerator over denominator: there are about 25.5 million infections in a total African population of about 840 million, meaning 3% infected and 97% uninfected. The broad trend in Africa is in fact toward higher levels of monogamy, fidelity, and abstinence, and the trend in HIV prevalence is incrementally downward. We now see HIV prevalence decline in Kenya, Zimbabwe, Senegal and probably other African countries as well. These welcome trends have come about in spite of the paucity of programs aimed at promoting fidelity and abstinence. The United States is the first major donor to include such programs in global AIDS prevention. This initiative should be applauded and supported, not condemned as a ploy to impose "abstinence-only" on Africa or the world. To illustrate the importance of AB factors (Abstinence and Being faithful, from Uganda?s ABC prevention model, where C means Condoms), let us consider Rwanda, the first example in the Washington Post article cited above. Most experts assume that instability, civil war, genocide, breakdown of law and order?in short, social instability--would both predict a high HIV prevalence rate and would limit the ability of Africans to practice AB behaviors. Yet DHS and surveillance data from Rwanda amount to powerful evidence that these factors may have less impact than assumed. As we saw, a careful population-based survey recently found that Rwanda has a 3% national HIV prevalence, significantly lower than Uganda at present, and much lower that earlier UNAIDS estimates.

How is this possible? Well, according to a recent Demographic and Health Survey (DHS, considered the gold standard of surveys on sexual behavior in less developed countries), only 9% of males and 4% of females ages 15-24 report premarital sex in the past year. Likewise, only 4% of males and 1% of females of those sexually active, ages 15-49, report multiple partners in last year. Male circumcision (a protective factor, especially in heterosexually driven epidemics) is not practiced often in Rwanda. The DHS further found that condom use in Rwanda is at one of the lowest rates in Africa: 6% of males, and 1% of females, among sexually active adults ages 15-49, report condom use at last intercourse with any type of partner. There seems to be no explanation other than AB behaviors to explain why an impoverished east African population that has suffered great social instability should have a prevalence rate of only 3%, half that of Uganda?s rate at present.

Thus we have strong arguments to add the components of fidelity and abstinence (or ?delay of sex?) to AIDS prevention, not to replace the condoms-testing-drugs approach of the past 20+ years, but to and up with a balanced, comprehensive approach to AIDS prevention that provides more behavioral options for individuals, and more interventions for prevention programs. As I have been urging in recent conclusions to papers, I wish to stress that I am not arguing for shifting attention and resources away from those at high risk, including the powerless, oppressed, exploited, raped and abused. I am saying that it is inaccurate to characterize all Africans this way. Survey and biological data suggest that only minorities of Africans are in such situations. Thus we can no longer target all HIV prevention resources to minority groups. It is a tragedy that all-or-nothing thinking and polemics have dominated the AIDS debate to date and have deemed the only compassionate response one that targets the most oppressed and treats everyone as equally high-risk.

What has been missing in this bitter debate is a calm, even-handed, balanced viewpoint that recognizes that some resources clearly must be targeted to high-risk groups, while some resources must be directed to what survey and epidemiological evidence show are the majority of people. If Uganda, with very few resources in the early years of its response to AIDS, could design and implement a balanced and targeted ABC-plus program, surely the major donors with billions of dollars can do the same.

Remember, this discussion has been about African AIDS, and therefore about ?generalized? epidemics. HIV epidemics in America and Europe are somewhat different affecting certain high-risk groups, therefore a different approach may be called for. As this is going to press, the Washington Post ran an editorial on April 10 pointing to the importance of the article cited above showing lower HIV infection rates, and noting that the credibility of UNAIDS will suffer for being the primary source of overestimations in the past.

The writer is Senior Research Scientist at Harvard Center for Population and Development Studies, a member of the Presidential Advisory Council for HIV/AIDS, and on the board of AIDS.org.