Africa, the West, and the Fight against AIDS By Helen Epstein June 6, 2007 UCLA School of Public Health

The countries in Africa most affected by AIDS

Adult HIV Prevalence Worldwide Source: UNAIDS 2004: 2004 Report on the Global AIDS Epidemic This map does not reflect a position by the UN on the legal status of any country or territory or the delimitations of any frontiers.

Adult Prevalence Projections, to 2030

“HIGH RISK GROUP” MODEL ACCORDING TO “HRG” MODEL, THE EXTENT OF SPREAD OF HIV IN A POPULATION WILL DEPEND ON: FRACTION OF PEOPLE IN “HRG”s (CSWs, MIGRANT LABORERS, ETC) AND THE DEGREE OF “MIXING” BETWEEN HIGH AND LOWER RISK GROUPS.

Who has HIV? (Zambia)

Frequency of concurrent and suspected concurrent relationships. Redrawn from Carael M. “Sexual Behavior” Chapter 4 in Cleland and Ferry 1995

Concurrency Slides By Stewart Parkinson

Effects of Concurrency HIV Negative Male HIV Positive Viremic Male HIV Positive Non-Viremic Male HIV Negative Female HIV Positive Viremic Female HIV Positive Non-Viremic Female

Concurrency December

Concurrency January

Concurrency February

Concurrency March

Concurrency April

Concurrency May

Concurrency June

Concurrency July

Concurrency August

Serial Monogamy December

Serial Monogamy January

Serial Monogamy February

Serial Monogamy March

Serial Monogamy April

Serial Monogamy May

Serial Monogamy June

Serial Monogamy July

Serial Monogamy August

WHERE DID MARTINA MORRIS GET THE IDEA THAT LONG TERM CONCURRENCY WAS DRIVING THE HIV EPIDEMIC IN AFRICA? UGANDAN DOCTORS……

Premarital sex: % of never married women years old who had sex in the past year ORC Macro Early 90s/late 80s Mid 90s Late 90s/early 2000s UgandaZambia Cameroon Kenya Zimbabwe

Condoms? Since the beginning of the HIV/AIDS epidemic, a considerable amount of programmatic effort has focused on condom promotion… Reported condom use last higher-risk sex for ages (UNAIDS, 2001 & BAIS 2001) Given that Botswana has for some time featured some of the highest rates of (self-reported) condom use in the world, why isn’t Botswana hailed alongside of Uganda as a major success story? Percent

The condom quandary Condom sales HIV Prevalence

C is for condomize 1 Shelton, et al (2004) “Ever” use of condoms among adults increased from 15 to 30 percent in men, and from 7 to 20 percent for women, from 1989 to Botswana may have the highest levels of reported condom use in Sub-Saharan Africa Uganda:Botswana:

“CONSISTENT” CONDOM USE PROTECTS, BUT NOT TOTALLY….(PROBABLY BECAUSE THE USE IS NOT AS CONSISTENT AS IT SHOULD BE.)

Consistent condom use by type of partner, Zambia 2003

B is for be faithful Uganda coined (from agricultural tradition) the “zero- grazing” approach to prevention 1 Shelton, et al (in press) 3 BAIS (2001) 2 UNAIDS (2002) Uganda: Botswana: Uganda 1 :

Early successes: Uganda and “zero grazing”

From Warren Winkelstein Jr et al, “The San Francisco Men’s Health Study: Continued Decline in HIV Seroconversion Rates among Homosexual/Bisexual Men.” AJPH November 1988 vol 78, pp

Early successes: Thailand and “100% condoms”

The HIV rate is beginning to decline in several African countries, including Kenya, Zimbabwe and I think maybe Malawi and Zambia. But—why did it take so long? And why is the HIV rate still so high in southern Africa?

IMPLICATIONS FOR PREVENTION? AFRICAN PEOPLE NEED TO KNOW WHERE THEIR RISKS ARE COMING FROM—IE NOT JUST FROM “PROMISCUOUS PEOPLE.” MY HYPOTHESIS IN INVISIBLE CURE IS THAT AN UNDERSTANDING OF CONCURRENCY NETWORKS COULD HELP REDUCE THE STIGMA AND DENIAL SURROUNDING THE EPIDEMIC IN MUCH OF SOUTHERN AFRICA, AS IT DID IN UGANDA, AND THIS COULD FOSTER A MORE PRAGMATIC RESPONSE TO THE EPIDEMIC.. UGANDANS DID KNOW EARLY ON THAT HIV WAS SPREADING THROUGH CONCURRENT LONG TERM RELATIONSHIPS ALTHOUGH THEY DIDN’T USE THE WORLD “CONCURRENCY.” UGANDAN GOVERNMENT CAMPAIGNS MADE IT CLEAR THAT EVERYONE WAS AT RISK, NOT JUST SEX WORKERS AND PROMISCUOUS, ‘IMMORAL’ PEOPLE. THIS HELPED ROUSE A MORE COMPASSIONATE, OPEN REPONSE TO THE AFFLICTED, AND A GENERAL RECOGNITION THAT AIDS WAS NEITHER AN ACT OF GOD OR A PUNISHMENT FOR SIN, BUT A TERRIBLE DISEASE THAT NO ONE DESERVES. TOO MANY HIV PREVENTION PROGRAMS HAVE DIVIDED PEOPLE: HIV POS FROM HIV NEG, MORAL FROM IMMORAL, YOUNGER PEOPLE FROM ELDERS, MEN FROM WOMEN. WHAT WE NEED ARE MORE PROGRAMS THAT BRING PEOPLE TOGETHER: WOMEN’S RIGHTS PROGRAMS, MICROFINANCE PROGRAMS, ORPHAN CARE PROGRAMS, HOME BASED CARE PROGRAMS, ETC.