AFRO-NETS> Mbeki vs. the AIDS Establishment... (9)

["Robert S. Pond" <rpond@usaid.gov>]

Mbeki vs. the AIDS Establishment... (9)
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The Durban conference has demonstrated that there are plenty of 
strong feelings to go around. Given the disastrous impact of AIDS, 
anger is fitting, even unavoidable. It would be more helpful, how-
ever, if more of this acting up were directed towards preventing fur-
ther transmission of HIV. What more can we do to increase condom use, 
to treat STDs, to reduce the number of sexual partners, to reduce un-
safe injecting practices?

Effective means to control this epidemic already exist. Nevertheless, 
as noted by Martha Ainsworth and Waranva Teokul in a recent issue of 
The Lancet (Breaking the silence: setting realistic priorities for 
AIDS control in less-developed countries -- The Lancet, 1 July 2000; 
pages 55 to 60) 

"... there are few examples of national AIDS control programmes that 
have had an impact on the epidemic.... governments are reluctant to 
act. AIDS prevention treads on sensitive topics that neither govern-
ments nor the public are eager to discuss: sexual behaviour, marital 
fidelity, prostitution, sexual orientation, and injecting drug use. 
Every country has engaged in denial; leaders typically assert that 
the moral values of their society would not permit transmission of an 
agent such as HIV that is associated with risky sexual behaviour, ho-
mosexuality, or injecting drug use. But behaviours that spread HIV 
exist in every country. Denial merely delays the response and worsens 
the epidemic." 

"Even when denial is conquered, governments can hesitate to undertake 
the interventions most likely to have an impact. The key to stopping 
the AIDS epidemic is to bring the reproductive rate of HIV (the aver-
age number of susceptible people infected by an infected person over 
his or her lifetime) to below one. When that happens, the epidemic 
will eventually die out. The most efficient way to constrain the 
spread of HIV in the whole population is to prevent transmission 
among those for whom the reproductive rate is very high-- i.e., those 
with the most sexual partners or who share unsterilised injecting 
equipment. However, there is no political constituency for programmes 
perceived to help people at the margins of society. Once the general 
population feels at risk, there is political pressure for other pro-
grammes that are thought to benefit the average citizen, such as safe 
blood supply and treatment to prevent mother-to-child transmission. 
These programmes have important benefits but virtually no effect on 
the course of an epidemic fuelled by sexual transmission... Treatment 
programmes do not require public discussion of taboo subjects, and 
when people get sick there is a constituency that will demand treat-
ment. But by then it is too late to prevent an epidemic. Both early 
and late in an AIDS epidemic, the constituency for prevention tends 
to be weak."

If we are angry -- and we have every reason to be -- shouldn't we di-
rect much of our energy at overcoming the denial and squeamishness 
and personal behaviours responsible for further spread of HIV?

Bob Pond, MD
Accra, Ghana 
mailto:rpond@usaid.gov

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