(Alex Robbins for The Washington Post)
March 9, 2012

Optimism has never run higher that the AIDS epidemic can be defeated. Effective medications have reached millions of people worldwide over the past decade, and new research also suggests that even more investment in distributing HIV drugs mighthelp slow the disease’s spread. Secretary of State Hillary Rodham Clinton spoke recently of an “AIDS-free generation” on the horizon.

But for those living in the hardest-hit parts of Africa, there are risks in the policy shifts underway in Washington and other Western capitals. The rising enthusiasm for providing more medicines threatens to come at the expense of promising initiatives for preventing HIV infections in the first place — initiatives that could save many lives, with less money.

Ambitious treatment efforts and smart prevention programs are, of course, not inherently at odds. But especially in an era of fiscal constraint, these two goals could come into conflict. The result, wasteful in dollars spent and lives diminished, would represent only the latest misjudgment by powerful donor nations such as the United States, which still struggle to understand the root causes of an epidemic that has spread most widely in weaker, poorer nations.

In Africa, the most important cause of the epidemic is sexual cultures in which it’s not unusual for people to have more than one partner in the same week or month. Sound strategies for stemming the spread of HIV would pay particular attention to those places where Africans themselves — in nations such as Uganda and Zimbabwe— have reversed the epidemic and saved millions of lives by changing sexual behavior.

Failing to address this is a bit like targeting lung cancer mainly through more chemotherapy, while doing little to curb high smoking rates.

HIV was born in a remote central African forest near the beginning of 20th century, amid the disastrous intrusions of Western co­lo­ni­al­ism. Broad social changes — the rise of cities, the undermining of traditional values, the creation of modern transport routes — helped spread a host of sexually transmitted diseases. No one knew it at the time, but HIV was among them.

The growth of sex work is often cited as the key element of the epidemic. But even more consequential was a shift away from traditional polygamy — common across much of Africa but scorned by Christian missionaries — toward more informal relationships. In these, men often had one wife but maintained secretive and less permanent relationships with other women. And with their husbands often spending months at a time working at far-off mines, plantations or factories, wives increasingly took sex partners outside of marriage.

The changing sexual mores alarmed colonial officials, who worried about the future of the workforce as birth rates plunged from the ravages of syphilis and chlamydia. In the Belgian Congo, a levy was imposed on all single women to encourage monogamous, Christian-style marriages. Instead, a new, freewheeling sexual culture took hold, one efficient at spreading disease.

Another factor was also crucial. The ancient ritual of circumcising boys was as essential to most African societies as it was to Jews and Muslims; on most of the continent, nearly all men were circumcised. Though no one knew it at the time, the simple absence of foreskins — the parts of men’s bodies that were often infected — was a powerful drag on HIV’s spread. Yet some ethnic groups, mainly in southern and East Africa, did not circumcise, and others saw the tradition fade away, often under the influence of Westernization.

Post-colonial sexual practices and low circumcision rates combined to create an explosion in the AIDS epidemic. Perhaps one out of 100 adults in colonial Congo, where men were circumcised, contracted HIV. In countries such as Zimbabwe and Botswana, where few men were circumcised, the virus would eventually infect about one in four adults.

President George W. Bush’s $15 billioncommitment to fighting the epidemic overseas was a turning point in the drive to get AIDS medicine to nations that couldn’t afford it. President Obama has overseen an expansion of funding and a focus on providing drugs and other biomedical tools for fighting the epidemic.

Of course, AIDS drugs do not cure the disease; recent estimates suggest that even well-treated patients may have their life spans shortened by about a decade. Still, these treatment initiatives allow many people with HIV to live much longer, better lives.

On the prevention side, however, the United States and other donors have fallen short. Part of the problem has been the polarized nature of AIDS politics, with its battles over condoms vs.abstinence. Few outsiders — not the U.S. government, the United Nations, religiously based charities, or even the Bill & Melinda Gates Foundation — have made impressive gains in preventing the spread of HIV among adults, despite massive investments of money and political will. (The steepest drop in HIV rates during the Bush years was in Zimbabwe, a country that received far less foreign aid than its neighbors.)

For AIDS experts and policymakers, the long-standing frustration with donor-funded prevention campaigns has fed the excitement about new science on the power of drugs to slow the spread of HIV. People treated effectively are much less likely to pass the virus to others, and healthy people given a daily, low-dose regimen of medicine are less likely to contract HIV.

These breakthroughs have raised hopes that further widening access to AIDS drugs is the key to reversing the epidemic’s march. The Lancet medical journal editorialized in May that it was time to consider shifting funding from AIDS programs that seek to alter sexual behavior toward those that expand access to drugs.

Western policymakers call this approach “treatment as prevention,” while some activists go further, saying “treatment is prevention.”

But the relationship between treating AIDS and preventing HIV infection is hardly so simple, and the enthusiasm inspired by “treatment as prevention” already is sapping resources and energy away from some other initiatives for fighting the disease.

Clinton’s formulation, in a November speech, was telling. She rightly celebrated the gains in using drugs to prevent the transmission of HIV from mothers to their babies, and she noted the urgent need to bolster programs offering safe, voluntary circumcision to men. The third key element in her push for an “AIDS-free generation” was expanding treatment, in the hope that this will lead to fewer infections. Yet many of the places with the most successful treatment programs — Australia and San Francisco, for example — have seen only relatively small declines, if any, in rates of new infections.

A key reason is that whatever protection the drugs confer often is offset by what social scientists call “risk compensation” — a lessening of the fear that might inspire more careful behavior. The same force leads some people wearing sunblock to spend more time lying on the beach, and some people wearing seat belts to drive faster.

It’s also not clear that, even with massive new investments, the drugs can reach enough people to cause meaningful declines in HIV’s spread. Even in the United States, with a medical system far superior to any in Africa, most people with HIV are not in treatment or are not taking drugs consistently enough to suppress the virus to the point where the risk of transmission is significantly reduced.

When debating how to prevent HIV, liberals like to talk about condoms, while conservatives often talk about abstinence. Yet the track record for both ideas has been disappointing. Reported condom usage rates soared in many parts of Africa years ago, but HIV infection has remained high, probably because they are not consistently used in ongoing sexual relationships. Abstinence programs have prompted some teens to delay sexual activity, but only briefly, typically pushing the risk into the future by a year or less.

Both sides often fail to emphasize what some Africans in the hardest-hit countries have brought up when discussing how to stop the AIDS epidemic: having fewer sexual partners.

Africans know that polygamy is part of their culture; Swaziland’s king, for instance, has 14 wives and counting. They also know that modern variants of polygamy, in which both men and women have a spouse and another partner or two, are even more common. The connections between such practices and the spread of sexually transmitted diseases are unavoidable.

Virtually every place in Africa that has seen a major drop in HIV infections also has seen a significant decline in the frequency of multiple sex partners. Uganda in the late 1980s had a famously effective program, called “Zero Grazing,” in which cultural and political leaders urged people to not stray from their primary relationships. But there have been other successes, typically led by churches, popular singers and occasionally even politicians.

The message is easy to grasp and, to many Africans, more appealing than admonitions about abstinence or condoms. Of course, many already have monogamous relationships, or in some cases none at all, because of the fear of AIDS. But if those with multiple relationships pare down their number of partners, the sexual networks that spread disease will start to break apart, and the pace of new infections will slow.

Only recently have Western donors begun focusing on the power of partner reduction to reverse HIV’s spread and supporting local efforts to promote it.These efforts have included a South African soap opera exploring the dangers of sexual networks, a Mozambican initiative that used local slang to warn “To Walk Outside Is Very Risky!” and a Kenyan program that sent text messages to help people understand the perils of having multiple partners.

Keeping sexual behavior at the center of the conversation about preventing HIV is essential to reversing the spread of the virus. Only in this way can the vision of an “AIDS-free generation” someday become reality.

timbergc@washpost.com

Craig Timberg is The Washington Post’s deputy national security editor. Daniel Halperin is an epidemiologist at the University of North Carolina. They are the co-authors of “Tinderbox: How the West Sparked the AIDS Epidemic and How the World Can Finally Overcome It.”

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Craig Timberg is a national technology reporter for The Post.