Studies Find Blind Spots in African AIDS Prevention

Sexual Culture, Focus on Drug Distribution Lend to HIV's Spread

In relatively prosperous Botswana, a fourth of adults have AIDS --among women in Francistown in their early 30s, the rate is 69 percent.

Post Johannesburg Bureau Chief Craig Timberg was online Friday, March 2 at 1 p.m. ET take questions on his article on faltering anti-AIDS efforts in southern Africa, where a permissive sexual culture and a focus on providing free medicine appear to be helping the disease spread.

The transcript follows.

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Craig Timberg: This is Craig Timberg, and though I'm sitting in Kampala, Uganda, at the moment, I'd love to chat to anybody about my story from Botswana today about how sexual behavior has driven the AIDS epidemic in Africa. For the record, I'm the Johannesburg Bureau Chief for The Post, and in that job write quite a bit about AIDS, which sadly is all around me in South Africa.

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Cambridge, Mass.: You say that the epidemic is spreading in Botswana, but the UNAIDS prevalence data shows that HIV prevalence rates have leveled off in the past four years. Taken with the increased life span of HIV-positive patients on therapy, this would mean that fewer people are becoming newly infected. This trend of lower rates is even more prevalent in Zimbabwe, where HIV prevalence rates actually are falling.

Craig Timberg: You make an excellent point that illustrates how complex it is to understand the dynamics of the epidemic based on available data. Here's the story: The UNAIDS reports, which were inflated for years in most countries in Africa (see a story I wrote from Rwanda about a year ago), have gotten much better recently -- and I also think it's fair to say that the epidemic in Botswana and in most of Africa has leveled off and may well be starting to declined. But the most important question for the future health of these nations is how quickly new infections are being created right now -- in that measure (called incidence), Botswana just about leads the world. And despite treatment, many Batswana still are dying of AIDS, just fewer than before.

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Fairfax, Va.: Thanks for the very interesting piece Craig. I couldn't help but notice the "judgment-neutral" language throughout your piece. The sexual behavior you describe (multiple, concurrent partners) would be considered "promiscuous" by most standards, yet you never describe it that way. Is that approach/philosophy embraced by public health officials in Botswana, and do you think that bypassing the use of "shame" to alter behavior is a healthy approach, or a missed opportunity? I don't mean to come off as a militant Bible-thumper, because I'm not. It's just that the crisis is so alarming and it seems that public health officials in Botswana need a new and more effective approach.

Craig Timberg: You are right that I seek to avoid making moral judgments about sexual behavior, especially in cultures other than my own. My impression is that the question of morality has greatly clouded the world's response to AIDS, both because some people were quick to condemn behavior they didn't like and, equally, others were so reluctant to be perceived as making moral judgments that they didn't give out necessary medical information that could keep people safe. So my philosophy is: People must understand a problem to solve it, and we owe it to Africans (and those whose judgments direct their response to AIDS) to give them the clear story, free of my morality or anybody else's.

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Washington, D.C.: Thank you for taking my comment. I have always thought that the way we fight AIDS in Africa makes no sense -- we just throw money at the problem. How can we go there and say that if you don't wear a condom you are going to die by the time you're 50? A lot of them are going to die anyway. We need to have the courage to say "your cultural lifestyle of female circumcision, abuse of women, and lack of education is causing your civilization to be destroyed" -- but in today's world making judgments is a bad thing. Throwing money at the problem wont solve it! Thank you.

Craig Timberg: Um, I agree that money is, at best, a necessary but insufficient condition for battling AIDS and many other problems. For the record, female circumcision is not so common in southern Africa, and the relationship between AIDS and either abuse of women or low education levels is tenuous at best. Africa is a tricky place, familiar in many ways but unfamiliar in many others. It takes time and preferably a decently long visit to begin to understand it.

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washingtonpost.com: How much of a role do the free AIDS drugs play in this problem -- do people in Botswana feel less pressure to be monogamous or use condoms because AIDS seems more survivable, even tolerable?

Craig Timberg: That's a really great question. I think it's clear that AIDS drugs, because they make people so much healthier for so much longer, have diminished the fear that may be a key driver of safer behavior. But my point in the story is that Botswana (and most southern African countries) never really tried hard enough to push a message that has worked in some places -- namely, stick with one sex partner and you probably won't get sick; have three and you probably will.

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Washington, D.C.: Hi Craig. I just returned from Durban, South Africa, and attended a community meeting regarding the urgent need for a variety of HIV prevention options, including microbicides. My first question is, why so you think more leaders encourage a no-grazing policy, like in Uganda?

Craig Timberg: I think the Western world and its big donors have gotten very fixated on the possibility of big-dollar high-tech fixes such as microbicides and vaccines, while neglecting things that (while uncomfortable to talk about like modifying sexual behavior) have shown some track record of working.

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Fairfax, Va.: You must have tough skin, being around AIDS all the time in South Africa. Does the situation there ever get to you? Does it affect your ability to unemotionally cover a story?

Craig Timberg: Sometimes, yes. I've known a few people who have died of AIDS, and a few others who I suspect have. What's crazy about this disease, however, is how relatively invisible it is in many societies. People don't look sick for 80-90 percent of the time they are carrying HIV, and with drugs and other treatment (for opportunistic infections) increasingly available, it's easy to overlook. I go looking for it, of course.

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Washington, D.C.: My theory on AIDS is that because of the vast efforts of governments and NGOs, the largest barrier to preventing the spread of AIDS is the connection between people and the world media. What I mean by this is that the only people who don't know about AIDS must be in the remotest reaches of the planet. Therefore the challenge isn't teaching those who are reachable, but is instead reaching those who are unreachable by any infrastructure, roads, radio, water, electricity, education.

Craig Timberg: Sorry, not true -- everybody knows about AIDS. The problem is that so much of what people think they know is wrong.

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Minneapolis: There are many who are championing the cause of awareness and prevention efforts for the AIDS pandemic in Africa. In your experience, which of these efforts and programs actually are having a positive effect?

Craig Timberg: That's a tough question. I think that awareness is an excellent thing, and there clearly is a gradual decline in stigma thanks to publicity and the courage of people with the disease who speak out, but rarely do I see prevention efforts on billboards -- or on the radio or TV -- that seem on target. Even here in Uganda, sadly, the things that worked 20 years ago are not terribly visible anymore.

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Freising, Germany: It sounds like all is not well in the land of Precious Ramotswe. I spent a couple of weeks in Maun and the Okavanga Delta a couple of years ago, and I managed to meet some of the locals who were involved in the tourism business, but I never had the sense that a crisis was occurring or building up. What have been the effects on Gaberone or Francistown regarding AIDS and the workforce or AIDS and the cultural aspect (nightlife, music, etc.)?

Craig Timberg: I don't get to either place often enough to measure the cultural impact. And Botswana is leading Africa in treating this disease with antiretroviral drugs, which are remarkably effective at making people live relatively normal lives for a long time. So the kind of massive deaths you saw there in the late 1990s and the early part of that decade have eased off to something more manageable. The problem, of course, is that HIV still is a sickness, and people still die -- you may recall in the story that Botswana has the second-highest death rate in the world. Not impressive given their relatively high level of development, good governance and health care.

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Washington, D.C.: Thanks, Craig, for this important story. Have you looked into how communities in the region are coping with children left behind by one or more parents, given the prevalence of the disease among so many people of child-bearing age? Do villages take them in? Are there grandparents left to care for them?

Craig Timberg: AIDS orphans are a massive problem in most of these sub-Saharan countries with high HIV rates, and I'm glad that many NGOs etc. are helping them, but it's worth remembering that rarely are African children dropped off at an orphanage. In most cases family members (of increasingly extended families nowadays) take children in. The sense of family here is both deeper and wider than anything I've experience before, so though it's horrible to lose a parent -- or lose both parents -- children often end up with somebody they know.

That said, I've run into plenty of grandmas who are raising a dozen young grandchildren because their own children have died of AIDS. And sadly there also are plenty of households headed by 12-year-olds. Sometimes younger too.

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washingtonpost.com: Recently there was a story about Gambia's president claiming that an herbal concoction he had invented was a sure-fire cure for AIDS. How prevalent are these sorts of "homeopathic" remedies in Africa?

Craig Timberg: Very common, but in many places they aren't seen necessarily as alternatives to sensible treatments such as antiretroviral drugs -- most Africans I know at least occasionally will seek traditional medicines, and if those don't work they see a doctor (if there's one accessible). Of course that story from Gambia was horrible. Wish I knew what could be done about it.

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Washington, D.C.: That's why a zero grazing policy has to come from their leaders, their presidents. So why isn't that happening? One South African woman told me that they resent Westerners thinking Africans have too much sex, but your article kind of proves that they do.

Craig Timberg: This whole question of sexuality is deeply fraught pretty much everywhere, and of course it's triply fraught when you have outsiders (especially outsiders whose countries have not always acted out of the purest of motives) telling people how to have sex or with whom. This is personal stuff.

In the places where a sexual fidelity message worked, especially Uganda in the late 1980s and early 1990s, it was Africans speaking to other Africans about these very personal and sensitive matters, not Westerners.

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The 700-pound gorilla: Among others, former President Carter has said in the past that our view of dealing with Africa is compromised by our unending struggle with race. Your comments?

Craig Timberg: Everything we do is compromised by our unending struggle with race, in the U.S. and in Africa. Any lens you take to a problem -- race, gender, age, profession, you name it -- has the capacity to distort. Given our horrendous racial history and the West's even-more-horrendous history in how we've viewed and treated Africans, you can't expect that suddenly we'll be seen as somehow beyond our many hang-ups on the subject.

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Madison, Wisc.: The current administration has committed the largest funding ever to address the pandemic of AIDS in Africa. Has this funding amounted to more than a manifestation on paper only? If so, how are the funds being used?

Craig Timberg: President Bush's financial commitment to fighting AIDS in the developing world is, without question, historic in its scope and ambition. The main thrust has been to drive much wider availability of antiretroviral drugs, which have saved many lives.

Now, that program does some things that have been problematic, including (see a story I did in June 2005) exaggerating their accomplishments, but they seem to be a net plus in fighting AIDS. Researchers on the U.S. government payroll also have made some of the important discoveries about the connections between HIV and sexual behavior.

Many Africans will tell you that the Americans are pushy, and the reliance on only name-brand drugs rather than generics has won no friends. In addition their focus on abstinence programs seems to have only marginal benefits in slowing the spread of HIV. Young people in some cases are delaying sex, which is good in preventing the disease, but it's not clear they are over the long term less likely to catch it. In addition, once people start having sex, they don't generally stop and become abstinent.

That's a long answer, but it's a complicated program with lots of facets, which I'm only touching briefly on here.

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Washington, D.C.: Have you read Dr. Eileen Stillwaggon's book, "AIDS and the Ecology of Poverty"? I heard her speak and it really changed the way I thought about AIDS. So much of the debate on AIDS prevention is on condom vs. abstinence-only, but that limits the discussion to the sexual and moral arena only. Stillwaggon's book highlights that the diseases of poverty (worms, anemia, malnutrition, parasites, and many more) that are all-too-common in sub-Saharan Africa (and rare in wealthy nations) all feed into making people more susceptible to HIV. They cause lesions in the vagina, attack the very immune cells that best fight HIV and weaken the body to fight off any infection -- including HIV. It's interesting that what is at base a health crisis is fought so much with sexual and behavior-change modification, rather than with health improvements that would make people less likely to become infected on any given encounter with the virus. What do you think?

Craig Timberg: I haven't read her book, but I'll share a couple of perhaps underinformed impressions on the subject. The first is that the connection between poverty and AIDS is far more tenuous than many people think -- I've spent time in Darfur and Somalia, and it's hard for me to think of poorer places, but they have very low levels of HIV. In South Africa and Botswana, poverty is much less severe and pervasive, yet HIV levels are far higher. So something is not quite right with the poverty equals AIDS equation. What does seem to be a major factor, however, is income inequity: When you have a few people with money and nice cars amid lots of poor people (especially women), there clearly is a force pushing people into more-reckless behavior.

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Freising, Germany: How is the current situation in South Africa regarding AIDS? Has the beetroot cure officially been denounced?

Craig Timberg: The South Africans have come a long way in the past six months in distancing themselves from the more worrisome elements of their national response to AIDS, and the health minister who made the beetroot and garlic stuff famous no longer is health minister as of Monday (see story Tuesday). She is in fact quite sick, and has been replaced on an interim basis, but even before that happened the powers that be in South Africa essentially had taken the AIDS portfolio away from her. It's still a complicate issue there, clouded by lots of stuff, but I can tell you there are forces in that government who really want to make their AIDS program top-notch.

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Washington, D.C.: Twenty years ago they said it would be 20 years before they had a vaccine for AIDS. Where are they on delivering on the promise they made? Were they too optimistic, or have they lost focus?

Craig Timberg: Too optimistic. HIV is an amazingly diabolical disease -- every few months I learn something new that makes my jaw drop. I get the impression that the vaccine researchers have had a similar experience. It just has turned out to be amazingly hard to craft an effective vaccine. One is at least a decade away, which is why other approaches need to be considered while the high-tech fix brews in the lab.

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Washington, D.C.: Obviously, married couples are not going to suddenly abstain, and married women in Africa (or anywhere, for that matter) can't demand that their husbands use condoms. This is why microbicides, in a variety of forms, are crucial. You refer to microbicides and vaccines as high-tech, high-dollar solutions, but don't you think investment in both is necessary in addition to behavioral changes?

Craig Timberg: Um, that's a tough one. I think a microbicide would be a very valuable thing if the scientific dilemmas can be sorted out, but if you don't believe women can demand condoms (some clearly can, by the way), then are they going to be able to interrupt their husband/boyfriend/etc. to take a moment in the bathroom and insert a gel? we don't know the answer to that question yet. Lots of things that look good on paper haven't slowed the spread of HIV to a meaningful extent.

As for a vaccine, yes, it would be great. But the vaccines they are talking about would be, at best, maybe 50 percent effective - which is less effective than circumcision (a readily available technology, though clearly a more intrusive one) at preventing HIV.

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Belmont, Mass.: I have read Stillwaggon's work, and with all due respect, I agree with your answer, Craig. Most of the countries in the world with the highest rates of HIV (which are mostly in southern Africa) are not the poorest countries in Africa, and very few people in Botswana, for example, have "worms" or compromised immune systems because of malnutrition, etc. It's all about the (sexual) behavior, stupid! But people like work like hers because it's a lot less uncomfortable to talk about hunger or worms being the cause of AIDS (hey, didn't South Africa's President say similar things?), than to talk about sex.

Craig Timberg: Hmmm. There's something strangely familiar about that last comment from Belmont, Mass. Is that by any chance the Harvard researcher quoted in today's article?

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Washington, D.C.: Thanks for your great work at understanding this plague without stigmatizing those caught in it. I'm struck by the final paragraph in your article, which states that a 2004 government study, presumably in Botswana, revealed that 50 percent of the respondents were aware that abstinence could stop the spread of HIV. What do you make of that, with respect to people's understanding of what they're up against and opportunities for improvement?

Craig Timberg: Thanks for your very nice note. And to answer your question, my impression is that Africans are overwhelmed with information on AIDS but not nearly enough that is useful. During interviews, I periodically flip over my notebook and scratch out what a sexual network looks like. I'll draw a circle for the person I'm interviewing, two or three lines to other circles for their partners, two or three lines to each of their partners, and so one. After about a minute, without fail, they startle, their head pitches back. So if the prevention campaigns were working, wouldn't everybody in a high-infection country already know this stuff?

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Craig Timberg: It seems the questions have run out, so I'll sign off here -- please keep reading, and I'll keep writing.

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