Los Angeles Times - August 3, 2008
Helen Epstein**

What future do the organizers of this event envision? One of them, the UNAIDS program, recently presented a possible scenario in a promotional video for its new AIDS2031 project, which aims to "change the face of AIDS by 2031" -- the 50th anniversary of the discovery of the disease. The scene opens with a group of kids in a sleek, modern classroom working on transparent computers. A black teenager in a school uniform shyly excuses herself and goes out to a bank of vending machines in the hall, where she selects a red-ribboned box of anti-retroviral drugs.

There is no AIDS stigma in this fantasy world, nor are there barriers to healthcare or any dangerous drug side effects. But there is also no cure or prevention. In other words, the future belongs to the pharmaceutical companies.

We aren't told where this scene takes place, but if this is supposed to be Africa, I doubt we'll getthere by 2031. Public health officials once hoped that AIDS medicine would make the disease less frightening and that this in turn would reduce stigma and denial and encourage behavior change. This has not happened, probably because, unlike diabetes or asthma, HIV can derail relationships.

In Zambia, for instance, Human Rights Watch has documented what happens to women when they bring their medicine home from the HIV clinic. These bottles are often the only modern object in the house, and they become potent symbols of infidelity and the spark for domestic violence. Some women hide their medicine in aspirin boxes or in bags of cornmeal. "Once [my husband] threw away my medication ... into the pit latrine," one woman explained. "He said that he did not want to see these medicines in his house."

Such reactions may help explain why nearly half of all Africans who enroll in AIDS treatment programs are no longer taking the drugs two years later, and why for every African receiving AIDS drugs from an internationally funded treatment program, as many as five more may become infected.

Twenty-seven years and 17 gigantic conferences into the epidemic, we have reached an impasse. To find a way out, I suggest that we look to the past, not the future. AIDS is not the first sexually transmitted disease to ravage Africa. Syphilis and gonorrhea were introduced into African populations by Europeans during early colonial times, and by the early 20th century, so great was the toll of infant mortality, sterility, disease and death from these diseases that one East African tribe described itself as a "dying people."

The colonial authorities vigorously debated the causes of this calamity and how to deal with it. Many missionaries attributed it to the shock of civilization, which disturbed the moral order of tribal life. They tried to help people change their behavior by delivering community health talks, pamphlets and sermons on virtue. Many African elites agreed; even Ugandan dictator Idi Amin took time out from murdering Cabinet ministers and raiding the treasury to lecture the nation on moral rectitude.

Medical doctors tended to disagree with this approach, pessimistically attributing the scourge of venereal disease to what Cambridge University historian Megan Vaughan called "the enduring evils of primitive society." They maintained that behavior change was impossible and instead promoted medical treatment, however rudimentary. (Historian Michael Tuck of Northeastern Illinois University later discovered that by the 1950s, some Ugandan hospitals were dosing every pregnant woman with mercury, which was state-of-the-art syphilis treatment in the colonies in those days. The long-term effects on the children exposed to this treatment are not known.)

Ultimately, the doctors won this debate. Medical treatment for venereal disease improved, and public health officials in recent years have generally eschewed cultural or behavioral approaches as moralistic and ineffective.

This was fine until AIDS came along. But AIDS is different, because the drugs we have cannot cure the disease, they don't work for everyone, some have severe side effects and administering them costs a fortune in relation to the health budgets of most African countries. They also do nothing to mitigate the disastrous effects of AIDS on families, relationships and communities.

Something else is clearly needed. You can't fight AIDS without medicine, but you also can't fight AIDS with medicine alone.

In the 1980s, Birgitta Larsson, a young Swedish historian studying a successful syphilis campaign in the Kagera region of northern Tanzania, discovered that behavior can change. In the 1940s, she found, a powerful religious revival drew thousands of East Africans into the Protestant church and radically changed gender relations, bringing about a new sense of equality between men and women.

Oddly enough, this revival was led in part by a generation of women who had made their fortunes as prostitutes in the railway towns of Kenya and Uganda. When they returned to Kagera, these women helped other poor women escape abusive marriages, and they paid tuition for legions of children. Some former prostitutes even became church elders.

For the first time, women -- normally silent in the presence of men -- stood up in church and addressed large congregations. They urged men to stop philandering and squandering all their money on beer. Syphilis rates dropped steeply.

During the 1990s, a small number of American and British researchers also recognized that sexual behavior can change. They studied places where HIV infection rates had fallen, and discovered that from the market towns of Uganda to the brothels of Thailand to the gay enclaves of San Francisco, significant numbers of people were taking on fewer sexual partners. Universal monogamy is an impossible goal anywhere, but even small reductions in the fraction of people with multiple sexual partners can have a dramatic effect on the epidemic. Where HIV rates dropped, relationships also changed. In the U.S., gay men, who 30 years ago sneered at bourgeois heterosexual morality, began clamoring for the right to marry. In Uganda, rape laws and property rights for divorced women were strengthened.

Partner reduction works especially well in Africa because of the nature of sexual behavior there. HIV spreads rapidly not because Africans have so many sexual partners but because African men and women are more likely than people elsewhere to have more than one long-term partner at a time.

Ugandan officials realized this relatively early and put in place a campaign urging "zero grazing" -- meaning, roughly, "reduce your partners." It worked. Partner reduction did occur, and HIV infection rates fell by more than 60%.

But when researchers presented their findings on these examples of behavior change at conferences and in academic journals, all the big agencies working on the epidemic at the time, including the UNAIDS program, the U.S. Agency for International Development and the European Union, already determined to pursue a medical approach, ignored them. Reports were shelved or never made public, and in one particularly egregious case, the results of a key study on partner reduction in Uganda appear to have been distorted to make it seem as though partner reduction had not occurred. Meanwhile, researchers who understood the primacy of partner reduction early on saw their careers falter.

It has become increasingly clear that those researchers were right after all, and so, to some extent, were the missionaries.

Cultures do change, especially when it is a matter of survival. If they didn't, no medicine could possibly save us.

Helen Epstein is the author of "The Invisible Cure: Why We Are Losing the Fight Against AIDS in Africa."

**Reproduced with permission from the author.
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