The Wall Street Journal - September 15, 1999
Michael Waldholz, Staff Reporter of the Wall Street Journal

A new study that tested 8,000 men and women randomly selected in four African towns found that in two of the towns -- one in Kenya and one in Zambia -- between 15% and 23% of girls ages 15 to 19 were infected by HIV, the virus that causes AIDS. The infection rate among similarly aged boys was only about 3% to 4% in those two towns, strongly suggesting young girls are contracting HIV from older men. Indeed, the rate of infection in men over the age of 25 was found to be between 26% and 40%.

For several years, health officials have warned, based on anecdotal surveys, that sex between older men and younger girls -- combined with a high incidence of sexually transmitted diseases such as genital herpes and syphilis -- was making teenage girls in some communities especially vulnerable to HIV. But the new data, presented yesterday at the 11th International Conference on AIDS and Sexually Transmitted Disease in Africa, are the strongest confirmations yet that HIV is exploding among very young women, even in women who report having had only one or two sexual contacts.

Peter Piot, executive director of the Joint United Nations Programme on HIV/AIDS (UNAIDS), which helped fund the study, called the new data "extremely shocking." If a similarly high rate of infection were found in the U.S., he said, "a national state of emergency would be declared." Dr. Piot added: "The fact that the young women are getting HIV from older men shows us where the problem is." But he added, "it also shows us how very difficult it will be to attack this problem."

The sheer breadth of the AIDS crisis is daunting in sub-Sahara Africa, where two-thirds of the world's 33.4 million HIV-infected people live and where the infection rate is rising by 20% a year. Last year, an estimated two million Africans died from AIDS, making the disease the leading cause of death among Africans for the first time.

The new study, also funded by the World Health Organization, is expected to force some policy changes from governments that have been slow to acknowledge and address ingrained sexual behaviors that put young women at high risk. The data, compiled in smaller towns outside big cities, "show us there has been a dramatic shift in the epidemic," requiring a change in priorities, said Nkandu Luo, Zambia's Health Minister.

In the Zambian town of Ndola, one of the four test sites, researchers found the rate of infection among teenage, unmarried girls was almost one in five. Dr. Luo said her government has focused most of its prevention and education efforts in urban centers where infection rates had been highest, but that such efforts must now be targeted to "forgotten" areas. "We must quickly invest our efforts to educating young girls in these areas," she said in a telephone interview from the conference, which is being held in Lusaka, Zambia.

'Outside Investments'

Dr. Luo said Zambia will need "outside investments" from international organizations and countries to help it carry outreach programs into rural areas where travel can be difficult.

The data is expected to draw the attention of African leaders to one of the many disturbing trends in the AIDS epidemic, which is ravaging parts of central and southern Africa. But some public-health activists say they're angry that no national leader from any African country attended the conference, not even Zambian president Frederick Chiluba, to hear about the new findings first hand. (Dr. Luo, who is also a member of Zambia's parliament, declined to comment on this.) "Finally, at least, we have some cabinet ministers attending," the conference, said UNAIDS's Dr. Piot, noting that African leaders have been slow to place AIDS at the very top of their agendas.

The new study was first organized in 1994 to investigate why some parts of sub-Saharan Africa have higher rates of infection than others. In a six-month period at the end of 1997 and the beginning of 1998, researchers tested 1,000 men and 1,000 women between the ages of 15 and 49 in Ndola and Kisumu, Kenya, where infection rates are high. They also tested similar numbers of people in Cotonou, Benin, and Yaounde, Cameroon, where rates are lower.

Not surprisingly, the researchers found higher rates of sexually-transmitted diseases (STDs) in the towns with high rates of HIV infection. STDs can cause lesions that can foster HIV infections. In all four towns, genital herpes and syphilis, which create open sores, were strongly associated with a higher risk of HIV. The study also suggested, for reasons that aren't clear, that young girls seemed to be especially susceptible to becoming infected with only a few exposures. The researchers believe that being infected with an STD makes them vulnerable. Almost 50% of the 15- to 19-year-old girls in Kisumu and Ndola had been exposed to the herpes virus, and 16% had syphilis.

'An Emergency'

But the researchers were surprised to find that one reason the rates may be lower in Cotonou and Yaounde is that almost all men there are circumcised, while very few men are circumcised in Ndola and Kisumu. Ann Buve of the Institute of Tropical Studies in Antwerp, one of the study's lead authors, said encouraging circumcision isn't the most practical solution, although the results do strongly suggest that circumcision may help slow the spread of STDs and HIV. Instead, she said, the study's strength was simply in showing that "for millions of young African girls in their early teens, this is an emergency" and that for them "prevention efforts can't wait."

Rosemary Musonda, of the Tropical Disease Research Center based in Ndola, who helped run the study, said house-to-house interviews disclosed that many poor young girls were having sex with older infected men for "socioeconomic" reasons -- often engaging in sex in exchange for gifts or for money to buy food, clothes, or even school supplies. Dr. Musonda said the men often are attracted to the younger girls because the men believe they are less likely to be infected than sex workers or other older women. "We have to break through to our young girls. We have to empower them and we have to educate our men," she said.

Dr. Musonda said some African governments have been reluctant to promote sex education -- such as aggressively encouraging condom use and explaining the risk of infection from even casual sex -- to girls as young as 10 to 14 years old because that might be seen as condoning or promoting sex. "But the data show these girls are already having sex," she said, "so we must help them learn how to protect themselves."
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