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Misanet.com / IPS, 12 May - AIDS prevention strategies in Africa are doomed to fail if they continue to emphasise condom use at the expense of other factors, experts say. "Because of the over-emphasis on changing behaviour we are missing a lot," says Eileen Stillwaggon, a health and development economist at Gettysburg College in Pennsylvania. - Because in the United States and Europe behaviour change worked in stemming new infections, this model has been taken and applied to other regions without modification, she goes on. One of the central ideas in a series of papers written by Stillwaggon, who has worked in Tanzania and Zimbabwe, is that international AIDS policy is based on the mistaken preconception that the higher rates of transmission in Africa are primarily due to higher rates of sexual partner change. - In Africa and in similarly impoverished populations, however, biological factors that result from poverty play a determining role in the high rates of HIV transmission, Stillwaggon notes. "Failure to recognise these biological factors and to integrate them into a model for poor populations has led to prevention strategies that have failed and to the perpetuation of racial stereotypes." UN Population Fund (UNFPA) spokesman Alex Marshall endorses Stillwaggon's argument. "It says clearly what needs to be said. Generalisations in Africa have often been made on thin research and there are many, many factors involved in the spread of AIDS," he says. AIDS prevention policies in Africa are primarily focused on putting a barrier between HIV positive people and their HIV negative sexual partners rather than on improving general health and nutrition, even when the people expected to use condoms may be starving, according to Stillwaggon. Sub-Saharan Africa is the only region in the world to experience a decrease in calorie and protein supply per capita during the last three decades. It was also the setting for 18 of the 19 famines that struck the world between 1975 and 1998. A holistic AIDS prevention model, says Stillwaggon, would include condom distribution but also focus on beating malnutrition, diarrhoeal and parasitic diseases like malaria. These are rampant on the continent and reduce the body's immunity. Upgrading a declining health service infrastructure also ranks high among Stillwaggon's priorities. Some of the prevention methods are relatively cheap. For instance providing a person with a year's supply of vitamin A, iron and iodine in order to fortify his food supply and increase immunity would cost less than 10 condoms. Supplementing food with iron would cost about 20 cents per person per year, but neither African governments nor their donor partners are adequately addressing such basic prevention methods, Stillwaggon argues. Vitamin A deficiency weakens the bodies' immunity, including the skin and mucous membranes, which are particularly important in protecting the body from infections such as sexually transmitted diseases (STDs) and HIV. - I was under the false impression that this debate was behind us, says Debrework Zewdie, the World Bank's HIV/AIDS co-ordinator. "Across the whole southern African belt, HIV prevalence is very high because there is high population movement and migrant workers are exposed to prostitutes and they, in turn, pass it on to their wives." Zewdie says AIDS workers have learned during the last two decades that changing behaviour should be the central tenet of any sustainable prevention programme. But, she add, there is growing realization that other factors also are important. These include health education and improving women's position in society. Whether there has been a shift in approach to AIDS prevention is debatable. What is certain, however, is that the environment in Africa continues to provide a fertile breeding ground for the spread of AIDS. Poverty continues to rise and health facilities remain under-funded, partly due to cost-cutting measures implemented under structural adjustment programmes (SAPS) engineered by the World Bank. The water supply is poor and, where hospitals are present, they often lack basic antibiotics. To make matters worse, even the condoms are in short supply. UNFPA Executive Director Thoraya Obaid announced at a recent African AIDS summit in Abuja, Nigeria that funding for condoms and other contraceptives is at its lowest level in five years and is failing to meet current requirements. Next year, 950 million dollars will be required in this area and UNFPA has of late been beating the drum for more funding. "It's simple: You wear a condom, you don't get AIDS," says UNFPA's Marshall. "But we are not simply a condom-pushing agency. We believe in putting in place comprehensive health systems." - We have not succeeded - when I say we, I mean African governments, donors, and civil society - mainly due to a lack of resources, he adds. "SAPs have also hurt African health systems because health is often the first victim of public sector cuts, but the World Bank is beginning to realise that," he adds. The continent is home to 70 percent of the 36 million people infected with HIV/AIDS. Last year alone, another 3.8 million people were infected in sub-Saharan Africa, the largest number of any continent, and 2.4 million people died as AIDS emerged as the principal cause of death. The important question on how different the HIV/AIDS epidemic in Africa is from other areas remains largely muted, with AIDS prevention programmes focusing more on how different Africans are. Stereotypes of hyper-sexualised Africans abound, based on social science literature exhibiting lower standards of proof than would be required in publications on Europeans and North Americans, says Stillwaggon. In its 1999 Update on AIDS, UNFPA declared that "the problem is promiscuity" and this "underscores the primacy of cultural factors" in the HIV infection rate in Africa. But, how much sex would people in Botswana have to indulge in, barring other more specific conditions pertaining on the continent, to have infection rates that are more than 50 times those in the United States or 1,000 times more than in Cuba, asks Stillwaggon. Despite high incidence of unprotected sex in rich countries - evidenced by high STD rates in the United States, for example - there has not been a heterosexual AIDS epidemic in these countries. South African President Thabo Mbeki also has raised questions about the distinguishing characteristics of the AIDS epidemic in Africa, the dearth of solid research on the issue, and the role of poverty in the spread of HIV. The AIDS orthodoxy, however, has been vocal in dismissing him as having been co-opted by dissident AIDS scientists who believe there is no link between HIV and AIDS. By Gumisai Mutume, IPS
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