Fighting The Disease: What Can Be Done

Can AIDS be stopped in Africa? The temptation, when we confront suffering on such a ghastly scale, is to assume it's beyond human control. But it's not. We know we can contain the spread of HIV, because vulnerable nations have already succeeded. Senegal has held its infection rate below 2 percent throughout the epidemic. And Uganda, once the plague's epicenter, cut its infection rate by half during the 1990s. Replicating such victories won't be easy; every community is different. A strategy that succeeds in one nation can fail in another. But researchers have learned a lot from the successes of the past two decades. Here are some prescriptions for slowing the devastation.

Break the silence. The first challenge is simply to face reality. Until recently, few African leaders acknowledged that AIDS was a problem. The disease still carries a strong stigma, but the official silence is breaking. The presidents of Zimbabwe and Kenya are now calling AIDS an urgent problem. Botswana, Namibia and Swaziland have all announced new anti-AIDS initiatives in the past year. And many governments are teaming up with corporations and community groups to raise public awareness.

Promote safer sex. The greater challenge is to change the behavior that spreads the disease. If people lacked only information, a good leaflet might end the epidemic. The trouble is that no one, rich or poor, makes health choices on the basis of information alone. If everyone in your community lives on junk food, chances are you'll live on it too--no matter how much you read about obesity and heart disease. And if prostitution is your livelihood--or the sole source of intimacy in your mineworkers' dormitory--you learn to live with the risk. The most successful prevention efforts have aimed not just to inform people but to change social norms. In Uganda, for example, health workers turned "Protector" condoms into must-have fashion accessories, simply by introducing a flashy new package and a marketing slogan ("So Strong. So Smooth"). To keep the brand hot, the promoters launched a safe-sex radio show and even a traveling theater production.

Target women. Unfortunately, African women have little say in condom use, or anything else, and their powerlessness is costing them dearly. Women account for 55 percent of the continent's HIV infections, and teenage girls suffer five to six times the infection rate of boys, because older men prey on them. "Empowering women is critical to controlling the epidemic," says Barry Bloom, dean of the Harvard School of Public Health. In addition to more social clout, women need contraceptives that they control directly. The female condom, which the nonprofit group Population Services International markets in 20 countries, is effective but costly, and it can't be used without a partner's knowledge. A good vaginal microbicide would be far more practical. Scientists are now studying 60 compounds, but most are still in early stages of testing.

Develop a vaccine. Condoms and spermicides are not the only possible barriers to HIV infection. The lesions caused by other sexually transmitted diseases, such as chlamydia and gonorrhea, make people more susceptible to HIV. Studies suggest that treating those conditions with cheap, accessible antibiotics can cut new HIV infections by as much as 40 percent. Important as they are, though, none of these measures is likely to drive HIV out of Africa. The ultimate weapon against any virus is a preventive vaccine. And on that front, progress has been slow. Drug development has flourished spectacularly during the past 15 years, but until recently no vaccine had even entered human clinical trials. The hurdles are political as well as technical. Of the estimated $200 billion the world now spends on AIDS research, care and prevention and each year, says Dr. Seth Berkeley of the International AIDS Vaccine Initiative (IAVI), only $300 million goes into vaccine research. Thanks in part to IAVI's aggressive advocacy, the pace is picking up. Backed by large grants from the Gates Foundation, the U.K. government and others, IAVI is supporting trials of two experimental vaccines, and backing development of several others. No one expects miracles from the early candidates. We can only hope they lead to better ones before Africa loses another generation.