“[Brown’s] ability to make a complicated subject accessible to the general reader is remarkable...” –Katherine Salant, Washington Post
Chapter 7. Eradicating Poverty, Stabilizing Population: Curbing the HIV Epidemic
The key to curbing the AIDS epidemic, which has so disrupted economic and social progress in Africa, is education about prevention. We know how the disease is transmitted; it is not a medical mystery. In Africa, where once there was a stigma associated with even mentioning the disease, governments are beginning to design effective prevention education programs. The first goal is to reduce quickly the number of new infections, dropping it below the number of deaths from the disease, thus shrinking the number of those who are capable of infecting others.
Concentrating on the groups in a society who are most likely to spread the disease is particularly effective. In Africa, infected truck drivers who travel far from home for extended periods often engage in commercial sex, spreading HIV from one country to another. They are thus a target group for reducing infections. Sex workers are also centrally involved in the spread of the disease. In India, for example, the country’s 2 million female sex workers have an average of two encounters per day, making them a key group to educate about HIV risks and the life-saving value of using a condom. 45
Another target group is the military. After soldiers become infected, usually from engaging in commercial sex, they return to their home communities and spread the virus further. In Nigeria, where the adult HIV infection rate is 5 percent, President Olusegun Obasanjo requires free distribution of condoms to all military personnel. A fourth target group, intravenous drug users who share needles, figures prominently in the spread of the virus in the former Soviet republics. 46
At the most fundamental level, dealing with the HIV threat requires roughly 10 billion condoms a year in the developing world and Eastern Europe. Including those needed for contraception adds another 2 billion. But of the 12 billion condoms needed, only 2.5 billion are being distributed, leaving a shortfall of 9.5 billion. At only 3¢ each, or $285 million, the cost of saved lives by supplying condoms is minuscule. 47
The condom gap is huge, but the costs of filling it are small. In the excellent study Condoms Count: Meeting the Need in the Era of HIV/AIDS, Population Action International notes that “the costs of getting condoms into the hands of users—which involves improving access, logistics and distribution capacity, raising awareness, and promoting use—is many times that of the supplies themselves.” If we assume that these costs are six times the price of the condoms themselves, filling this gap would still cost only $2 billion. 48
Sadly, even though condoms are the only technology available to prevent the spread of HIV, the U.S. government is de-emphasizing their use, insisting that abstinence be given top priority. While encouraging abstinence is important, an effective campaign to curb the HIV epidemic cannot function without condoms. 49
One of the few African countries to successfully lower the HIV infection rate after the epidemic became well established is Uganda. Under the strong personal leadership of President Yoweri Museveni, the share of adults infected has dropped from a peak of 13 percent in the early 1990s to 4 percent in 2003. More recently, Zambia also appears to be making progress in reducing infection rates among young people as a result of a concerted national campaign led by church groups. Senegal, which acted early and decisively to check the spread of the virus, has an infection rate among adults of less than 1 percent today. It is a model for other African countries. 50
The financial resources and medical personnel currently available to treat people who are already HIV-positive are severely limited compared with the need. For example, of the 4.7 million people who exhibited symptoms of AIDS in sub-Saharan Africa in June of 2005, only 500,000 were receiving the anti-retroviral drug treatment that is widely available in industrial countries. However, this was up threefold from a year earlier. The increase is part of a worldwide effort by the World Health Organization to reach 3 million people in low- and middle-income countries by the end of 2005, known as the 3 by 5 Initiative. 51
There is a growing body of evidence that the prospect of treatment encourages people to get tested for HIV. It also raises awareness and understanding of the disease and how it is transmitted. And if people know they are infected, they may try to avoid infecting others. To the extent that treatment extends life, and the average extension in the United States is about 15 years, it is not only the humanitarian thing to do, it also makes economic sense. Once society has invested in the rearing, education, and on-job training of an individual, the value of extending the working lifetime is high. 52
Treating those with HIV infections is costly, but ignoring the need for treatment is a strategic mistake simply because treatment strengthens prevention efforts. Africa is paying a heavy cost for its delayed response to the epidemic. It is a window on the future of other countries, such as India and China, if they do not move quickly to contain the virus that is already well established within their borders. 53
45. Nita Bhalla, “Teaching Truck Drivers About AIDS,” BBC, 25 June 2001; Hugh Ellis, “Truck Drivers Targeted in New AIDS Offensive,” The Namibian, 17 March 2003; C. B. S. Venkataramana and
P. V. Sarada, “Extent and Speed of Spread of HIV Infection in India Through the Commercial Sex Networks: A Perspective,” Tropical Medicine and International Health, vol. 6, no. 12 (December 2001),
pp. 1,040–61, cited in “HIV Spread Via Female Sex Workers in India Set to Increase Significantly by 2005,” Reuters Health, 26 December 2001.
46. Mark Covey, “Target Soldiers in Fight Against AIDS Says New Report,” press release (London: Panos Institute, 8 July 2002); “Free Condoms for Soldiers,” South Africa Press Association, 5 August 2001; HIV prevalence rate from Joint United Nations Programme on HIV/AIDS (UNAIDS), 2004 Report on the Global AIDS Epidemic (Geneva: July 2004), p. 191.
47. Nada Chaya and Sarah Haddock, Condoms Count: Meeting the Need in the Era of HIV/AIDS, 2004 Data Update (Washington, DC: Population Action International, 2004); Nada Chaya and Kai-Ahset Amen, with Michael Fox, Condoms Count: Meeting the Need in the Era of HIV/AIDS (Washington, DC: Population Action International, 2002); Population Action International, “Counting Condoms: Donors Coming Up Short,” press release (Washington, DC: 14 July 2004); 2 billion condoms needed for contraception based on estimates from Robert Gardner et al., Closing the Condom Gap (Baltimore, MD: Johns Hopkins University School of Public Health, Population Information Program, April 1999); “Who Pays for Condoms,” in Chaya and Amen, with Fox, op. cit. this note, pp. 29–36; Communications Consortium Media Center, “U.N. Special Session on Children Ends in Acrimony,” PLANetWIRE.org, 14 May 2002; Adam Clymer, “U.S. Revises Sex Information, and a Fight Goes On,” New York Times, 27 December 2002.
48. Chaya and Amen, with Fox, op. cit. note 47.
49. “Who Pays for Condoms,” op. cit. note 47, pp. 29–36; Communications Consortium Media Center, op. cit. note 47; Clymer, op. cit. note 47.
50. UNAIDS, op. cit. note 46; UNAIDS, AIDS Epidemic Update (Geneva: December 2004), p. 13; UNAIDS, Report on the Global HIV/AIDS Epidemic (Geneva: June 2000), pp. 9–11.
51. UNAIDS and WHO, Progress on Global Access to HIV Antiretroviral Therapy: An Update on “3 by 5” (Geneva: 2005), pp. 7, 13.
52. Clive Bell, Shantayanan Devarajan, and Hans Gersbach, “The Long-run Economic Cost of AIDS: Theory and an Application to South Africa,” Policy Research Working Paper Series (Washington, DC: World Bank, 2003); “AIDS Summit: The Economics of Letting People Die,” Star Tribune, 16 July 2003; Deborah Mitchell, “HIV Treatment: 2 Million Years of Life Saved,” Reuters Health, 28 February 2005.
53. “AIDS Summit,” op. cit. note 52.
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