Young Nelson Mandela sat in a row of 27 teenage boys, anxiously awaiting the arrival of the ingcibi, who was about to change them from boys to men. The old man soon knelt before the future president of South Africa, pulled the 16-year-old’s foreskin forward, and brought down the ceremonial blade in a single, swift motion.
“I looked down and saw a perfect cut, clean and round, like a ring,” Mandela wrote in his remarkable autobiography, “Long Walk to Freedom.” “I count my years as a man from the date of my circumcision.”
At the dawn of the 21st century, circumcision may confer more than manhood to a new generation of African boys. It could help to determine whether or not they, their future wives and girlfriends, or their children will die of AIDS.
As the latest United Nations report laid out in stark detail this week, the epidemic is now threatening an entire generation of Africans. In nations where the adult infection rate exceeds 15 percent, UNAIDS projects that one-third of today’s 15-year-olds will eventually die of AIDS. In South Africa, where HIV infection rates jumped to 20 percent from 12 percent two years ago, half the 15-year-olds are similarly doomed. And in neighboring Botswana, where 36 percent of adults are infected, only one in three 15-year-olds can expect to be spared.
For more than a decade, AIDS researchers studying the catastrophic spread of HIV throughout Africa have been amassing a body of evidence suggesting that the epidemic is not consuming populations at a uniform rate, but seems cruelly selective in the people and places it does the most harm. In 1988, American anthropologist Priscilla Reining drew up a map of the African cities enduring the highest HIV infection rates and superimposed upon it a map of those places where the predominant cultural practices were to circumcise or not to circumcise. The correlation was striking: HIV was spreading fastest in places where male circumcision was not routinely performed. Despite this, in the decade since the correlation’s discovery, the issue has been routinely ignored, ducked and dismissed.
“It’s fascinating that the one intervention that is simple, apparently effective, cheap and lifelong is the one most violently opposed by men in this field,” said Brian Williams, a South African AIDS researcher who is studying the disease in the mining communities west of Johannesburg. Even members of his own government health department do not take the issue seriously, he said. “There is a strange reluctance even to discuss it.”
There will be no way to avoid the topic, however, at the 13th International AIDS Conference to be held in South Africa next month. Armed with years of epidemiological data, researchers are determined to bring the debate out of the shadows. No one expects the developing world to embark on a sudden, mass circumcision program, but supporters are hopeful for an open and frank debate. With hope for a vaccine a distant dream and the cost of medications out of reach, circumcision could be a low-cost, one-time intervention that could slow the spread of this global plague.
“The more you look at AIDS, the more you can see that the circumcision hypothesis has a lot of explanatory power,” said Edward Green, an anthropological consultant with the U.S. Agency for International Development. “Look at Nigeria, a country with a high level of sexually transmitted disease, but a low rate of HIV [4 percent]. In Nigeria, they circumcise.”
Circumcision is the surgical removal of the prepuce, or foreskin, the highly vascularized sheath of tissue that surrounds, lubricates and protects the tender glans, or head of the penis. Ritual removal of the prepuce, like that practiced in Mandela’s Xhosa (pronounced KO-sah) tribe, is a rite of passage common in many African cultures. The presence or lack of a foreskin is sometimes linked to tribal identity, although many circumcising cultures have abandoned the painful and potentially unsanitary rituals, opting instead for a sterile procedure performed in a modern medical setting.
Infant circumcision in the United States was not widespread until the beginning of the century, when it was promoted as a medical procedure with an odd variety of purposes: to enchance cleanliness, prevent disease and discourage masturbation.
Since then, support for the medical benefits of circumcision has eroded. In 1971, the American Academy of Pediatrics declared there were “no valid medical indications” for infant circumcision, a position that has been debated and restated with various degrees of ambiguity ever since. But AIDS could change all that.
Predictably, anti-circumcision advocates are outraged by this latest push to promote the procedure in developing countries. “The foreskin is not dangerous,” insisted Marilyn Milos, a nurse and founder of NOCIRC, an organization based in San Anselmo, Calif. She said circumcision has been justified for more than a century by dubious scientific theories. “The scare tactics are always consistent with the dreaded disease of the times. There was a penile cancer scare in the ’30s; a cervical cancer scare in the ’50s; and the sexually transmitted disease scare of the ’60s.” HIV is no different, she said.
Author David Gollaher, whose medical history of circumcision dubs it “the world’s most controversial surgery,” argues that the evidence for an HIV link is not strong enough to warrant such an invasive and permanent medical fix. “This whole argument has surfaced in America, a nation with one of the highest circumcision rates, and also the highest HIV rate in the industrialized world,” he said. In Europe, he added, there is a low rate of circumcision, and a low rate of HIV.
Moreover, Gollaher believes that the symbolic significance that circumcision rituals play in various cultures make it a poor candidate for a public health measure. “Even if the link to HIV were well established, people would not accept it,” he said. “The social and cultural meanings of the surgery are vastly more important than any single scientific argument.”
Gollaher and other critics complain that pro-circumcision researchers are ignoring a range of factors among religious and ethnic groups that can muddy results, including differing sexual practices, hygienic standards, levels of sanitation, endemic diseases, economic status and consistency in condom use.
But the evidence is not limited to arcane epidemiology. There are biological reasons that suggest the foreskin is especially vulnerable to HIV. Initially, the fragility of tissue was suspected. The foreskin can tear and bleed during sex, providing a pathway for pathogens into the bloodstream. Circumcision proponents have long argued that the procedure reduces susceptibility to a variety of sexually transmitted diseases, particularly those that form soft sores, such as syphilis. There is ample evidence that men who have a history of STDs, particularly ulcerative forms, run a higher risk of HIV infection.
More recent research has determined that the prepuce is exceptionally rich in a specialized white blood cell that acts as a sentry for the human immune system. These blood cells, known as Langerhans cells, lodge in the fragile mucosal tissue of the inner lining of the foreskin, an environment similar to that found in the vagina, cervix or rectum. When Langerhans’ cells encounter invading microbes, they churn out a variety of chemical signals that, like a bugler’s call, rally the bloodstream’s various immunological warriors. But the problem is that HIV has a particular affinity for these cells. The virus can lock onto a specific receptor on their surface.
Designed to protect the tender prepuce from microbial attack, these specialized white blood cells make the foreskin the port of entry for HIV infection of males. Cultures that do not engage in the ancient practice of foreskin removal may therefore become more vulnerable, proponents say. Although the protective effect of male circumcision directly affects men, it also carries over to women, who are often infected by male partners.
While the evidence for a link between lack of circumcision and the spread of HIV in Africa is strong, researchers are also looking for other reasons to explain why some countries have high infection rates, while others are relatively spared. High on the list is a suspicion that certain strains of the virus itself may be more virulent, such as the so-called subtype C strain that is cutting a swath through South Africa. If certain strains are eventually proved to be more virulent, it won’t necessarily rule out a connection to lack of circumcision: the more virulent strains may have a greater affinity for Langerhans’ cells, and thus are more likely to infect men with foreskins, and subsequently their sexual partners.
Long after Reining put her maps together, HIV’s tendency to take hold in non-circumcising cultures seems clearer than ever. Of the 23.3 million people in sub-Saharan Africa believed by UNAIDS to be infected with HIV, the overwhelming majority live in places with low rates of male circumcision, such as Botswana, Mozambique, Uganda and Zimbabwe. The “AIDS Belt” stretches like a question mark across central and eastern Africa, down to South Africa, where the current hot spot for the epidemic is in the province of KwaZulu-Natal. That is the home of the non-circumcising Zulu tribe, where one-third of the women at pregnancy clinics test positive for the virus.
There is little evidence of such high infection rates in Western Africa, where traditions of circumcision date back thousands of years. In Asia, a similar trend is developing. Both Thailand and the Philippines are nations with a thriving commercial sex industry. Yet the HIV rate in Thailand is nearly 40 times the 0.06 percent prevalence rate in the Philippines. In the Philippines, most men are circumsized; in Thailand, they are not.
University of Illinois at Chicago anthropologist Robert Bailey estimates that lack of male circumcision may account for up to 55 percent of HIV infections in nations where fewer than one in five men are circumcised. A program to flip the percentage, raising circumcision rates to four out of five, could save millions of lives, he believes. A pilot program in Kenya is providing circumcisions for about $5.40 each. “If you can have a public health measure that reduces infection or illness by 25 percent to 30 percent, that is considered to be a very successful intervention,” Bailey said. “We’re talking about a 50 percent reduction. That is huge by public health standards. If you could reduce car fatalities by 20 percent, that’s huge. If you can reduce homicides by 20 percent, that’s worthy of headlines.”
Yet from Asia to Africa to North America, the notion that there is a link between circumcision and protection against HIV has met stubborn resistance.
At a fireside meeting with American AIDS reporters, KwaZulu Natal health minister Dr. Zweli Mkhize reflected on the prospects for circumcision in his province. “Very few individuals will do this,” he said.
It was Shaka, the legendary king of the Zulus, who decreed the tradition’s end in the 1820s. Since then, an intact foreskin has been a mark of the proud Zulu male.
“Circumcision is too human a solution,” suggested Daniel Halperin, a medical anthropologist at the University of California at San Francisco, and a leading international proponent of circumcision as a tool in the fight against AIDS. “It’s funky. It’s tribal. It’s not modern medicine. It’s not coming in with a pill,” he said.
Fueling the debate over adding circumcision to the list of HIV prevention programs is the sheer preponderance of evidence from years of research, and a stunning surprise from Uganda’s heavily studied Rakai District. Johns Hopkins University researcher Dr. Thomas Quinn tracked the health of 415 rural Ugandan couples who were sero-discordant, meaning that, at the start of the 30-month trial, one partner was HIV positive, while the other was not. The primary purpose was to prove that the higher a person’s level of virus in the bloodstream, the more likely he or she is to infect someone else. Though criticized on ethical grounds — participants were offered counseling and condoms, but were not told by researchers the serostatus of their partners — the study proved its point: Infectiousness was closely tied to the “viral load” measured in the bloodstream.
But even circumcision proponents were startled by the findings in another part of the Quinn study: Of 137 uncircumcised men with HIV-infected partners, 40 eventually became infected over a two-and-a-half-year period. Among a smaller group of 50 circumcised men with HIV-positive partners, not one contracted the virus.
Since 1988, when the first study was presented on the topic, there have been at least 45 additional studies worldwide examining a link between lack of male circumcision and HIV. The most scientifically rigorous showed that men who were not circumcised ran between 2.3 and 4.5 times the risk of contracting AIDS as men who had the procedure done.
Circumcision may have already prevented around 8 million HIV infections in 15 African and Asian countries, according to Malcolm Potts, an epidemiologist at the University of California at Berkeley’s School of Public Health.
If lack of male circumcision is a major risk factor for the spread of a heterosexual HIV epidemic in developing countries, the future is truly frightful for the heavily populated, non-circumcising cultures of India and China, where HIV is just beginning to make inroads.
But skeptics say the best way to fight the spread of HIV is through prevention education, testing and STD treatment. According to Wisconsin pediatrician Robert Van Howe, studies in Tanzania found that for about 39 cents per person, such a program could reduce HIV infections by 40 percent — the same range of protection claimed by circumcision proponents. “For circumcision to compete, it would have to be done for less than $1.52, and I don’t think you can do that, in a sterile setting, with the education that has to go along with it,” he said.
Advocates of circumcision recognize that promoting it for HIV prevention poses its own set of problems. Circumcision itself is a potentially dangerous operation, particularly if performed in the traditional manner experienced by Nelson Mandela. Each year, the African press carries stories of charlatan circumcisers who botch the operation, causing infection and even amputation for the unfortunate young victims. The use of unsanitary tools and traditional blades, called assegai, on multiple penises could spread HIV rather than stop it. Circumcision rites are also sometimes accompanied by celebratory sex parties, where the virus can be spread to multiple partners by the freshly bloodied organs.
But the biggest fear is that it will be viewed as so protective against HIV that safer sex practices will be jettisoned. Proponents stress that circumcision alone is not the answer. It does not eliminate the risk of HIV infection: It merely may reduce it. And HIV still appears at unacceptably high rates in cities where circumcision is widely practiced. Poor hygiene, lack of condom use, alcohol abuse, promiscuity, commercial sex and the use of vaginal astringents in so-called “dry sex” may all play a role in the spread of HIV. All of these conditions combined, along with the lack of male circumcision, may explain the disproportionately high levels of HIV among Africa’s non-circumcising cultures.
In the western Kenyan city of Kisumu, Population Council researcher Jane Chege has been studying the circumcision and HIV trends among a population of members of the Luo tribe. Chege’s unpublished data showed that the HIV infection rate was 26 percent among those Luo tribesmen who were not circumcised before their first sexual experience, compared to 6 percent among those who were circumcised. The results are part of a UNAIDS study that has found that HIV rates are lower among circumcised populations, even those that showed the highest rates of risky sexual behavior. The studies examined many different factors, including sexual practices, sexually transmitted disease rates and different subtypes of the virus to determine what might explain higher infection rates. The results of the study found that only two factors stood out with statistical significance: infection with a herpes virus and lack of male circumcision.
The impact of AIDS on Kisumu is devastating: Twenty-three percent of girls ages 15 to 19 are HIV positive. Chege shakes her head sadly. “These kids are going to die. But before they do, they are likely to get married, and their children are very likely to be born HIV positive.”
As a member of Kenya’s majority Kikuyu tribe, Chege said she has been accused of “tribal imperialism” for advocating circumcision among the Luo. But she said the epidemiological data are so striking that the issue needs to be addressed.
“This is a big issue. It is not something you can just ignore,” she said. “Even a 5 percent difference in HIV rates is significant, because we are talking about a killer.”
As a lens to explore the complex and deeply fraught relationship between Africa and the West, the AIDS epidemic is as revealing and disturbing as it gets. Born in colonial Africa and discovered in gay America, the devastating rise of AIDS has been fueled in no small part by the clash of cultures that played out over the past 130 years or so between Africa, Europe and the U.S. — and the rivers of resentment those conflicts have sown.
“Tinderbox,” an insightful new book from a journalist and an AIDS researcher, tells the story of the epidemic from its birth in colonial Congo — where it lingered undetected for decades — to its sudden spread around the globe in the 1980s, to its status today as the object of a global public health war directed from Washington and Geneva and targeting Africa, home to some 70 percent of all AIDS cases today.
Narrating this disturbing tale are Craig Timberg, former South Africa bureau chief for the Washington Post, and Daniel Halperin, an epidemiologist, AIDS researcher and former advisor to the U.S. government’s anti-AIDS program. Timberg met Halperin in the middle of his five-year stint as the Post’s Johannesburg bureau chief and the two began exploring questions that had bothered Timberg since his arrival in South Africa.
Timberg, now back in Washington as the Post’s deputy national security editor, spoke with Salon about the book.
Perceptions about the origins and spread of AIDS have changed over time in fascinating ways. First, it was seen as a gay disease. When it was detected in Africa, people assumed it came from the West. Over time, scientists showed it originated in Africa, a notion rejected by many Africans but in keeping with Western notions about third-world diseases. You show in the book that AIDS arose as a result of sweeping changes in social structure brought to Africa by European colonialism. Describe its origins.
Scientists have known for more than a decade that the version of HIV that has caused almost all cases of AIDS is virtually identical to a virus common in central African chimpanzees. That’s not controversial. The location of the transmission was determined by a group of scientists who narrowed it down to chimpanzees living in southeastern Cameroon by collecting their feces, detecting the virus and comparing it to other strains collected elsewhere. Michael Worobey from the University of Arizona and his team mapped the genetic structure of pieces of HIV from all over the world, looking at the extent of mutations between them. They were able to make assumptions about how many years it would have taken to produce these changes. The time frame puts you close to the turn of the 20th century for the original virus, the ancestor to all modern HIV.
How was the spread of AIDS to humans linked to colonialism?
In southeastern Cameroon, at the exact moment scientists now believe HIV entered the human population, you had steamships going up rivers that never had steamships before. You have porters who are virtually human pack animals carrying ivory or gear for colonial companies through dense forests. One of those porters would have been the first human to contract HIV. It looks like HIV goes from the chimp population into a hunter who cuts himself while butchering a chimpanzee for food. It then spreads in a localized way along these porter paths and colonial trading posts and eventually comes down river on a steamship into Kinshasa, then called Leopoldville, the first major city in that part of the world.
And that leads to what you call the Big Bang – when HIV explodes and moves out of the Congo.
That’s right. A single spark emanating from southeastern Cameroon works its way to colonial Leopoldville. But HIV doesn’t spread fast on its own. It needs particular conditions to race through a population and Leopoldville had them. It was big and growing fast. It had a high concentration of men working in factories, separated from their wives and girlfriends. It had an emerging population of sex workers and transport to get people back and forth. Gonorrhea, syphilis, chlamydia spread like wildfire; HIV doesn’t but starts to spread along railroad lines, porter paths and rivers during the early and middle part of the 20th century. When scientists look at the genetic structures of different types of HIV they all seem to have come from a single piece of ancestral HIV that existed in Leopoldville at the beginning of the 20th century.
So HIV lingered in small numbers of people but doesn’t exit this area. When researchers go back to blood samples collected during the 1976 outbreak of Ebola virus, they find HIV.
Yes, so in the middle part of the 20th century about 1 percent of adults in major population centers of the Congo had HIV. Before they died, they developed symptoms of other familiar maladies—pneumonia, tuberculosis, wasting. It wasn’t obvious there was a new epidemic loose in the land until gay men in the United States started getting sick in the early 1980s. Before that, it didn’t spread far and it didn’t spread fast. The reason seems to be that in colonial Congo, the majority of adult men would have been circumcised and circumcised men are much less likely to contract HIV and pass it on. It’s only when HIV makes its way out of the Congo River basin to other places more hospitable to its spread that we get a true explosion.
Many people assume AIDS must be a disease of poverty. But you argue that wealth, modern transportation and economic development were key factors that allowed AIDS to break out.
When I first went to Africa as a correspondent in 2004, I carried this question with me: Why is HIV so severe in some places and not in others? Logic said: Africa, poverty, poor medical systems — there had to be a connection. But when I started traveling to different countries I discovered that most truly outrageous hellholes — places with warfare and incredible poverty — didn’t have much HIV. Other places with modern transport and sophisticated economies had a lot. When I met my co-author, Daniel Halperin, it began to come together. I saw that while being poor and having HIV is certainly a very bad thing because you’re more likely to die when you can’t afford medicine, some degree of economic activity actually makes you more vulnerable. When the epidemic starts spreading widely in some African societies it’s in the cities. Wealthier people — doctors, teachers, politicians, singers — get HIV in completely disastrous numbers. Some of that has to do with access to resources and multiple sexual partners.
You begin with a chapter on the city of Francistown, Botswana, an affluent place with a horrendous HIV rate. What struck you about Francistown?
I drove to Francistown for the first time in 2006 and it felt like driving into anywhere, USA. I could buy a hamburger at Wimpy’s, order a shot of espresso. There were cafes and ATMs. Yet it had this horrendous HIV rate. Among women in their 30s, two-thirds were infected. The picture of poverty before HIV didn’t add up. When you scratch the surface you begin to realize that other factors — human movement, transport, sexual behavior, circumcision or lack of it — are decisive in how the virus spread.
You describe the AIDS belt, an area in southern Africa at the very heart of the African epidemic. What are the characteristics that made it, as you call it, a tinderbox?
There’s a giant swath of the continent that starts at the southern end of Sudan, goes down through east Africa to South Africa and out to the sea where you have this combination of sexual networks and low rates of male circumcision. Together they produce the tinderbox. Two centuries ago most of Africa had polygamous societies in which the richest, most powerful men had multiple wives. In contemporary Africa, in part because of that tradition and in part because of the ravages of colonialism and migratory labor, many men and women have more than one sexual partner over the course of a week or month. But to be part of the AIDS belt, you need one more thing: low rates of male circumcision. The people who migrated down the Nile River basin from Sudan never had circumcision as part of their tradition. In the southern part of the continent, it was a tradition pretty much everywhere until about 200 years ago when some ethnic groups began to give it up. In those places you see HIV rates of 10, 15, even 25 percent.
Why is circumcision effective and why was early evidence of its power missed?
A man’s foreskin is unusually vulnerable to HIV; the skin is thinner, softer and more easily penetrated by HIV and other pathogens. When it’s removed, the remaining skin is rougher and more resistant to infection. That makes no difference if you’re a gay man who is the receptive partner in anal sex. But the African epidemic is spread predominantly through heterosexual sex, particularly vaginal sex, and circumcision is crucial. Circumcised men are at least 70 percent less likely to get HIV. This science first began to appear in the mid-1980s.
That’s three decades ago!
That’s right. That data seemed to offer this miraculous new insight. But the global public health community was deeply uncomfortable with the subject. It took another 20 years to come up with evidence so definitive they accepted it. Peter Piot, one of the central characters in the AIDS response, was part of that research team. Yet during all the years he was head of UNAIDS he was not enthusiastic about this science. To be fair, establishing correlation is not the same as establishing causality. And it’s a pretty serious thing to contemplate altering men’s penises if you’re the global health community.
One area of culture clash between global health agencies and Africa is over condoms. What happened?
People who had watched AIDS in the U.S. were mindful of the way condoms seemed to slow the spread of HIV there and especially in Thailand, where the epidemic was transmitted mainly in brothels. It was hard for those officials to understand how different the African epidemics were. In several places, Africans were saying, “Hey, our best chance for surviving is for people to have fewer sex partners at a time.” But Westerners had condoms on their minds. The U.S. government and other organizations made a huge bet on condoms and reasoned that if you could just get enough of them to people in vulnerable places you could reverse the epidemic. Instead, reported usage of condoms in some African societies went to rates far higher than anywhere else but HIV also went up. That puzzled people until it became clear that people were using condoms with prostitutes or one-night stands but not in long-term relationships with their husbands, wives, boyfriends or girlfriends. And that’s how HIV is most likely to spread.
Uganda emerged in the early days of the epidemic as a place that took effective action, changed people’s behavior and lowered HIV transmission.
In 1986 a new government took over and confronted the facts of AIDS. They knew it was fatal, they knew it was incurable, they knew it was spread by sex, and they knew a lot of people already had it. So political, religious and cultural leaders focused on changing the sexual behavior that was at the core of HIV’s spread. The most famous terms for this was zero grazing, a metaphor that worked well in an overwhelmingly agrarian society. When leaders said zero grazing, Ugandans understood at an intuitive level that having sex with your primary partner is much safer than having sex with a primary partner and others. If a large number of people make a relatively small change in their number of sex partners it can make a massive difference in the spread of HIV. That’s what happened in Uganda and hundreds of thousands of lives were saved.
Why were the powers that be in global health so reluctant to focus on behavior change?
The global health infrastructure was uncomfortable talking about differences in sexual behavior. That’s a shame because a sexually transmitted epidemic is by definition spread by sex. To understand why it’s worse in some places than others you have to dive into some inherently uncomfortable questions about a very private matter.
Yet there was historical evidence here that changing behavior made a difference. San Francisco closed the bathhouses and it helped. In New York, behavior changes led to lower rates of anal gonorrhea in the early days of the epidemic.
Those changes were instituted within coherent communities. Gay men advocated the closing of bathhouses and made the choice to have fewer partners or use condoms. In Africa that process was hampered by the slowness to accept that AIDS was real and the fact that people are understandably resistant to being told what to do by a large and powerful outside force. Many of these societies need our financial aid, our technical assistance to do things that matter to them, including improving public health. The tension over how much to listen to outsiders while not wanting to be told what to do has troubling consequences that have infused the world’s response to AIDS in all sorts of ways.
What lessons do you draw from the way the epidemic has been addressed in Africa?
The overriding lesson is that sex matters. Those of us who care about people getting this terrible disease can’t be squeamish in discussing sexual behavior because we’re afraid of how it makes us look. The research has to be good, the messaging has to be forceful and clear. It’s not enough to tell people to use condoms all the time because the evidence after more than 30 years is that people don’t, not often enough to be truly decisive. We also have to be willing to engage in questions about how many partners people are having, we need to tell people that from the viewpoint of sexually transmitted infections, anal sex is more dangerous than vaginal or oral sex. These things are uncomfortable to talk about. At the same time, if we take seriously the moral question of trying to prevent as many infections as we can, we can’t be frightened of these subjects.
KISUMU, Kenya – Thirty years after the discovery of AIDS, scientists believe for the first time that they now have the tools to beat back the deadly virus.
The evidence is found in HIV prevention research conducted here on the shores of Lake Victoria and in several other parts of sub-Saharan Africa, long the epicenter of AIDS. The most notable research discovery stems from the HIV Prevention Trials Network 052 clinical trial, a U.S.-funded, nine-country study that found early treatment reduced the risk of HIV transmission to an uninfected partner by 96 percent.
The 052 results – announced to a standing ovation in Rome at the International AIDS Society conference in July – was one in a line of recent breakthroughs, including the benefits of male circumcision to prevent infection, and smaller conceptual advances in an HIV vaccine candidate as well as with microbicides, or gels used by women to stop transmission.
But the gloomy global economic situation, and recent scale-backs in HIV funding around the world, have cast great doubt as to whether policymakers will take advantage of the combination of new prevention tools to fight AIDS.
This collision of scientific advances vs. economic realities also comes at a heightened political moment of the U.S.’s own making: Secretary of State Hillary Rodham Clinton earlier this month called for an “AIDS-free generation,” and the United States’ actions on AIDS will be in the spotlight during next July’s International AIDS Society conference in Washington, D.C., which is being held in the U.S. for the first time in 22 years due to the Obama administration’s decision last year to end U.S. entry restrictions on people who have HIV. The conference is expected to attract more than 25,000 people from around the world.
President Obama is expected on Thursday — World AIDS Day — to talk about his administration’s next steps on AIDS, following Clinton’s speech. This would be his first major speech on AIDS as president; he has remained largely silent on all global health issues. Even when Obama announced a bold new Global Health Initiative, the White House put out only an eight-paragraph statement.
“The terrific science in the last year is coming up against the fiscal constraints,” said Chris Collins, vice president and director of public policy amfAR, the Foundation for AIDS Research. “It is going to take choices. That is the big challenge for policymakers in the next couple of years: How to get above the day-to-day politics here and use the resources as strictly as possible. We now need to hear our president articulate his policy action plan for an AIDS-free generation.”
Several sources within the Obama administration said in interviews that Clinton’s speech at the National Institutes of Health was at least partially spurred by the realization that next year’s AIDS conference will shine a spotlight on the U.S. commitment to fighting the virus, both globally and domestically. The idea was that the United States will be able to report back to the conference on its plan of action globally, while also speak about ongoing research in several U.S. cities about the most effective ways of finding those who are infected and then putting them on treatment.
In the meantime, Obama’s top scientists are urging that the research discoveries to prevent HIV transmission are put to use. The one in the forefront is the best known of all: Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, who has advised U.S. presidents since Ronald Reagan on how best to address AIDS.
“All of a sudden we have a convergence of prevention approaches, which includes treatment as prevention, and that really validates the concept of combination prevention,” Fauci told GlobalPost in an interview earlier this month. “There is now an enthusiasm and an excitement if we can implement some of these scientific advances, we can have a major impact in turning around the trajectory of the epidemic.”
Fauci said that future modeling of the AIDS epidemic shows that if prevention tools are effective and if fewer people are infecting others, a precipitous fall in HIV infections could follow. Then, he said, the whole arc of the epidemic could crumble.
“When we can get the incidence of HIV down enough to turn the trajectory of the pandemic, it will assume a momentum of its own in diminishing HIV,” he said.
“That’s because the fewer people who are transmitting infection and the more people who are trying to protect themselves from infection – those are the two arms of the problem – that diminishes the pool of people capable of infecting the other people.”
A UNAIDS report released last week concluded that the global expansion of AIDS treatment has made a significant difference in terms of saving lives and almost surely in preventing infections. It estimated that new HIV infections were reduced by 21 percent since 1997, and deaths from AIDS-related illnesses decreased by 21 percent since 2005. It also found that 6.6 million people were on life-extending antiretroviral treatment in 2010, an increase of 1.35 million from the previous year.
Given the findings of the 052 study, scientists and researchers said that the more people who are put on treatment, the more infections will be averted. The experts said that funding isn’t the only issue. Another key one is making sure the prevention strategy matches the specific epidemic in a country.
“Funding is not enough today and probably will never be adequate,” said Robert Hecht, a principal and managing director at Results for Development who has done extensive modeling on what will happen in various scenarios with AIDS funding.
He continued: “What will be important is getting some of these countries to recognize that if they don’t have all the money they need, they need to target programs for the high-risk groups. If you had to choose, say, between a few more dollars for sex education in the schools, or spending it more to reach gay men, or injecting drug users, the countries would be better to use it in the latter programs.”
In Kisumu, the principal city of western Kenya, with a population of roughly 500,000, the 052 trial was stopped in May because it was working so well that researchers felt it was no longer ethically defensible to keep a control group on placebos. Dr. Lisa Mills, the principal investigator for the western Kenya part of the study, and chief of the HIV Research Branch at KEMRI-CDC (a long-time collaboration between Kenya and U.S. researchers), said the Kenyan government already had started people earlier on treatment, but she and others hoped that more funding would allow for another expansion.
“The modeling shows that the amount of funds used for treatment would be much lower by 2015 if you started earlier,” Mills said. “And 2020, there would be a huge savings. There is an increase in start-up costs, but with the costs of the drugs gradually dropping, more efficiencies in treatment, and a reduction in new infections, including pediatric infections, all those add up to fewer people on treatment” in a few years.
Mills said that in fighting AIDS, like other epidemics, “the real issue is when you turn off the tap,” referring to stopping the numbers of new infections. “When you have fewer and fewer new people getting infected every year, turning off the tap starts to happen,” she said.
Kayla Laserson, the director of KEMRI/CDC Research and Public Health Collaboration, said the AIDS research is part of a multi-pronged global health research agenda aimed at finding new drugs, vaccines, and diagnostic tools for a host of diseases. “We have the 052 trial here, but we also have the malaria vaccine trail, and the site for a TB vaccine trial, and many others,” she said. “We see how we make an enormous impact because the results from the community we serve are all around us.”
In the nearby village of Ematsayi, Peter Owiti Omotsi, 39, a father of five, is one of thousands of people in the region now on antiretroviral drugs to fight AIDS. He started treatment in 2008. His wife was HIV negative at the time of his diagnosis, and she has remained negative, he said. Omotsi said the drugs, plus changes to improve the nutrition in his diet, have made him much healthier.
“These drugs work,” he said. “I believe before I die, I will see my grandchildren. Without these drugs, that probably wouldn’t happen. But I have some years to live now. I can at least be proud of my grandchildren.”
In the months and years ahead, the U.S. government will need to make decisions on whether to expand AIDS treatment in the United States as well as around the world to people who are infected but are not acutely ill from the disease. No one is making any promises yet. But no one doubts either that the range of prevention approaches now available, taken together, create a new, powerful weapon to halt AIDS.
“In the last year or so, we have enough scientific advances so that we can start to see some significant turnarounds in the trajectory of the pandemic,” said Fauci, the longtime U.S. AIDS researcher. “But it’s not going to happen alone. We’re going to need a lot more host-country involvement, we’re going to need other donors, we’re going to need to be more efficient in what we do with the resources that we have. Now is a critical time in the history of the AIDS pandemic.”
Recently, an elderly woman in Mississippi was left alone on the curb outside a hospital emergency room. The woman didn’t have a medical emergency. She’d been dumped by the nursing room employees who had learned that she had HIV, according to a lawyer at the Mississippi Center for Justice to whom she was eventually referred.
Mississippi’s neighbors have been known to thank God for Mississippi — when your state ranks 48th or 49th in just about every sad statistic about health or poverty in America, it’s nice to know you’ll always look better than someone. The state’s indicators for HIV and AIDS are about as horrific, although the 9,546 people in the state reported to have the virus probably aren’t particularly grateful about it.
The state has the highest new infection rate and greatest percentage of people living with HIV in the country, and by many measures, the least interest in helping them. Elsewhere, HIV/AIDS has become manageable with anti-retroviral therapy, but a Mississippian with HIV/AIDS is almost twice as likely to die than the average American with the virus; HIV-positive African-Americans in Mississippi are ten times as likely to die from it than their white neighbors. African-Americans are only 37.5 percent of the population, but represent 78 percent of new HIV infections. Meanwhile, an abstinence-education statute forbids even programs offering information about condoms to demonstrate how to use them, but does include a requirement to mention the anti-sodomy laws still on the books.
Combine racism and political indifference to poverty with homophobia — there’s been a rapid rise in infections among young men having sex with men in the state — and you’ve got a public health disaster that state politicians mostly ignore, or worse. ”I’ve been called a nigger and a faggot by state legislators right in the Capitol,” Alonzo Dukes, executive director of the Southern AIDS Commission in Greenville, Miss., told Human Rights Watch for a recent report. One of the few advocates for people living with HIV, state Rep. John Hines, says in the same report, “Legislators in Mississippi don’t see it as a public health crisis; they see it as a punishment for an unhealthy lifestyle.” The state contributes only $750,000 towards HIV/AIDS programs, out of a budget of $4.9 billion.
In other words, there’s very little to prevent employers and housing providers from discriminating against people with HIV, especially because the state doesn’t have any anti-discrimination laws and Mississippi also ranks 49th in funding civil legal services for the poor, according to the state’s Access to Justice Commission.
Even those who can afford a lawyer might have trouble. “I’ve heard stories of even lawyers turning clients away when they have AIDS,” says Marni von Wilpert, a fellow with the Mississippi Center for Justice. “People think they can get it from handshakes or hugs.”
Human Rights Watch also indicted the state for “punitive, stigmatizing, and discriminatory policies that undermine efforts to reach the population’s most vulnerable to HIV … leav[ing] people with HIV/AIDS without treatment at rates comparable to those in Botswana, Ethiopia, and Rwanda.” Advocates report hearing stories of public health officials showing up at workplaces and homes without any regard for confidentiality — terrifying in small rural communities where the stigma of HIV is brutalizing.
Robin Webb, executive director of A Brave New Day, which provides support services to people with HIV/AIDS, says this fans long-standing mistrust of government medical services in the African-American community going back to the Tuskegee syphilis studies. “The government actually plays out that whole Tuskegee scenario when it becomes a punitive force. The way they handle public health is all about authoritative punishment.” They are also terrified of what will happen to their lives if their infection is discovered. ”The No. 1 punishment is to kick people out of the church,” says Webb. “These are the people who talk about Jesus and the lepers.”
One MCJ client, admitted to the hospital for seizures, woke up to discover the doctor had informed a relative, in violation of medical privacy laws, that the patient had AIDS. ”People are not going to seek care if they think everyone in their family is going to find out,” says Von Wilpert. Meanwhile, Von Wilpert says, the state has chosen only to distribute free AIDS drugs at limited Department of Health locations. “People are traveling two or three counties over to even get the drugs,” she says — or not traveling at all.
The good news is that advocates believe they have an ally in the state’s new STD/HIV director, Nicholas Mosca. Von Wilpert and her colleagues are launching a new medical-legal partnership program, as well as an office in the hard-hit Delta region. Webb, who grew up in the Delta but lived in New York during the AIDS crisis and subsequent activism, says he’s trying to import that language of empowerment and self-management to his home state, and try to undo the shame and stigmatization. “I think most of us realize that diseases, especially lethal diseases, love secrets,” he said.
(Credit: Reuters/Yiorgos Karahalis) 
(Credit: jocic via Shutterstock) 
