Ten steps Africans can take to curb AIDS epidemic

LIVINGSTONE, Zambia -- The most critical problem today in the AIDS pandemic, especially in its epicenter in southern Africa, isn't treating the region's estimated 25 million who are infected with the deadly virus. Experts say the biggest issue is preventing the spread of HIV, the virus that causes AIDS, to the 700 million in Africa who are not infected.

Yet finding prevention strategies that work is exceedingly difficult.

``Treatment is relatively easy, but prevention is rocket science," Dr. Jim Yong Kim , a Harvard infectious disease specialist and one of the world's leading thinkers on AIDS, said during a trip earlier this year to the southern African mountain kingdom of Lesotho, where one in four adults is HIV-positive.

For a quarter-century, African countries and foreign donors have tried a variety of prevention strategies -- especially promoting condom use, but also pushing abstinence and being faithful to one partner.

But AIDS has largely bested the experts; in some countries, HIV now infects roughly one in three adults. Few nations have found answers to basic questions: Why can't policies reverse the consistently high levels of infection? Why don't young people, seeing death all around them, change their behavior?

That latter question is the most haunting, and the most curious. Americans ask it frequently about Africans. But the reality in many African communities is that many young people don't or can't afford to protect themselves. Many young women resort to prostitution to eat, for instance.

What needs to happen is that more brave infected people must reveal their status, more religious leaders must embrace those who are infected and warn those who are not, and more youth groups must practice and preach the difficult message that they want to be an HIV-free generation.

From hundreds of interviews and three years of reporting on AIDS around Africa, here is a list of 10 ideas that countries, communities, and individuals could adopt to greatly slow the spread of the virus.

(1) Make HIV testing part of regular health checkups.

South African Supreme Court Justice Edwin Cameron , who is HIV-positive, recently supported this idea, as has Kim, who has helped persuade Lesotho to test as many people as possible. People can opt out, but widespread testing should be a top priority for every country that has a high HIV prevalence, say many experts. (In recent weeks, the US Centers for Disease Control and Prevention recommended HIV tests for American adults during regular checkups.)

Testing is the crucial first step because those who are negative will have further incentive to protect themselves and those who are positive can seek life-extending treatment before they become critically ill.

Those who test positive should be counseled about nutrition, using condoms, and treatment availability. Even number-crunching statisticians agree: A person with AIDS in Africa without treatment, a lives a little more than eight years; with treatment the average almost doubles, to 15 years.

(2) Test couples together.

Promote testing on the first date. Couples need to see each other's results. Make testing at least an annual affair; pitch it as a special anniversary present they do for each other.

(3) Promote male circumcision.

One large-scale study has already shown that male circumcision can be a major preventive factor, apparently because the removal of the penis's foreskin reduces an entry point for the virus. Two more studies are about to be released, and if they offer similar evidence, countries and donors should rapidly begin training health workers to perform the operation and then fund millions of circumcisions for newborns, older boys, and adult men.

(4) Focus the public health message.

Countries should flood the market with a mix of free and low-cost condoms, making them readily available in all the obvious places as part of a strategy toward 100 percent condom usage with high-risk groups and within long-term relationships in which one person is positive and the other negative. But the condom billboards and radio and TV ads all over Africa undercut abstinence and faithfulness messages. The public message should be consistent and strong: Young people should abstain from sex until marriage, and couples should remain faithful and know each other's HIV status.

(5) Make Africa a sports mecca .

Unemployment is sky-high. Young people have time on their hands. They need something besides sex that is free and fun. Governments and donors should look into expanding sports possibilities: creating local leagues, hiring coaches and coordinators, improving facilities, and starting summer camps.

(6) Enforce drinking laws.

During weekend nights in Livingstone, one bar stays open until 3 a.m. and another until 5 a.m. Bartenders serve beer to children as young as 10. And yet the law calls for shutting down bars at 11 p.m. and no sale of alcohol to minors. ``Young boys who never used to drink or smoke are out playing eight-ball pool and drinking and smoking," said Chris Lubasi, 24, who runs youth programs in Livingstone. Drinking to excess clouds judgment, increasing the risk of unprotected sex.

(7) Protect the babies.

In countries with high HIV prevalence, give nevirapine to every woman during childbirth except those who have tested negative or who refuse the drug; roughly half of HIV-positive mothers giving birth pass on the virus to their newborn, but nevirapine reduces that risk by 50 percent. The drug does no harm, but one drawback is some women will develop a resistance to it after the single dose, meaning they will not be able to use it later in their three-drug cocktail. Giving nevirapine during birth to the mother and child is worth the tradeoff.

(8) Encourage men to communicate.

Women in Africa have far higher rates of infection in part because they are more easily infected during intercourse and also because of twin social horrors: domestic violence and rape. Organize neighborhood meetings for men to talk about violence against women. Work with traditional leaders to promote a culture of respect for women. Men and women leaders should pressure governments to aggressively investigate and prosecute domestic violence and rape cases. Don't write off men: several groups, especially in South Africa, are helping change these dangerous behaviors.

(9) Build networks of hospice workers.

AIDS treatment is keeping people alive, but many still are bed-ridden at times. Trained hospice workers provide the most cost-effective and highest quality of care. Countries and donors should make sure these workers, often now volunteers, are paid in order to sustain this critical safety net.

(10) Support local journalists covering the problem. The most powerful people fighting AIDS can be local journalists, especially those working in radio because they reach hundreds of millions of Africans. A first step is to ramp up existing journalist training programs. Create awards for excellence in reporting on AIDS and health in general. Fly promising journalists to conferences. Bring more mentors from the outside. And encourage journalists to investigate whether governments -- rich and poor ones -- are helping prevent the spread of AIDS.

Most AIDS money in Africa is spent on treatment because of the cost of medicine, health workers' salaries, and delivering the drugs to often remote locations. More money should be funneled into prevention, because successful programs will save millions -- in dollars and lives.

John Donnelly can be reached at donnelly@globe.com.