Progress in halting the deadly progression of HIV/AIDS takes concerted effort led from the tops of governments. We have examples in Thailand, Uganda, Brazil, and Senegal, which have periodically decreased HIV infection rates through behavior change. In Thailand it was through education and condom promotion, and in Uganda via their "ABC" program -- for abstinence, "be faithful", and condoms, implemented in the early 90's. The governments that showed progress made slowing the human and economic toll of the disease a priority of their administrations and poured tremendous resources into the effort. But even with these efforts success has been sporadic. Uganda undermined its program last year by collaborating with the U.S. world AIDS project that promotes abstinence only. The new campaign does not support condom use, in fact promotional material was distributed declaring condoms to be porous, along with the "new" message that pre-marital sex a form of "deviance", reports Human Rights Watch (HRW).
Thailand's program has sometimes wavered, but after an up tick in infections Thailand in recent years the country is reporting decreased deaths in 2005 due to the new availability of anti-retroviral drugs (ART). Senegal has an infection rate of about 1%, compared to rated of 25-30% of some African countries. This is attributed to strong government intervention and concerted longtime measures at education and prevention. Brazil's comprehensive program includes prevention and treatment. The latter goal was attained only through Brazil's fierce perseverance in manufacturing drugs and providing free treatment to all citizens despite obstructive international politics around patent and trade regimes.
Public health advocates studying HIV/AIDS epidemics are experienced enough (in grim, close-up, heartbreaking terms), to acknowledge that long term success requires consistent intense effort. To date, any level of "success" includes political activism from the highest levels of government (and as in Brazil's case, from activist citizens), participation and leadership by women, access to medication, public campaigns (for instance via churches and radio) and community education to de-stigmatize the disease and promote testing and monitoring. This is in a addition to supporting behavior modification, building vital public health infrastructure, having financial resources and trained medical staff. This isn't necessarily an exhaustive list.
Brazil's success in particular is instructive and hopeful, however that country has clear advantages because it is one of the world's largest economies and has some historical idea of what public health infrastructure looks like. Most countries where AIDS rampages are extremely disadvantaged by comparison.
Contrary what most public health advocates agree makes as effective prevention policy, the Bush administration pushes an "abstinence" only message that lets a lot of these success factors slip through the cracks. For example, abstinence until marriage without condoms leaves women, who have 40% infection rates in some countries, tragically vulnerable. No access to drugs or treatment gives some people little incentive to be tested. The policy flies in the face of decades worth of scientific experience and leaves many who are engaged in preventing and controlling HIV/AIDS sputtering with frustration.
Yet to confuse matters perhaps, researchers reported last week that in a province in Zimbabwe called Manicaland, HIV infections decreased between 1998 to 2003 from 23 percent to 20.5 percent by delaying when they first have sex and having fewer casual partners. The research by scientists at the Imperial college of London showed that people had modified their behavior over the years resulting in the "first" reduction of HIV infection in sub-Saharan Africa, the region most stricken by the spread of the virus. The study; "HIV Decline Associated with Behavior Change in Eastern Zimbabwe", was published in last week's Science: (Gregson et al.: Vol. 311. no. 5761, pp. 664 - 666).
The news is hopeful and confirms reports by the World Health Organization last year. Yet many are warning that these research findings are open for interpretation and could possibly undermine the fight against the disease. If some of the factors assumed to be necessary for success, like political leadership and public health infrastructure, are important to the mitigation the disease, as public health advocates almost uniformly concur, Zimbabwe's current government has the opposite profile. This study takes place against a backdrop of political depravity, violence, eviction, forced migration, a depressed economy and international isolation, a situation that seems to only worsen.
In addition there is inherent difficulty interpreting these types of studies. For instance Bush's abstinence idea is purportedly based on Uganda's erstwhile successful ABC program. But a study last year from Uganda concluded that HIV infection rates had actually decreased because of condom use and high mortality rates (C and D (death)), not (A and B) of the "ABC" program. Acronym Required wrote briefly on this last year. Increased death rates would lead to spurious results because individuals with multiple partners would die off and distort the distribution patterns of the population and the interpretation behavior-infection link over the course of the study. The authors of the current study seem to address this: "given the relatively small numbers of individuals who died, AIDS-associated mortality explained only 6.3% of the observed reduction in sexual partner change in men and 8.6% in women.... They add: "It cannot be discounted as an important long-term factor." (Does their death rate seem low?)
In addition, the number of changing variables within the data make it hopeful but challenging to believe that the results (even assuming reliable data) represent long-term success. So perhaps the study is good news, anything that implies a positive change in the HIV/AIDS situation is good news, however only time (or a more nuanced understanding of the data) will tell.
