Health: Africa: Dr Eileen Stillwagon of Gettysburg College proposes "radical approach to HIV/AIDS prevention"

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Taking a swipe at those who try to blame sexual behaviour for the rampant HIV epidemic in southern Africa, Professor Eileen Stillwaggon says that they are caught up in “exotic notions” about Africans. Instead, AIDS prevention efforts will be more successful if they focus on “biological and socio-economic factors” that can be addressed relatively easily and cheaply, she argues persuasively in the latest edition of Africa Policy Journal. “Differences in sexual behaviour cannot explain 50-fold differences in HIV prevalence around the world,” writes the economics professor from Gettysburg College. “Yet global AIDS policy relies almost entirely on behavioural interventions – abstinence or condoms – for HIV prevention.”

Southern Africa’s very high AIDS rate has been a source of much speculation. President Thabo Mbeki has been the most vocal proponent for poverty to be put on the global AIDS agenda, and has also condemned Western notions of African sexuality in the context of AIDS – but then undermined his cause by says that ‘a virus (HIV) cannot cause a syndrome (AIDS)”.

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Stillwaggon is no AIDS denialist, but she doesn’t mince her words when she condemns those who propose that changing sexual behaviour is the main solution to Africa’s AIDS epidemic. “Policymakers seem to be convinced (without evidence) that Africans are having more sex than Americans. “They do not ask why US college campuses, where rates of chlamydia [a sexually transmitted infection] and genital herpes are as high as 30 to 40 percent, do not have high rates of HIV.” She argues compelling for a return to “the fundamental causes” of the raid spread of AIDS in poor countries - biological and socio-economic factors.

As far as biology is concerned, says Stillwaggon, the immune systems of people in southern Africa are weakened by malnutrition and parasitic illnesses. First, malnutrition – a deficiency of energy, protein and minerals such as iron, zinc and vitamins – makes a person far more susceptible to infectious and parasitic diseases. These deficiencies make it hard for new cells to be built, including CD4 cells that protect the body from infections. A malnourished person usually has a high viral load because they have few resources in their body to combat the virus. People with higher viral loads are much more infectious, thus making their partners far more susceptible to getting HIV.

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Malaria, bilharzia and intestinal worms also drive up a person’s viral load

The malaria parasite stimulates the replication of HIV. Malawian men with malaria were found to have seven times the viral loads of HIV positive men who didn’t have malaria. Bilharzia is a freshwater worm that infects the urinary tracts of people. In young women, “its eggs infect the vulva, cervix and vagina, creating open sores,” says Stillwater. These sores make it easy for the HIV to get into the women’s bodies. A study of 500 Zimbabwean women found that those who had genital cuts caused by bilharzia were three times more likely to be HIV positive. Bilharzia is very high all over South Africa, particularly in KwaZulu-Natal, Gauteng, Mpumalanga and North West – provinces with high HIV rates.

“A malnourished, parasite-laden population gives rise to a very different epidemic dynamics from that of a healthier population, but models used by the major AIDS organisations do not take this into consideration,” says Stillwater. Instead, she says, they use a “one-size-fits-all” approach based on behaviour change that ignores factors that make poor people especially vulnerable to HIV.

The easier, cheaper approach would be to address nutritional deficiencies and parasite infections.

Aside from addressing biological risks, says Stillwaggon, there are straightforward, effective economic solutions that can reduce people’s risk of HIV infection. One, surprisingly enough, is “cumbersome trade regulations” that makes moving goods from one southern African country to another so slow. It can take 10 days to move goods into Zimbabwe, while Ugandan border officials don’t work over weekends and in some places border posts close at 4pm, says Stillwaggon. All this means that truck drivers have to hang around at borders, often with sex workers.

HIV among both truck drivers and the sex workers that service them is high. Addressing the efficiency of the border posts would reduce the risk of HIV transmission. But instead of modernising trucking and trade by computerising customs, says Stillwaggon, a costly US-sponsored AIDS initiative at borders focuses on “behaviour-change communication and condom distribution”. Yet behaviour change, while important, is out of the control of governments, whereas border reform is directly in their control, she points out. “Governments can change customs regulations or deliver safe water supplies and multivitamins more easily than they can chase down every person having unprotected sex,” says Stillwaggon. In addition, she says, we already know how to treat malaria, bilharzia and worms – and strategies to improve governments’ efficiencies are also known.
Stillwaggon’s approach is a radical departure from the norm, and offers fresh solutions to AIDS prevention where the decades-old mantra of “abstain, be faithful and condomise” has been unable to stop the spread of HIV.