US Policy and Public Health — AIDS in Africa

Interview with Benjamin Silverman

Benjamin Silverman is currently a medical student at the Johns Hopkins University School of Medicine. He has a BA degree from Johns Hopkins in the Biology and the History of Science, Medicine, and Technology. His Senior Thesis evaluated trends in hospice and end-of-life care in the United States. Benjamin has been interested in medical ethics and social responsibility throughout his academic career, and began involvement in Student Pugwash during college. He served as President of the Johns Hopkins chapter of Student Pugwash during his Sophomore and Junior years in college (1999-2001), and Chapter Advisor during his Senior year and continuing into the present. Additionally, he became involved in Student Pugwash USA at a national level as a SPUSA Board Member and Chapter Advisory Council Representative from 2000 to 2002.

In your opinion, what is the general American perception of AIDS in sub-Saharan Africa?

In recent years, the tragic epidemic of AIDS in sub-Saharan Africa has come to public attention, both in the United States and throughout the world. Most major news services have dedicated substantial coverage to the topic. A quick online search brings out cover stories from CNN, Time Magazine, and the Washington Post, among others, within the past two years. Despite this coverage, however, I have the feeling that most Americans remain unaware of the extent of the epidemic in Africa or are not empathetic to it. AIDS continues to be a problem in the United States, with new infection rates among heterosexual adolescents continuing to be particularly troublesome. Until the problems in our own country are conquered, I find it unlikely that most citizens will give an appropriate amount of concern to the AIDS epidemic elsewhere. It is also interesting to note that most of the special reports on AIDS in the United States occurred between one and two years ago. At this time, many reports marked the anniversary of the twentieth year of fighting against the epidemic in the United States. After this, the topic of AIDS has taken a back seat in the American health care arena to discussions of national security and public health efforts to combat potential bioterrorism.

Is there a difference in perceptions between generations?

Unfortunately, I do not have a good grasp of the answer to this question.

Are students aware of the developments and/or perceptions of AIDS in sub-Saharan Africa?

In my opinion, students are as aware as any population group of the problems of AIDS in sub-Saharan Africa. Groups on college campuses have worked hard to promote awareness and to support the global fight against AIDS.

Are there any unique cultural myths about AIDS in sub-Saharan Africa?

The most troublesome myths about AIDS in sub-Saharan Africa center on the poor of treatment women in African culture. Woman are frequently forced to have sex with men in the male-dominated cultures, preventing them from being able to look out for their own health. In some countries, a particularly tragic myth is that men infected with HIV can be cured by having sex with a virgin. As a result, many teenage girls become infected with the virus. At the same time, the atrocities of the male culture are not entirely to blame for the worsening AIDS epidemic. One myth held by African women is that a man who looks healthy can not have AIDS. Clearly, the understanding of AIDS in these countries is not accurate, and highlights the need for public health and education in the effort to slow the AIDS epidemic.

What is the percentage of people HIV+ or with AIDS in sub-Saharan Africa?

The document, AIDS Epidemic Update, published in December 2002 by the Joint United Nations Programme on HIV/AIDS (UNAIDS), provides the most recent and accurate surveillance of AIDS in sub-Saharan Africa. This region is by far the area most devastated by AIDS in the World. Currently, 29.4 million people are living with HIV/AIDS in sub-Saharan Africa. Approximately 3.5 million new HIV infections occurred in the region in 2002, while an estimated 2.4 million Africans died as a result of the epidemic in the past year. Based on 2002 population estimates, the prevalence of adults (ages 15 to 49) with HIV/AIDS in sub-Saharan Africa is 8.8 percent. In some countries, prevalence rates are particularly startling and are higher than ever thought possible: Botswana (38.8%), Lesotho (31%), Swaziland (33.4%), and Zimbabwe (33.7%). Even more troubling, 10 million people between the ages of 15 and 24 and 3 million children under the age of 15 are living with HIV/AIDS in sub-Saharan Africa. Unfortunately, these numbers show us that this epidemic, on its current path, will not be going away anytime soon and that the worst of it has yet to come.

How are the people HIV+ or with AIDS treated in sub-Saharan Africa?

Only a tiny fraction of the millions of individuals infected with HIV in sub-Saharan Africa receive appropriate antiretroviral treatments. Similarly, opportunistic infections are rarely treated sufficiently. Most news reports indicate that a positive HIV test in Africa is effectively a death sentence. In fact, a majority of countries in the region spend less than ten dollars per year on each citizen for health care. Even with reduced drug costs and generic medications, this figure pales in comparison to the amount needed for basic health care. Despite these reports, however, it is important to remember the power of human spirit in fighting against illness. Accounts of the bubonic plague terrorizing Europe in the Middle Ages frequently describe a population of people who were helpless in the face of infection and waited to die without treatment. This is a similar picture as is painted for HIV/AIDS patients in Africa. However, in Europe during that time, as I would speculate is also the current case in Africa, people did everything they could to fight against illness, from folk remedies to behavioral changes. It is rare that people give up all hope, even when medications are unavailable. The primary difference between these stories is that Europeans did not know how to treat plague, while Africans simply do not have access to well-established and effective therapies.

What programs are available to the public to promote awareness, specifically to the youth?

Although I am unable to comment on specifics of programs to educate the youth in sub-Saharan Africa about HIV/AIDS, I can offer evidence, from the UNAIDS AIDS Epidemic Update, that promoting safe sex and sexual health in young people does in fact have a positive effect on the AIDS epidemic. In Uganda, the rates of new infection seem to be declining in recent years, as evidenced by a steady drop in HIV prevalence rates in pregnant women between the ages of 15 and 24. At the same time, condom use by single women in this age group has almost doubled from 1995 to 2001, while an increasing number of women this age are tending to abstain from or delay their participation in sexual activity. The facts have shown that public health and educational programs have been effective, offering hope that we can conquer the AIDS epidemic, both in the sub-Saharan Africa and throughout the World. It is important to remember in addition to advancing medical technology, public health efforts played an indispensable role in decreasing the transmission rates of HIV/AIDS in the United States and other developed countries. The problem is not coming up with ideas to fight the epidemic, but in generating the money to implement them.

Who do you believe is responsible for the education of AIDS in sub-Saharan African countries?

Education is clearly the most important method of fighting the AIDS epidemic in developing countries. From an economic standpoint, I believe it is the responsibility of both African governments and those of developed counties to fund the fight against AIDS, from a medical and outreach perspective. However, I think the governments of the countries themselves have a unique ability to provide more effective education than outside interests. Education must take into account cultural practices and backgrounds to be successful, an approach most easily accomplished by local governments. At the same time, it is the responsibility of other countries to assure that the educational programs are accurate and unbiased.

What is the general stance of sub-Saharan African governments on HIV/AIDS?

The stance of African governments on HIV/AIDS has been a source of intense controversy over the past decade. The President of the African National Congress and of South Africa, Thabo Mbeki, had in the past questioned the well-established medical link between HIV infection and AIDS. Instead, he publicly suggested that life-saving antiretroviral treatments were part of a racist campaign to poison blacks. He refused to pay for such treatments because of their perceived lethality. In recent years, the reluctant governments in sub-Saharan Africa have been forced to take action against the AIDS epidemic, pressured by advocacy groups, churches, courts, media, businesses, and other countries, among other sources. In many ways, the countries still act in denial, but are at least heading in the right direction.

Do governments deem it a medical emergency?

Unfortunately, I do not have a good grasp of the answer to this question.

Are there any regional collaborative efforts?

Unfortunately, I do not have a good grasp of the answer to this question.

What role do you think the United Nations should play in fighting the AIDS pandemic in sub-Saharan Africa?

Currently, the United Nations has taken a leading role in coordinating the effort to fight the AIDS epidemic in sub-Saharan Africa. Established in 1994, the Joint United Nations Programme on HIV/AIDS (UNAIDS), teamed with the World Health Organization (WHO), has the mission of preventing new HIV infections, treating infected individuals, and mitigating the World wide impact of the epidemic. It aims to support a coordinated response to the AIDS epidemic, engaging partners from governments and the private sector.

It is my opinion that the United Nations has taken on an appropriate role in fighting the AIDS epidemic, but needs to continue to strengthen its efforts as well. Any effort to stop the AIDS epidemic must occur at a global level, a task which can be properly carried out only by an international governing body, such as the United Nations.

What do you think the role of developed/ industrialized nations should be in fighting the AIDS pandemic in sub-Saharan Africa?

The cost of properly treating AIDS in sub-Saharan Africa is prohibitive when considering the budgets of countries in this region. According to a WHO study (Bernard Hirschel), as reported by the Washington Post in 2000, the potential cost of treating all eligible people with antiretroviral drugs would be approximately 11.2 billion dollars in Uganda and 18 billion dollars in Zimbabwe. These estimates, based on a three drug therapy costing 12,000 dollars per year, are much larger than the entire GNP of the countries, not to mention the health budgets themselves: 172% of the GNP in Uganda and 265% of the GNP in Zimbabwe.

A similar study, "Cost and Financing Aspects of Providing Anti-Retroviral Therapy," by Katherine Floyd and Charles Gilks, reports that in 1996, the estimated cost for providing triple combination therapy to all eligible people in sub-Saharan Africa would amount to between 101.9 and 161.4 billion dollars.

While such numbers are astounding, they fail to take into account several recent developments. The production of reduced cost and generic medicines for use in Africa would dramatically decrease the expected cost of pharmaceuticals per person. On the other hand, the use of antiretroviral treatments on their own may not be truly cost effective; instead, they must be supplemented by educational and outreach activities and primary care health monitoring.

In any case, the costs are staggering in comparison to the health care budgets of countries in sub-Saharan Africa. If the developed nations of the World ever hope to end the AIDS epidemic, they must work to prevent transmission throughout the world. It is only a matter of time before strains of AIDS in Africa reach the developed World.

As a result, it seems to me that it is responsibility of developed nations to provide the funds to treat AIDS in developing countries, including regions in sub-Saharan Africa. This year, the United States has pledged 350 million dollars to the Global AIDS Fund. AIDS rights advocates argue that the United States should contribute to the fight for AIDS a percentage sum equal to its share of the World GDP, a number far surpassing current contributions. I believe that the US should set an example and make a strong effort to stem the AIDS epidemic in the developing World. Otherwise, the problem will not stay at a distance forever.

Submitted by: Liz Walsh, Education Program Coordinator