No Easy Answers to the AIDS Pandemic

The Invisible Cure: Africa, the West, and the Fight Against HIV/AIDS by Helen Epstein (Farrar, Straus and Giroux, 352 pages)

Beyond statistics of the dead and infected, little is certain about the HIV/AIDS pandemic.

No confirmed origin. Plenty of potential magic bullets, but still no cure. And in sub-Saharan Africa, the virus' ground zero, the woeful, shopworn question persists: Why has the spread been so rapid, so devastating?

So when Helen Epstein decides to call her new book The Invisible Cure: Africa, the West, and the Fight Against HIV/AIDS, a reader might be justified in thinking that here, finally, might be some answers. Epstein, a molecular biologist turned writer, has made a career of investigating and writing -- often brilliantly -- about the spread of HIV/AIDS in sub-Saharan Africa. Her work, which has appeared chiefly in The New York Review of Books, combines the authority of her scientific background with a writer's talent for making wonkish talk of research studies and HIV/AIDS policies highly readable.

I'll rip the Band-Aid off early: Epstein's book does not quite deliver on its audacious title.

The titular cure -- localized campaigns, spearheaded by unified and mobilized community members, to encourage widespread behavioral change -- is certainly promising. Collective mobilization has often been cited as the cause of the dramatic reduction in HIV infection rates in southern Uganda and northwest Tanzania through the late 1980s and early 1990s -- the lone victory in sub-Saharan Africa's nearly three-decade war against the virus. But Epstein doesn't extend her cure much beyond the theoretical, leaving it for others to consider the practicality of implementing most of her suggestions.

Yet Epstein's book is far from a disappointment. In fact, there is much to commend it as a primer for the legions of future HIV/AIDS policy-makers. By delving into the vast cannon of HIV/AIDS research and doing plenty of her own legwork as she approaches her remedy, Epstein roots out plausible answers to many of the most pressing questions on the subcontinent. And though a definitive cure remains elusive, her work could be instrumental in crafting more effective HIV prevention programs.

The book's first quarter is easily its most important. In the most illuminating chapter, Epstein reviews the conventional wisdom about how HIV is spread in sub-Saharan Africa. Specifically, she targets the theory that it is the result of high-risk groups -- truck drivers, prostitutes, migratory workers -- mixing with the rest of the population. This theory has led Western governments and NGOs, as well as many African administrations, to support prevention programs that focus on abstinence-only messaging or condom distribution.

But the reality of African sexual relationships has never borne out this theory. Africans who aren't mixing with high-risk groups are still getting infected. And the theory itself builds on the false premise that Africans are more sexually active, thus "mixing" more frequently, than any other races or nationalities. Studies show that Africans on the whole are no more promiscuous than their American counterparts, yet the spread of HIV has been limited in the United States, even as it has exploded across sub-Saharan Africa.

Instead, Epstein lights on a key difference in the nature of African sexual relationships, which goes a long way in explaining the virus' spread. While Western culture puts great emphasis on monogamous relationships, many Sub-Saharan Africans tend to engage in what Epstein calls "concurrent" relationships. Several simultaneous, long-term sexual partnerships.

These relationships develop for a variety of reasons: polygamous traditions, a culture of patriarchy, the economic advantages of such arrangements, especially for young, undereducated women. The tragic result is that these partnerships create "a stable interlocking sexual network," which, once HIV is introduced by a member, becomes a "superhighway" for the spread of the virus. Even the "stray spokes" -- the women or men who are faithful to one partner -- are at risk if that partner is linked to the broader network.

The reality of "concurrent" relationships has yet to permeate prevention strategies in Africa, which continue to hammer home messages of abstinence or condom use. Yet, as Epstein points out, many of the people who are at risk are in long-term, intimate relationships, making condoms a hard sell. And the focus on abstinence has been largely ineffectual, rarely significantly delaying the onset of sexual activity.

Instead of abstinence or condoms, she argues, dollars should be directed toward the third of the "ABC" prevention trifecta -- "Be Faithful" (or at least, "Reduce Your Partners"). Programs and campaigns that encourage partner reduction have "played a key role wherever HIV rates have fallen -- from the market towns of East Africa to the red-light districts of Asia to the gay enclaves of the United State," Epstein writes.

The success of these campaigns often hinges on whether they grow organically from or are adopted by communities, who will then ensure local customs are respected and traditional modes of disseminating information are utilized. "The intimate, personalized nature of Uganda's early AIDS campaign ... helped people see AIDS not as a disease spread by disreputable high-risk groups or 'others' but as a shared calamity affecting everyone," Epstein writes.

She also finds merit in national campaigns, like the Ugandan government's "Zero Grazing" effort in the late 1980s, which emphasized avoiding "indiscriminate sexual relationships." The key is that these broader campaigns dovetail with the messages of the community-based organizations, as Zero Grazing did in Uganda.

All of which leads naturally to her conclusion that, short of a magic bullet, the best solution available is targeted messaging and culturally derived suggestions for behavioral change spurred by committed communities.

Although she usefully highlights this promising approach, Epstein doesn't translate it into a workable framework for other governments or organizations to adopt. For instance, recognizing the importance of community-based organizations is helpful, but equally important is finding ways to ensure their sustainability. And how, exactly, does one go about inculcating a sense of collective responsibility, especially given the stigma already attached to AIDS? These and other issues aren't insurmountable, but they will require more extensive research and debate.

Perhaps Epstein's intention was to provide the insights and pass the onus of policy-making off to government officials, NGO leaders, and other writers and thinkers. If so, her timing couldn't be better. The publication of her book in May coincided with a House vote to allow the current and future presidents to waive the abstinence spending requirement of the President's Emergency Plan for AIDS Relief (PEPFAR). Currently one-third of all PEPFAR money must be directed to abstinence campaigns. While President Bush has been loathe to opt out and offend his conservative religious base, future presidents might. Former Sen. John Edwards, the first of the presidential candidates to announce a specific HIV/AIDS policy, called the emphasis on abstinence-only education "fighting with one hand tied behind our back."

As he and other contenders join the broader community of people searching for solutions to the AIDS pandemic, they would be well served to look in Epstein's direction for guidance.