"It is the most interesting book I have ever read and inspires me to do something immediate to save our civilization." —Hanh Lien, translator for the Vietnamese edition of World on the Edge
Chapter 7. Eradicating Poverty, Stabilizing Population: Curbing the HIV Epidemic
Although progress is being made in curbing the spread of HIV, 4.3 million people were newly infected in 2006. More than 40 million have died from AIDS thus far, two thirds of them in Africa—the epicenter of the disease. 56
The key to curbing the AIDS epidemic, which has so disrupted economic and social progress in Africa, is education about prevention. We know how the disease is transmitted; it is not a medical mystery. In Africa, where once there was a stigma associated with even mentioning the disease, governments are beginning to design effective prevention education programs. The first goal is to reduce quickly the number of new infections, dropping it below the number of deaths from the disease, thus shrinking the number of those who are capable of infecting others.
Concentrating on the groups in a society that are most likely to spread the disease is particularly effective. In Africa, infected truck drivers who travel far from home for extended periods often engage in commercial sex, spreading HIV from one country to another. Sex workers are also centrally involved in spreading the disease. In India, for example, educating the country’s 2 million female sex workers, who have an average of two encounters per day, about HIV risks and the life-saving value of using a condom pays huge dividends. 57
Another target group is the military. After soldiers become infected, usually from engaging in commercial sex, they return to their home communities and spread the virus further. In Nigeria, where the adult HIV infection rate is 4 percent, former President Olusegun Obasanjo introduced free distribution of condoms to all military personnel. A fourth target group, intravenous drug users who share needles, figures prominently in the spread of the virus in the former Soviet republics. 58
At the most fundamental level, dealing with the HIV threat requires roughly 13.1 billion condoms a year in the developing world and Eastern Europe. Including those needed for contraception adds another 4.4 billion. But of the 17.5 billion condoms needed, only 1.8 billion are being distributed, leaving a shortfall of 15.7 billion. At only 3.5¢ each, or $550 million, the cost of saved lives by supplying condoms is minuscule. 59
The condom gap is huge, but the costs of filling it are small. In the excellent study Condoms Count: Meeting the Need in the Era of HIV/AIDS, Population Action International notes that “the costs of getting condoms into the hands of users—which involves improving access, logistics and distribution capacity, raising awareness, and promoting use—is many times that of the supplies themselves.” If we assume that these costs are six times the price of the condoms themselves, filling this gap would still cost only $3 billion. 60
Sadly, even though condoms are the only technology available to prevent the sexual spread of HIV, the U.S. government is de-emphasizing their use, insisting that abstinence be given top priority. While encouraging abstinence is desirable, an effective campaign to curb the HIV epidemic cannot function without condoms. 61
One of the few African countries to successfully lower the HIV infection rate after the epidemic became well established is Uganda. Under the strong personal leadership of President Yoweri Museveni, the share of adults infected dropped substantially during the 1990s and has remained stable since 2000. Senegal, which acted early and decisively to check the spread of the virus and which has an adult infection rate of less than 1 percent, is also a model for other African countries. 62
The financial resources and medical personnel currently available to treat people who are already HIV-positive are severely limited compared with the need. For example, of the 4.6 million people who exhibited symptoms of AIDS in sub-Saharan Africa in 2006, just over 1 million were receiving the anti-retroviral drug treatment that is widely available in industrial countries. Although the number getting treatment is only one fourth of those in need, it is double the number treated during the preceding year. 63
There is a growing body of evidence that the prospect of treatment encourages people to get tested for HIV. It also raises awareness and understanding of the disease and how it is transmitted. And if people know they are infected, they may try to avoid infecting others. To the extent that treatment extends life (the average extension in the United States is about 15 years), it is not only the humanitarian thing to do, it also makes economic sense. Once society has invested in the rearing, education, and on-job training of individuals, the value of extending their working lifetime is high. 64
Treating HIV-infected individuals is relatively costly, but ignoring the need for treatment is a strategic mistake simply because treatment strengthens prevention efforts. Africa is paying a heavy cost for its delayed response to the epidemic. It is a window on the future of other countries, such as India and China, if they do not move quickly to contain the virus that is already well established within their borders. 65
56. Joint United Nations Programme on HIV/AIDS (UNAIDS) and WHO, 2006 AIDS Epidemic Update (Geneva: December 2006), p. 3; total deaths calculated using UNAIDS statistics in Worldwatch Institute, Signposts 2004, CD-Rom (Washington, DC: 2004), and in UNAIDS and WHO, AIDS Epidemic Update (Geneva: various years).
57. Nita Bhalla, “Teaching Truck Drivers About AIDS,” BBC, 25 June 2001; C. B. S. Venkataramana and P. V. Sarada, “Extent and Speed of Spread of HIV Infection in India Through the Commercial Sex Networks: A Perspective,” Tropical Medicine and International Health, vol. 6, no. 12 (December 2001), pp. 1040–61, cited in “HIV Spread Via Female Sex Workers in India Set to Increase Significantly by 2005,” Reuters Health, 26 December 2001.
58. Mark Covey, “Target Soldiers in Fight Against AIDS Says New Report,” press release (London: Panos Institute, 8 July 2002); “Free Condoms for Soldiers,” South Africa Press Association, 5 August 2001; HIV prevalence rate from UNAIDS, 2006 Report on the Global Aids Epidemic (Geneva: May 2006), p. 421.
59. Condoms needed from UNFPA, Donor Support for Contraceptives and Condoms for STI/HIV Prevention 2005 (New York: 2005); cost per condom from UNFPA, Achieving the ICPD Goals: Reproductive Health Commodity Requirements 2000–2015 (New York: 2005); Nada Chaya and Kai-Ahset Amen, with Michael Fox, Condoms Count: Meeting the Need in the Era of HIV/AIDS (Washington, DC: Population Action International, 2002).
60. Chaya and Amen, with Fox, op. cit. note 59; cost per condom from UNFPA, Achieving the ICPD Goals, op. cit. note 59.
61. “Who Pays for Condoms,” in Chaya and Amen, with Fox, op. cit. note 59; Communications Consortium Media Center, “U.N. Special Session on Children Ends in Acrimony,” PLANetWIRE.org, 14 May 2002; Adam Clymer, “U.S. Revises Sex Information, and a Fight Goes On,” New York Times, 27 December 2002.
62. UNAIDS, Report on the Global HIV/AIDS Epidemic (Geneva: June 2000), pp. 9–11; UNAIDS, op. cit. note 58, pp. 20, 446, 487; UNAIDS, “ Uganda: Country Situation Analysis,” at www.unaids.org/en/ Regions_Countries, viewed 14 September 2007.
63. UNAIDS and WHO, op. cit. note 56, p. 10; treated patients in 2005 from UNAIDS and WHO, Progress on Global Access to HIV Antiretroviral Therapy: An Update on “3 by 5” (Geneva: 2005), pp. 7, 13.
64. Clive Bell, Shantayanan Devarajan, and Hans Gersbach, “The Long-run Economic Cost of AIDS: Theory and an Application to South Africa,” Policy Research Working Paper Series (Washington, DC: World Bank, 2003); “AIDS Summit: The Economics of Letting People Die,” Star Tribune, 16 July 2003; Deborah Mitchell, “HIV Treatment: 2 Million Years of Life Saved,” Reuters Health, 28 February 2005.
65. “AIDS Summit,” op. cit. note 64.
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