Progress in Fighting AIDS in Africa?--Posner

With the decline in AIDS among the white population in the United States, the advent of effective treatment (the antiretroviral drugs), and the slowing in the growth of the international epidemic, Americans' interest in the disease has waned. Only about a third of one percent of the U.S. population is infected by the AIDS virus (HIV), and half of those are black (thus the per capita prevalence of the disease is roughly four times as great as its prevalence among whites). Among whites, the principal means of transmission are homosexual sex; among blacks, heterosexual sex and needle-sharing drug use. The international epidemic is undiminished, indeed growing, though at a diminished rate. Some 40 million people worldwide are infected by HIV, up from 8 million in 1990. But the international distribution of the epidemic is remarkably skewed. In North America and Western and Central Europe, it is only .3 percent, and in most of the world it is no higher than 1 percent. In the Caribbean countries, however, it is 1.2 percent (which is the approximate prevalence among U.S. blacks) and in sub-Saharan Africa it is at least 6 percent and perhaps as great as 10 percent. Because antiretroviral drugs are available to only about 20 percent of the infected population in sub-Saharan Africa, the death rate is much higher than elsewhere, and indeed about two-thirds of the world's AIDS-related deaths occur there. The ratio of total infected persons to annual number of deaths is about 10 percent in sub-Saharan Africa versus 1 percent in the United States. Even within sub-Saharan Africa, there are vast differences in the prevalence of the disease among the different countries. Most of the West African countries, including Nigeria (Africa's most populous country), have prevalance in the 5 to 7 percent range. But there are a number of countries in East Africa, notably the Republic of South Africa, where the prevalence is in excess of 20 percent (it is 24 percent in Botswana, for example). The overall prevalence of the disease in sub-Saharan Africa seems, however, to have peaked, so that the continuing increase in worldwide prevalence is being driven by increases in other countries, mainly in Asia. The disease is a principal focus of foreign aid by wealthy nations, multinational groups such as the United Nations, and private foundations such as the Bill and Melinda Gates Foundation. The total amount of money spent fighting AIDS in other than the wealthy countries has been estimated at $8.3 billion a year, of which $2.6 billion is spending by the affected countries themselves and the rest represents donations--so a total of about $5.7 billion in foreign aid. The money goes for such things as buying condoms, educating people about the disease, training health workers, and buying antiretroviral drugs. There is, of course, a great deal of waste. The United States devotes a significant fraction of its assistance to preaching sexual abstinence and requires that all the condoms it supplies be purchased from U.S. manufacturers, which charge much higher prices than Asian manufacturers. I am dubious that the foreign donations are money well spent, compared to alternatives. This is not because HIV-AIDS isn't a ghastly disease, and economically very harmful because of its debilitating effect on the working-age population, to which most of the victims belong; it is because the causes of its prevalence in those countries in which it is prevalent are social and economic conditions, or political decisions, that must be changed before there can be any real hope of significantly reducing the prevalence of the diseases, and that are unlikely to be changed by foreign money. The causes include profound ignorance about the disease (due in part to superstition and in any event an aspect of much broader deficiencies in education and literacy), miserable living conditions and short life expectancy which reduce aversion to risky behavior, migrant male labor that increases the demand for paid sex, cultural traditions of male promiscuity, female circumcision (a risk factor for HIV), and the extremely low status of women that drives many of them into prostitution and reduces their ability to bargain effectively with men over safe sex, to which men are more averse than women. Underlying all these things is the extreme poverty of most sub-Saharan countries, which in turn stems, in major part anyway. from the dreadful legal and political infrastructure of most of these nations. And, by the way, these awful conditions are not the legacy of colonialism, as is often charged. These countries were better administered when they were colonies, at least those that were French or British colonies; and many other former colonial nations, such as India, Singapore, Malaysia, Tunisia, and Trinidad, are prosperous relative to sub-Saharan countries, while Liberia, a sub-Saharan African nation that has never been a colony, remains profoundly disordered and impoverished. Because of the inadequate legal and political infrastructure in sub-Saharan countries, giving money to these countries for any purpose is likely to be a poor investment. This is dramatically shown by the case of South Africa, which has one of the highest rates of HIV-AIDS of any country in the world. Because of its mineral resources and its substantial white minority, South Africa is by African standards a wealthy country. Its GDP is almost $200 billion. Its leaders have been in a shocking state of denial concerning AIDS. Any money given to South Africa to fight AIDS is likely simply to replace the money that South Africans spend on AIDS. This of course is a general problem of charity, such as food stamps in the U.S.--if charity, even when earmarked for a specific expenditure, is less than the recipient would spend on the item anyway, his consumption of the item will be unaffected. So if a person spends $2,000 of his own money every year on food, and then is given $500 worth of food stamps, he will not eat more (unless having a larger total income increases his demand for food), but rather will spend $500 less out of his own pocket. The same may be true in the case of foreign assistance for fighting AIDS in Africa. An interesting contrast to South Africa is presented by Uganda. Unlike South Africa, Uganda is very poor; its annual GDP per capita is only about $1,500, compared to more than $12,000 for South Africa. Yet its HIV-AIDS prevalence dropped steeply in the 1990s, from 15 percent to 5 percent. Although its prevalence has been increasing somewhat since and there is dispute over the accuracy of the government’s statistics, it is generally believed that the prevalence of the disease in Uganda has indeed declined substantially--and has done so as a result of an inexpensive (only tens of millions of dollars) government campaign to educate people in the danger of AIDS. It is the kind of campaign that virtually any country could afford, without need for foreign assistance. In contrast, the antiretroviral drugs are expensive (even though sold at very low prices for use in poor countries) when the cost of the health-care infrastructure required for their effective administration is taken into account. Yet the drugs, unlike a vaccine (which has proved thus far impossible to develop, because of the extreme mutability of the virus), do not eliminate the disease; a person on the drugs can still transmit the virus. The South African and Ugandan cases suggest that political will rather than huge foreign charity holds the key to reducing the prevalence of AIDS in poor countries. HIV-AIDS is a disease readily preventable by financially inexpensive behavioral changes, such as the use of condoms, once people are alerted to the character and gravity of the disease. A government that communicates effectively with its people and makes condoms cheaply available to them will go far toward reining in the epidemic.

Comments

[Dan C]

Perhaps Americans should rewrite the tax code and restrict the ability of charities to set their own private foreign policy. However, I think the externalities these charities can create for America, such as positive feelings about the United States should be included in the calculations.

Also, don’t discount the ability of private firms in the United States to use government agencies to push an agenda overseas. I remember a friend who was working in East Africa telling me about the anger directed toward United States relief efforts. I was, at first, surprised that locals had very mixed feelings about receiving excess American grain. Until he explained that local farmers complained that they could not make a living farming when the United States was giving away grain (which did not always go to the most needy, but just entered the general market for grain because of government corruption etc.) Some of the more strident farmers claimed that it was a plot by the United States (and corporate interests) to encourage dependency.

On the Aids issue: A possible solution, devoid of moral restrictions, but still following Judge Posner’s logic, might suggest that the Gates Foundation should be running whorehouses in Africa.

The Gates could recruit prostitutes, raise salaries, and require that they keep clean houses (no unsafe sex, regular check-ups, etc.). Increased incomes and status for female prostitutes made possible from a Gates (or other foundation grant) could have, if you will pardon the phrase, the biggest bang for your charity buck.

Pay a premium for uncircumcised females, a discount to circumscribed males, fire prostitutes who don’t practice safer sex, etc. and you might create real social change. Not all positive changes, but if you want to concentrate on reducing Aids it may get you much closer to your goal.

I don’t think any current African governments are doing much to help female prostitutes, or females generally, so the crowding out issue becomes mute.

In combination with strict laws against freelance prostitutes, the government could grant (or sell) cathouse licenses to a private foundation, or have them government run, and have a real impact on Aids infections in Africa.

Rather then claim that private charity money is by nature largely wasteful, we should concentrate on new creative enterprises that generate the enthusiastic support of local politicians. What African despot could resist the profits from monopolistic bordellos that come with international subsidizes.

Heck, while I am going crazy, why not tax the whorehouses and use the revenue to finance the purchase of Aids medications.

Of course, the Gates would not, I think, enjoy being depicted as a pimp and madam in the international press. So the desire to look good is more important then to do good, so perhaps we should get rid of the tax advantages for these private foundations.

I leave the relative merits to others.

[Dan C]

Sorry
a discount to circumcised males

not

a discount to circumscribed males

[Randall Gremillion]

The whole logical underpinning of the African AIDS Epidemic makes little or no sense to me. Poverty and disease are rampant in sub-Saharan Africa and I don't understand how anything approaching meaningful statistical reporting and testing can be done. People are dying there certainly, but the WHO definition of AIDS is so vague that if you or I went to Africa and caught a flu bug we'd be classified as an AIDS patient. I sense that much of the AIDS hysteria in Africa and the subsequent tacit acceptance of it in the US media is a way of "getting the message out" (and therefore perhaps expiating some guilt) about African misery by connecting it to a disease that has a place in the US consciousness.

Am I wrong? Most of the studies and numbers I've seen are fairy tales made by interested parties.
Who can impartially answer these questions?

[alvin]

Judge Posner or anyone else:

I wish you would explain why you think sexual abstinence won't work, but that promotion of condom use can prevent spread of disease?

It seems pretty simple to avoid HIV/AIDS: Wait till you're married before having sex and don't share needles.

[Joel Pinheiro]

I am one with Alvin: why not support abstinence, which is the only 100% effective way?

[Haris]

Alvin/Joel
Because sadly, it doesn't work. In the long run, advocating abstinence is a viable strategy. But in the short run [like, a generation], it doesn't work. Abstinence is essentially a values issue - most people won't abstain if the choice is abstinence or safe sex, unless they value abstinence for another reason. An alternative to abstinence is necessary at least during a transitional period, in which the value of abstinence is instilled.

[KipEsquire]

"The causes include profound ignorance about the disease (due in part to superstition)..."

Due in far larger part to the Roman Catholic Church, which continues to insist that using a condom is a sin.

[Chris Hammond]

KipEsquire,
I'd argue that the Roman Catholic Church has less to do with the lack of condom use in Africa as does superstition, and African tribal religions.

After all, just 7% of South Africans are Roman Catholics, with an unknown but certainly higher percentage (I am guessing about 20%) being atheistic or subscribing to some form of tribal religion or superstition.

[Scape]

To Alvin:

95% of the American population engages in premarital sex, and has for generations. If the abstinence message doesn't work here, why should it work in sub-Saharan Africa? Condoms /are/ effective-- if they're used. Increasing the social and economic status of women would be a significant step in combating AIDS, as it would allow women greater power in insisting on the use of safer sex practices.

On average, Americans are more promiscuous than the citizens of African countries with even the worst rates of HIV infection. The difference is that Americans are far more likely to use protection than are their African counterparts.

[Randall Gremillion]

The kind of promiscuity you are talking about seems a little incredibles, in that it would have to involve an unenending string of serial partners of both sexes. I can understand different moral standards or norms, but is there some big sex party in Africa none of us know about? The numbers and sexual practices don't differ significantly from the US where AIDS is virtually exclusive to the gay community. As I said earlier, none of this makes any sense.

[Wes]

The total amount of money spent fighting AIDS in other than the wealthy countries has been estimated at $8.3 billion a year,...On the subject of inefficiency, the USA spends more in a month on the war in Iraq than the rest of the world spends in a year on the problem of AIDS in developing countries.

[Jack]

A few random comments:

The stats for sexual activity among youth who've taken a vow of abstinence til marriage are virtually identical to the rates for the general population.

While the rate of AIDS is higher for gay males the number of cases are about equal with heteros. Sadly one vector we have in common with Africa is that of traveling truckers or conventioneers getting it from drug using prostitutes and bringing it home to wife and perhaps new borns. (Here our health care techs would, mostly, prevent passage to infants but not so in most of Africa)

Did you know that in Canada's large cities there are health workers who actually go to the streets seeking out needle using drug addicts and give them clean needles along with a pamphlet on where to get treatment on demand when they are ready?

A big and important contrast from the US where "conservatives" from the Reagan era, policies of AIDS epidemic neglect, to the present have foolishly, but energetically opposed needle exchange programs.

Randall.... why so cynical? An AIDS test is now a simple and quick process. Just as with political polling statisticians can extrapolate from a small sample. For a nation or country they'd select geographic sampling areas to avoid applying a city or rural rate to the entire country.

BTW where'd you get this idea: "Most of the studies and numbers I've seen are fairy tales made by interested parties."

Who are the tellers? and who are the "interested parties?" Jack

[owinok]

Judge Posner is consistent in his views about what the problems in Africa and maintains that about the HIV epidemic. For once, I think that he ought to take cognizance of certain facts.

For instance, the comparison of the HIV /AIDs trajectory between Uganda and South Africa strikes me as very casual and inappropriate. The former was among the first countries in Africa to have a full blown AIDs epidemic which was also driven by the long civil war in that country. I think this factor is material for any dispassionate analysis because all interventions aside, the infection rates reached its peak much earlier than it would have in Southern Africa.

Secondly, granted that substantial portions of sub-Saharan African populations are uneducated, it is an overstatement to claim that there is widespread ignorance of the dynamics of HIV infection in that continent. Related to this is the very real question of female genital mutilation. While it is a repugnant and violent practice, I have never encountered evidence that it is a driver of the HIV epidemic.

Thirdly, if judge Posner's thesis is that Africa's institutional infrastructure is a signifcant part of the problem, then one would expect that countries that score higher in that regard would have a better handle on the prevention and treatment of HIV and AIDs. Botswana is one of Sub-Saharan Africa's better governed economies. In spite of its relatively good economic and political stability, the infection rates are virtually the highest in the continent.

Preliminary reports of a study concentrated in east Africa have established that malaria infection triples the likelihood of infection upon contact with HIV.

In sum, most sub-Saharan African countries are governed by undeniably incompetent fashion but for HIV, it appears that the institutional quality thesis does not explain it all.

[Garth]

I posted this on my blog... I agree generally with Posner's point...but the language used is priceless:
"effective bargaining" for safe sex - only a member of the Ivory Tower

Just what would effective bargaining for condoms etc entail?:

guy: oh that's so hot, keep doing it
girl: you like it?
guy: wait what are you doing, I don't wanna use that
girl: I just wanna be safe sweety
guy: but it feels weird
girl: I'll rub your feet later?
guy: Hmm, that's a decent proposition, but I'm not completely sold
girl: I could also go to that football game like you've been asking me to
guy: What about the foot rub, the game, and maybe we get to have sex later this afternoon
girl: I'm afraid the costs of all that exceed the benefit of using a condom - my utility preferences at this point is to not have intercourse with you at all
guy: That seems sub-optimal. Alright, you don't have to go to the game or give me a foot rub -
just some marginal sex this afternoon
...
girl: I dunno babe, we've been bargaining so long now that it's already dinner time.

[Dan]

An in-depth report from the LA Times today outlines how the
Gates Foundation's investments in oil companies and polluters undermine its work on AIDS and malaria. It dovetails nicely on this week's and last week's topics (maybe they've been reading the blog!).

http://www.latimes.com/news/la-na-gatesx07jan07,1,6935188.story

[Randall Gremillion]

I don't know if "the rate of AIDS is higher for gay males the number of cases are about equal with heteros" counts as a lie, a damn lie or statistics. Male homosexual and homosexual/intravenous drug use infections account for over half of the US' HIV+ cases, but you're talking about only 5% of the US population (probably much smaller if you limit it to homosexuals who regularly engage in high-risk practices).

As far as meaningful statistical analysis, how can this can be realistically achieved when you have African nations clamoring for foreign capital, The WHO and CDC which have included any poverty-related illness as part of the AIDS diagnosis without any HIV test been given, mind you), testing in Africa which is only done in pre-natal clinics (where pregnancy can create a false positive) and extrapolated to the general population, and finally US Gay and AIDS organizations looking for a bully pulpit to retain public interest and Federal funding?

[Jack]

Randall Re: "I don't know if "the rate of AIDS is higher for gay males the number of cases are about equal with heteros"counts as a lie, a damn lie or statistics."" ??????? This is what I found to corroborate what I posted with a single click. You may want to answer your question for yourself with a few other clicks.

* An estimated one million people are currently living with HIV in the United States, with approximately 40,000 new infections occurring each year.
* 70 percent of these new infections occur in men and 30 percent occur in women.
* By race, 54 percent of the new infections in the United States occur among African Americans, and 64 percent of the new infections in women occur in African American women.
* 75 percent of the new infections in women are heterosexually transmitted.
* Half of all new infections in the United States occur in people 25 years of age or younger.

JK.... I've an "absolutist" approach to the AIDS epidemic.... that is that and AIDS case is an AIDS case regardless. And with the cases being about 50-50 between hetros and gays we'd be fools to target eradication among only one group, especially at the fastest growing group are young hetros.

Your second paragraphs reads like the "stuff" of "talk radio" and "faith-based" ideologues. Is that the case?

Garth! good chuckles!

Dan: Perhaps we should have a thread here as to whether it does any good in an age of nationless international corporate activity, for large investors, or anyone else, to redline the, subjective, worst of them from their portfolios. I'd suggest it doesn't.

For example if Gates and any number of "good folk" withheld investment enough to have any effect at all on the stock price the resulting bargains will be attractive to someone willing to scoop up the "poor corporate citizen" premium so their stock would tend to revert to the norm. ie no effect.

I suspect the case is a bit different though on the positive action side of investing in companies one believes are trying to do well by doing good, such as companies that focus on conserving oil as compared to making their money by drilling for more in countries with little respect for civil rights and human dignity. Confusing? Yep! But I think investors can help the do-gooder company by making it easier and cheaper to raise capital but can not hurt a BP or Exxon.

[Anonymous]

Ben: First off I'd like to reiterate that I consider and AIDS case to be an AIDS case and that in combatting the epidemic it would be wise to work just as hard in lowering the absolute number of cases.... regardless.

But.... as you brought up the slippery nature of stats let's take a look at them in light of your post and your seeming approach of deciding some cases are more important that others:

As you point out the new cases among those engaging in homosexual activity (which goes well beyond just that subset identifying themselves as "gay".) are 65% plus 5% for IV drug users a total of 70%

Despite "AIDS is (physically) much harder to transmit heterosexually" (to which I'll agree) your CDC pie chart shows a 78% hetero contact as the source of infection for women along with a 16% for hetero males.

And can we agree that we're not doing too well at containing the epidemic? While the 42,500 new cases in 04 is not a lot higher than the 39,500 new cases of 000, it's not less either and we're still adding over 40,000 new cases each year to a base of 415,000, each of which is a potential vector for further spreading of the disease to both the smaller "gay" community and the much larger hetero community.

Given that IV drug use accounts for 20% of both male and female it would seem that the lowest cost "no brainer" would be that of free needle exchange, and because it would attack several very costly birds with one stone, a much higher committment to treatment on demand for those addicted to drugs.

Perhaps effective needle exchange alone could cut IV transmission in half? which would be a ten percent reduction in new infectees which I assume would compound downward as those 4,000 not infected in any given year would not be vectors for transmission in any subsequent year.

One thing you could NOT say might be that of retracting that "AIDS is not one of the major problems of Africa" as it's a bit on par with denial of the holocaust, except for there being many more victims; both those who are dead and dying and a generation of impoverished orphans left behind. Jack

[Garth]

What is all this talk that AIDS is not an epidemic in Africa???

I suppose you believe the holocaust didn't happen either?

From wikipedia - Inhabited by just over 12% of the world's population, Africa is estimated to have more than 60% of the AIDS-infected population.

...yeah, I'm sure it's a mass conspiracy.

And I find the quote: "AIDS is (physically) much harder to transmit heterosexually" to be at least misleading and at most wildly innacurate. What's so much "harder" about it. HIV is transmitted via seminal fluid. Condom use among heteros in Africa is virtually non-existant.

...Maybe I'm missing something. If so, please tell me.

[Dan C]

According to the Kaiser foundation:

In the United States, in 1985 women represented 8% of new Aids diagnoses. In 2005, women are 27%. As of 2005, 1.2 million people live with HIV/AIDS in the United States with about 300,000 of them women.

Black women in the United States account for 67 % of AIDS cases (for women over age 13). The rate in Black women is 24 times higher then for white women. In 2002, HIV was the leading cause of death for Black women aged 25-34.

In the United States, in 2005, 71% of women are infected through heterosexual sex, 27% percent from injection drug use. Having another STD increases risk of infection during heterosexual sex.

Cervical barriers and new microbicides are being researched as a way to prevent STDs in general and HIV.

Black Americans (male and female) account for 50% of the Aids cases diagnosed in 2005.

In 2005 the AIDS case rate per 100,000 for Black men is 103.6, black women, 49.9, white men 13.1. In 1985 Blacks were 25% of new AIDS diagnoses, in 2005 they are 50%.

The Kaiser study says that white men are much more likely to be infected through homosexual sex, but for some reason does not give data. But in a study of 5 major cities, 46% of black men who have sex with other men were infected: 21% for white men, 17% for Latino men.

Black teens (13-19) accounted for 73% of new AIDS cases reported among teens in 2004.

Accurate data from Africa seems to be difficult to acquire. There may be incentives to over count the number of AIDS cases. Since, I am told, diagnosis is often based on symptoms not test results, data can be easily distorted. Some data is based on pregnant women going to clinics, which is hardly a random sample of the general population.

Still, what is the root cause of the problem in Africa? If stories are to be believed, African men who engage in heterosexual sex are far more likely to acquire HIV/AIDS. Why? Perhaps they have untreated STD’s that make transmission easier. Perhaps prostitutes in Africa work until they die and have higher viral loads. Perhaps Blacks are more prone to the disease, for some reason (thus the higher infection rate in Black Americans and Africans.).

So what is the root cause? Since HIV/AIDS is transmitted by sex or injection drug use, reducing HIV/Aids means changing sexual activity. Treating STD’s in general may reduce the infection rate. Giving prostitutes, or others, microbicides to reduce the risk of transmission.

I do wonder about studies that claim that sexual activity in the United States and Africa are similar. While the frequency may be close, I doubt that Americans go to prostitutes at the same rate as Africans (labor patterns contribute to this). If Americans were somewhat randomly having sex with each other, you would expect lower infection rates then in Africa where some males are regularly going to prostitutes. The number of sexual encounters may be the same, but they are of a very different nature.

Perhaps, too many Africans do see the marginal benefit of a few more healthy years in the future as too low to compensate for the cost of safe sex today. But what is the cost of safe sex? Minimal. Perhaps the current emphasis on the orphans of AIDS will generate greater maternal instincts and encourage women to engage in safer sex, if not to protect them, then to protect their children.

[N.E.Hatfield]

The problem with trying to solve any societal problem lies with controlling the Devils Handmaidens; corruption, ignorance, and poverty. All readily apparent on the Dark Continentand in Asia. Perhaps, these should be dealt with first before venturing into the "Heart of Darkness". Ahh, Kurz! Here we come for better for worse! At least it would make each dollar spent more effective.

It's truly amazing how most Americans and Europeans are ignorant in the ways of most of the world.

[Randall Gremillion]

I'd like to dispel the notion that my comments somehow imply that the suffering of Gays or Africans merits any less attention or compassion than the suffering of your average over-privileged US White Male. Africans are dying in droves, as they always have, from the crushing weight of poverty, greed, political corruption, poor sanitation, internal warfare, vestiges of colonial mismanagement and a host of other problems.
I have only two points to make, which I believe are well documented for anyone with eyes to see, are

1. All objective evidence points to the conclusion that the African AIDS epidemic is a sham. People are dying in Africa, but from what they have always died of. The African AIDS Epidemic is a well-intentioned but logically vacuous fabrication meant to direct attention to the continually suffering but long-neglected peoples of Africa. It is perpetuated in this country because

2. the dire predictions of AIDS as "a disease that strikes everyone" have not materialized and the AIDS industry in this country, sensibly equating the loss of public attention in AIDS to a loss of their own funding has sought another arena to further their cause. I am not say that this is some sort of evil conspiracy, only the confluence of many of the baser elements of human nature.

Does this mean we should ignore the suffering of Sub-Saharan Africa? By no means! It just means that we should do the right things for the right reasons.

Thank you for reading.

[Dan C]

Randall
Even if AIDS cases in Africa were overstated by 500% it would still be a terrible health crisis. While accurate data on AIDS in Africa may be hard to obtain, I see no reason to believe that it is a fabrication.

If you had data from some village that showed that HIV deaths were really TB or something else, I might agree with you. But it is hard to believe that AIDS in Africa is some sort of myth. Why would so many create this grand conspiracy or - even harder to believe - independently create such a myth?

In any case, Posner's point is that external attempts to combat disease in Sub-Saharan Africa may be a waste of money. For Judge Posner a more cost effective course would be for these countries to take a rather low-tech approach - to educate people on the dangers of disease. Much as basic improvements in sanitation in previous generations had a huge impact on health outcomes, - simple preventative measures in Africa can reap large rewards.

I find a few problems with Judge Posner's approach. One, absent the political will in many African countries, I can support funding by foreign agencies to educate the population on the causes of diseases. Is it cost effective? While his approach may be more cost effective other approaches can still have a positive NPV - depends on how you value each year of life you safe.

Next, while I understand that the goal should be prevention, I am more optimistic that micro biotic research can find a way to block the virus from infecting. However, the African market for such a drug may not be profitable without the promise of payments by third parties, private or public.

With a smaller, but still serious, AIDS problem in the United States the market for such drugs is shrinking. Plus, the political pressure on drug companies to lower prices only serves to reduce research in such drugs. Absent a possibility of payment by a credible source (which eliminates most African leaders), who will take on the task?

Judge Posner can argue that simple steps will get us most of the way to the goal, less disease, if the African leaders have the will power. African leaders are the best change agents in their respective countries. I think medical research can take us farther but it requires outside assistance.

[Jack]

Hatfield: Thanks for the helpful Kaiser info. As for waiting until corruption is conquered or even "minimized" we here in the US would get little done were we to do such waiting. No, the running of a country is that of dealing with many issues at once and realizing that finding an equilibrium of getting the priorities right is an ongoing quest and one that is never achieved and even the best of democracies "muddles through".

Many of the posts here seem to indicate a complacent belief that we in the US have the AIDS epidemic under control or that it is a ho-hum/yawn "gay" or "black" problem of little risk to our "white" or should I say middle and upper income group as the "black" problem is largely one of poverty, prostitution and drug use.

But the US numbers are hardly encouraging: The new cases are increasing and keeping up with adding 10% per year to the 2004 base of 415,000. Though most of the new cases are among an age group perhaps centered around 25-30 let's assume that 30% of the new cases die within a year or so.

That still leaves a growth rate of 7% which gives us a doubling time of 10 years, (Rule of 72) that far outstrips the growth of our population. Perhaps the fairly young group, assisted by new medications, will live long enough (30 years) for three doubles before death from natural, or advanced AIDS causes, has much effect.

So, unless we find more effective means of lowering the infection rate we'd have perhaps 3.3 million by 2035. Today we've an infected rate of perhaps .2% of 200 million adults. The 2035 rate may be 1% of say 300 million adults or five times today's percentage. But, as the ratio of those infected to non-infected rises we'd expect the rate of of new infections to rise as well.

Much of the problem in Africa, Randall's unsupported claims aside, is that a sort of critical mass has been reached where a very high percentage of any sexual activity or birth-giving events carries a tremendous rate of risk and a nuclear expansion of new cases that will be very difficult to reverse. That's the reason CDC tries to nip epidemics in the bud.

The US would do WELL to redouble our own efforts to avoid the scenario my envelope scratchings above would indicate and in terms of cost alone an aggressive needle exchange program and treatment on demand for those addicted to drugs will seem a very good investment as compared to the costs of caring for three million or more AIDS patients in the near future.

I'm not leaving out hopes of changes in behavior, it's just that I know how to distribute clean needles and other than educational efforts I don't know how to change behavior in others. Treatment on demand is something we should have been doing for a whole host of reasons, not the least of which would lowering our crime and incarceration rates; the spread of AIDS is just one more compelling reason to get serious about it today.

[Paul]

Uganda uses an abstinence element in its educational program. Why the reluctance to concede that it has some utility?