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]

About 40,000 new cases a year are diagnosed in the United States. This has remained steady for a decade, down from 150,000 cases in the 1980's.

About 17,000 people a year die of aids. Age adjusted HIV death rate has declined more then 70% since a the peak in 94-95. The decline is in part from the decline in new cases (since the 80's) and the success of new medications.

Populations being infected have changed. Heterosexual transmission was 3% of new cases in 1985. It grew to 31% of all new cases in 2005. During the same period homosexual transmission dropped from 65 to 43%. As mentioned earlier, most of the growth in AIDS is in the Black community.

The above is from the Kaiser Foundation.

I have little faith in needle exchange efforts. I have yet to see a drug addict who will faithfully keep clean needles. As long as they remain an addict, they will continue to take unsafe risks.

Blacks still consider AIDS one of the top health issues. It has become less of an issue for others racial groups.

Homosexual sex is still the easiest way to transmit the disease with 58% of all new cases.

AIDS is still a very real problem but compared to what it looked like in the 1980's it is less of a problem for most groups.

So increasingly HIV/AIDS is becoming a Black problem in the United States. That is still an American problem.

[Dan C]

Correction
Should read:

Homosexual sex is still the easiest way to transmit the disease with 58% of all new cases in males.

This is getting off topic, but needle studies are very mixed. In my opinion, where they are used they have some impact but minimal. I believe that tracking studies will show that most addicts may exchange needles from time to time, if they can, but to expect this group to do it all the time is wishful thinking. The longer they remain an addict, the more likely they will slip into risky acts.

I could support paying addicts for turning in used needles to keep them from injurying sanitation workers and losing them near school yards.

But the way to save an addict is to end the addiction.

[me]

What if the Gates Foundation (or someone rich) invested in R&D to develop a fantastic condom that men want to use? A condom that actually *improves* sexual pleasure, distributed freely or cheaply, would be used more frequently and reduce AIDS transmission. If we can put a man on the moon, why can't we build a condom that feels great?

[NRWO]

KippEsquire:

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

There is a rational, empirically based argument that condoms do NOT reduce AIDS in Sub-Saharan Africa but, paradoxically, increase disease rates.

The theory is that condom campaigns encourage adults to have more sex, and more risky sex, than they otherwise would engage in, and that, given the failure rates of condoms for disease protection, the campaigns actually increase disease rates.

The intuitively appealing response (give condoms) may not always be the best one in some areas.

[Joel Pinheiro]

It is a very weak argument that which blames the teachings of the Catholic Church for the spread of AIDS.

Yes, she morally condemns the use of condoms. However, at the same time, she condemns sexual relations outside the bonds of marriage.

What a strange new breed of pious Catholics! So mindful of Church teaching when it comes to condoms, but who disregard entirely her teachings on chastity and marital fidelity, of which the prohibition of contraception is a consequence.

[Jack]

Dan? I'm wondering if you read the summary of needle exchange studies I posted? You're welcome, of course, to your opinion but it seems counter to what the studies showed.

Here's a simply question that may shed light on the subject in the US. As the US, unlike many other "advanced" countries bans over the counter sales of needles; what option does the addict have here? Why would we leave addicts cornered in such a manner? My bias leans heavily toward universal, free and easily available needle exchange over selling them over the counter to the general public.

The study summary went on to discuss, precisely, your concern of how long needles are out there and the percentage returned that are infected with AIDS.

Your concept of paying to get needles returned seems positive, but I guess exchanging clean for dirty would be payment enough and about all that could be hoped for in our current political climate/bankruptcy.

"But the way to save an addict is to end the addiction."

I too favor far more pro-active programs to treat and hopefully cure higher percentages of addicts for all the social and humanitarian reasons there are. But, for the purposes here of trying to prevent the further expansion of the AIDs epidemic, I have to assume the current addict population as a "given" and focus my attentions on how to mimimize them as the strong vector they are in spreading AIDS and creating a doubling rate of ten years those infected.

NRWO?
"There is a rational, empirically based argument that condoms do NOT reduce AIDS in Sub-Saharan Africa but, paradoxically, increase disease rates."

Ha! I can't help but ask if NRWO stands for New Right Wing Organization? But say you lost your spot as armchair empiricist and theoretician and instead were forced by extreme poverty to work as an African prostitute servicing 20 truck drivers per shift; are the tools of your trade going to include a very large box of condoms? Or, you later marry a truck driver, given what you know of Africa and truck drivers, might you feel unduly at risk having unprotected sex? Also, after he arrives home from a long trip what do you suggest as a tactic for having less sex?

[Edward]

"What a strange new breed of pious Catholics! So mindful of Church teaching when it comes to condoms, but who disregard entirely her teachings on chastity and marital fidelity,"

The problem is that the Catholic Church retains a great amount of power as an institution, (through it's hospitals, charitable organizations, politicians) yet as is the case around the world it can no longer persuade the masses to obey its dictates about sex.

One thing that's rarely mentioned in the debate about Aids in Africa is the striking difference between infection rates in Christian nations as opposed to Muslim nations. I assumed that this was because there is greater piety, and more draconian punishments for violating vice laws. But it's also true that some of these nations have been more receptive to distributing condoms than their Catholic neighbors.

[Jack]

Joel: As a matter of theology some guy once invited "he who is w/o sin to cast the first stone". Shall we follow His advice?

As a matter of history guiding us in public health perhaps we'll recall how syphillis ripped through the world before there was a cure, despite the death sentence risk.

It would be good for the Catholic Church and others to come to grips with their god having created creatures in which the sex urge trumps all else so frequently. In Africa they should square their position on unprotected sex with their positions on suicide and opposition to the death penalty. Fortunately, as posted here, they're only 7% of Africa.

[Dan C]

This is off topic but

The average injecting drug user injects themselves 1,000 a year. Do you think these people, even when clean needles are avaiable, are going to be that careful. I will argue that tracking studies will show, the longer you are an addict, the closer you are to AIDS. You stay using, needle exchanges will not safe you for long.

A study at Yale last year I think argued in favor of needle exchange programs but the real source of benefit is that the exchange process is done with attempts to counsel and test for HIV.

Also with more communities offering needle exchange programs, why are more drug users being infected with HIV.

[Dan C]

BTW

Sorry for typing errors, I'm tired.

But 40,000 new cases a year, 17,000 deaths a year. Net increase of 23,000 cases a year. It will take over 50 years to double the current HIV population. New cases are constant for the last decade, deaths may decline, but I don't see how you get twice the HIV/AIDS cases in the United States in ten years

[NRWO]

Jack:

Ha! I can't help but ask if NRWO stands for New Right Wing Organization?

No, it stands for Nothing Rhymes with Orange. I got tired of writing the full name, so I began using NRWO. I am a classic liberal.

I am not so sure that your (prostitution) example works: Giving condoms to prostitutes might encourage prostitutes to take on more and more risky sexual partners, and might encourage other poor women to enter prostitution under the (mistaken) presumption that condoms eliminate disease risk. This could very well increase disease rates. Indeed, there may be a parallel to regulations requiring seat belt use in cars. I believe that time series studies have shown that enactment of seat belt laws are typically followed by increased car accidents and bodily injury (but lower fatalities?). The theory: Once people wear seatbelts they are more prone to engage in risky driving, which increases accident rates. The general principle is that people are more prone to engage in reckless behavior when they believe that behavioral countermeasures (wearing seatbelts or condoms) minimizes it consequences. That’s probably true for individual events (individual sexual encounters or individual driving episodes) but the cumulative effect of engaging in repeated reckless behavior (which is encouraged by condom or seatbelt use) may, paradoxically, increase bad consequences.

To Judge Posner: I saw your piece on Second Life. Very cool.

[Haris]

No comments in two days. That must mean we solved AIDS in Africa, right? Good work everyone.

[Jack]

NRWO:

hmmm, is there a site where you can collect these, seeming, 180 degree canards? We've recently discussed drunk driving and auto "safety" and counter to your "beliefs" as safety belt usage has climbed to 80% or so US auto deaths have stayed flat in absolute terms but have dropped dramatically in terms of deaths per mile driven.

I hope you're no activist and that we'll be saved having to counter any campaign of yours for prostitutes to "go bare" and especially NOT in Africa where her odds of servicing HIV positives are likely one in two....... or worse.

BTW do you figure those tooling around in newer Volvos or other rigs with side air bags and all the safety stuff are the most reckless of drivers?

Howie: You've at least two truths going in your post. Observation of Bush does give one the feeling the Secret Service should have restraining gear close by. His announcement of the "surge" (escalation) and "new strategy" (your guess as good as mine) was flat and had none of the confidence or rallying effect of Churchhill's "we'll fight on the beaches.." speech and would have seemed even sillier if it did as this is NOT "America's finest hour" or anything even remotely in the neighborhood, but simply proof positive that he and his fellow, aging neo-cons, never learned any of the myriad lessons of Vietnam.

You're also right on housing, the Pollyanna's are "forgetting??" that while housing itself is but 6% of our economy the declines will be magnified by our multiplier rate that is about 4 times the primary economic activity.

Among the "smoked" numbers are some 10% of housing that has been "sold" but to "investors" (speculators) and they too are empty and on the market. As you mention some "solds" contracts are being canceled, and there'll be many who'll have to walk away from underwater values, ARMS and a host of other "deals" used to take a sale in the last couple of years. With the appreciation game being changed how many boomer couples say "Well this is it....... time to unload the family home? the speculative second home or condo?"

[Jack]

Dan I'll repost the summary of studies:

http://www.ucdmc.ucdavis.edu/news/syringe_exchange.html

????????? I asked the board what choice they have in a nation which A. does not SELL needles over the counter, B. has a sketchy programs of needle exchange? Let's take a look at your theory which I assume? you post in opposition to either A or B??

The average injecting drug user injects themselves 1,000 a year.

........ and were he, or more worrisomely she, the active drug using prostitute, to at least have one needle for themselves...... they can not infect themselves. It is the sharing of scarce needles that is the problem.

Do you think these people, even when clean needles are available, are going to be that careful.

......... often when folks say "these people" it's as though "they" have left the human race, have NO sense of self-preservation and have gone daft besides. This despite observing on nearly a daily basis what an otherwise sane, nicotine addict will go through or endure to feed his addiction. But why DO all this just to avoid making sure needles ARE readily available and offer an easy option of using one's own needle?

I will argue that tracking studies will show, the longer you are an addict, the closer you are to AIDS. You stay using, needle exchanges will not safe you for long.

........ no disagreement here. IV drug addiction is not life enhancing in the least, but ever were we a callous people unconcerned with "their" early deaths, we'd still be far better off lengthening that time.

...... Here's my path to a ten year doubling, using your numbers (despite my belief that life spans for HIV/AIDS is climbing rapidly)

OK 23,000 net new AIDS cases to be added to a base of 415,000 per year. Say, 5.5% increase. So, using "Rule of 72" for the increase of compounded interest we've a 14 year doubling rate. Rough envelope scratching to be sure as I don't know how many of the 415,000 base will die off in 13 years but we've already counted 17,000 AIDS deaths per year prior to compounding the additional percentages added to the base.

Why do I compound? Well, I figure that if the base "recruits" 5.5% new members, the next 23,000 will do the same.

What we need to see.... and why I'd sign on for a universal Federal needle exchange program in a heartbeat, would be a GROSS new infection rate of half what it is today. Subtract out the death rate and that base of 415,000 would be flat or begin its downward spiral. When, we, or even Africa turns the corner and the base begins shrinking by even 5% per year we're in a downward spiral of fewer to infect others and with a boost from natural lifespans ending for aging base members; the US problem could be near zero in that same 15 year period.

What tools do we have to fight with to cut the rate of new infections in half? "Behavior changes?" "Abstinence??" And needle exchange. Take your best shot? Jack

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