Mapping Pathways is a multi-national project to develop and nurture a research-driven, community-led global understanding of the emerging evidence base around the adoption of antiretroviral-based prevention strategies to end the HIV/AIDS epidemic. The evidence base is more than results from clinical trials - it must include stakeholder and community perspectives as well.

08 July 2011

The Great Paradox of the HIV Epidemic

Mark Chataway is co-chairman of Baird’s CMC, a Mapping Pathways partner organisation. Here, he discusses the HIV landscape in Botswana and Zimbabwe.

"Every now and then, it strikes me that despite all our progress in the field of HIV, there is still so much for us to find out. This seems most apparent when I consider the HIV situation in two African countries: Botswana and Zimbabwe.

In 2001, Botswana’s then-president, Festus Mogae, said, “We are threatened with extinction. People are dying in chillingly high numbers. It is a crisis of the first magnitude.” The government acknowledged that tackling the epidemic was a matter of national importance, and it acted accordingly – Botswana became the first African country to declare its objective of providing ARV drugs to all its needy citizens. As in so many other fields, Botswana was to become a model for the rest of the world. (Having worked for the Government of Botswana as a consultant, I often wish that we, in the UK, were governed with equivalent honesty, efficiency and vision.)

Botswana has two significant HIV/AIDS-related initiatives with international partners: ACHAP (African Comprehensive HIV/AIDS Partnerships) and BOTUSA. Its own funding for HIV programmes has increased steadily. Botswana has achieved universal treatment access (that means at least 80% of Batswana who need HIV treatment are receiving it). Almost every major political and religious leader has addressed AIDS openly and often. There are enormous, well-financed programmes focussed on behaviour change and risk reduction. Yet, HIV prevalence is not falling nearly as fast as many think it should have done (click here for prevalence details).

On the other hand, there is the puzzling case of Zimbabwe, where HIV prevalence has fallen dramatically over the last decade or so – it peaked at 26.5% in 1997 and, according to government figures, fell to 14.3% in 2010. While this is an excellent development, it is also rather inexplicable. Access to treatment is very limited. A long-serving health minister was accused of sexually molesting adolescents (although he vehemently denied it) and other political leaders have addressed AIDS only sporadically. Sustained persecution of men who have sex with men has driven the gay community underground. Many of the urban poor have been driven from their homes and forced to live as refugees in rural areas. According to everything we know, Zimbabwe’s political upheaval, economic distress, and the collapse of many primary healthcare services should have exacerbated the epidemic. While some researchers claim the declining prevalence is a result of successful public-awareness and behaviour-change programmes, there are many troubling doubts in the international public health community about whether those factors really constitute an adequate explanation. The real explanation is probably complicated and involves the rising mortality from other causes, the inability of people to travel and the disappearance of much of the middle class.

The difference between these two countries brings into sharp relief the great paradox of the HIV epidemic – we just do not know why the epidemic seems intractable in some places but declines rapidly in others (or fails ever to take hold). There is no model that explains Botswana and Zimbabwe. There are similar paradoxes all over the world: for example, in India, Tamil Nadu has more AIDS cases than any other state, but it has an excellent healthcare system, relatively good status for women and very high levels of literacy and health literacy. Bihar is almost the opposite on every count but has very low HIV prevalence.

For me, it highlights how, even after living with HIV/AIDS for nearly three decades, the world still has so much to learn about the dynamics of HIV and how it functions in various scenarios. The need of the hour is well controlled, randomised clinical trials and policy analysis. We can then create more effective programmes based on good science."

[Content that is linked from other sources is for informational purposes and should not construe a Mapping Pathways position.]

1 comment:

  1. To that add Uganda. What explanation is adequate for the fall in the 90s of the numbers? I dont hold the view that 'AB' campaign was that succesful......, I think that is too naive.