Does a middle road exist to successful HIV prevention in developing
countries? An interesting item appeared today on the western African country
of Senegal, summarizing a recent news article in the Washington Post. It
suggests that there might be such a middle road that combines a broad message
of fidelity and abstinence (supported by local religious leaders), special
focus on high risk groups (i.e., commercial sex workers), early recognition
and treatment of sexually transmitted diseases, an active HIV testing program
(i.e., every six months for CSWs and on demand for others), and availability
and promotion of condoms (likely through social marketing).
Based on UNAIDS estimates of 1997, the prevalence of HIV infection among
adults, aged 15-49 in Senegal was 1.77 percent. This level is lower but
similar to the high prevalence countries of South-east Asia (i.e., Cambodia,
2.40%; Thailand, 2.23%; and Myanmar, 1.79%).
Perhaps other groups in Asia are experimenting with similar innovative
efforts that combine multiple strategies, and would be willing to share
their experiences in SEA-AIDS.
Daily Kaiser Foundation HIV/AIDS Report, Feb. 3, 1999.
"SENEGAL HIV-Prevention Program Worthy of Emulation"
had marked success in controlling HIV infection rates, and other African
nations and the U.S. should follow its methods, Village Voice columnist
Mark Schoofs asserts in the Washington Post. Senegal's campaign includes
an "enlightened approach to preventing prostitutes from spreading the disease,
according to Schoofs. To operate legally, prostitutes must be tested every
month for STDs and every six months for HIV.
Prostitutes who test positive for HIV do not have their licenses revoked,
since the government recognizes this would only drive infected prostitutes
underground. Instead, Schoofs says, they are "counseled about why practicing
safe sex is in their own best interest. With a weakened immune system,
picking up an STD from one of their johns could be fatal."
The campaign was started more than a decade ago by gynecologist and
STD expert Dr. Ibrahima Ndoye, who enlisted the help of "unlikely allies
-- religious leaders." Ndoye said, "We said that they could preach fidelity
and abstinence, but permit us -- NGOs and the government -- to promote
condoms." The compromise appears to have worked. In 1988, only 800,000
condoms were distributed in Senegal, but "by 1996, that figure had soared
to 7 million." In addition, the number of STDs, including HIV, has fallen
among Senegalese prostitutes over the past three years. "We considered
AIDS an epidemic since the beginning. We didn't do denial," Ndoye said.
An estimated 60,000 people in Senegal have AIDS and 1.77% are HIV-positive,
far less than other sub- Saharan countries. Next ... the World!
Schoofs writes that Senegal's "unsung success needs to be heralded"
because "it proves that foresight, pragmatism and can, even in the midst
of deep poverty, hold one of the world's leading infectious killers at
bay." Referring to education and behavioral prevention, Peter Piot, director
of UNAIDS, said, "We don't need to come up with some super-technological
secret weapon. The answers are already in Africa." Schoofs calls on the
U.S. to embrace the realism of Senegal, and concludes, "While the molecular
biologists toil toward a cure and a vaccine, we need to heed the wisdom
of countries that are succeeding with the humbler, human resources that
are available right now" (Schoofs, Washington Post, 1/31).
Washington Post article gives additional detail on several
components of the Senegal program, including the unusual alliance between
public health, non-governmental organizations, and religious leaders (see
Schoofs, M. "In Senegal, Common Sense Spells Success." The
Washington Post, January 31, 1999, p. B02
...And right from the start, Ndoye enlisted the help of unlikely
allies -- religious
leaders. Senegal is heavily Muslim, and in two national meetings, one for
imams and the other for Christian priests and pastors, "We said that they
can preach fidelity and abstinence," Ndoye recalls, "but permit us NGOs
[nongovernmental organizations] and the government to promote condoms.
We came to this agreement, this modus vivendi. No organization should be
a barrier to the others."
It works. The Catholic organization Sida Service gives out condoms only
to married couples in which one or both partners are infected. But on posters
and in counseling sessions, the group does tell its clients to use condoms
if they can't be faithful. And in Senegal's bustling market, Paco, a young
cloth merchant, described to me the AIDS education he receives in his mosque.
"Condom is vulgar, so the imam uses another word," he explains. "He tells
us to wear a 'sock.' "