PSI’s President & CEO, Karl Hofmann, and Beth Skorochod, PSI’s Technical Advisor for HIV, talk with Daniel Halperin and Craig Timberg, authors of the new book Tinderbox: How the West Sparked the AIDS Epidemic and How the World Can Finally Overcome It.
What was the impetus for writing Tinderbox? What do you hope readers will take away from the book?
Daniel Halperin: Over the years I had published a number of more academic articles, but I thought it would be interesting to write for a more popular audience. One of the key motivations on my part was to dispel, expose or correct myths/misconceptions about the epidemic. Going back 15 or 20 years I have just had this burning sense that the story we are told about AIDS is incomplete or not totally accurately rendered. Also, a key motivation was to show some of the untold or under-told stories, especially of how some Africans themselves have responded to the epidemic.
Craig Timberg: For me, I had been a foreign correspondent in Africa during this horrendous epidemic, and I found that there were lots of things that I could see and sense that were hard to write at newspaper length. To tell the most important stories, I needed the broader canvas that a book has to offer. Even more profoundly, it was clear to me that the AIDS epidemic is poorly understood by the world, and that has consequences for the way that the global response works, given that most of the decisions are made by people who live thousands and thousands of miles away from where most of the victims are. The book is intentionally written for a more general audience. It is a little more science-y than I would write for your average Post readership, but more general than for your average Lancet readership. The idea was to bring the story back to as many readers as possible, without sacrificing its scientific rigor.
One of the premises of the book is that people and policies of the West, perhaps unwittingly, helped fuel the spread of HIV in Africa. How would you compare the West’s obligation to stem the tide with that of highly affected countries?
DH: Yes, I have been asked a number of times, ‘If Colonialism started the epidemic then what does that mean? What’s the implication of that?’ Some people have responded by thinking that if the West actually started this epidemic then it really has the main responsibility to fix it. But I hope that not too many people carry that conclusion away because that could, again, end up inadvertently causing more harm than good. (“The road to hell is paved with good intentions…”) One key point is that it’s like the Hippocratic Oath: at the very least, let’s try not to do harm. And it’s imperative that anybody, Westerners or not, who’s involved in this epidemic commit to disseminate the most accurate scientific information. We should continually seek to find and share the most accurate information on how the virus is spread and how it can be prevented. Certainly Westerners can and should help, but ultimately what will really turn the tide is when African societies, cultures and countries themselves take informed actions.
CT: The model that I favor is one in which Western nations provide the best science and practices possible and some degree of funding, but also stop short of just taking over the national responses in these countries, even those that have very serious problems with HIV. In the end, I think if there is going to be less HIV in the world, it is much more likely the cause will be that the South Africans or the Swazis or the Kenyans are able to talk effectively to their own citizens about how to change sexual behavior or educate people on means of transmission. That conversation is automatically going to be more effective than something that is heavy-handed or prescriptive from the West.
The book strongly supports male circumcision (MC) for HIV prevention. More resources have been devoted to male circumcision in the past few years, but target countries are still quite far from hitting 80 percent coverage. What more needs to be done to get there?
DH: Ironically, I think that in some ways the pendulum has swung from one extreme to the other. For years the World Health Organization, the Joint United Nations Programme on HIV and AIDS, and the Centers for Disease Control and Prevention and many others basically just ignored the issue and the few of us who talked about it were even ridiculed. The 2002 U.S. Agency for International Development conference, attended by some 150 experts, came to the conclusion that affordable MC services should be made available for men, not explicitly for HIV prevention, but essentially as a basic reproductive health service, for which men will want to avail themselves for a multitude of reasons. That is what I mainly still believe. But now the pendulum seems to have swung to the other extreme. So many international organizations are excited about MC and pushing quite hard for HIV prevention – sometimes too hard, I think. If we were just making MC widely available, period, we would, ironically, probably be seeing more uptake. For various reasons, I think it is actually slowing the process down and having a backfire effect in some places, especially in southern Africa.
Advocates will fight resource cuts to HIV programs, but global budget pressures are real and likely to be sustained. What are the most innovative approaches you’ve seen in fighting HIV in a smarter, more cost-effective fashion?
DH: One good example of something that almost no one seems to be doing right is promotion of exclusive breastfeeding (or more to the point, warning communities about the dangers of mixed feeding). Organizations are basically counseling HIV-positive women in a narrow clinical context, saying ‘You should practice exclusive breastfeeding for six months.’ But why not encourage everybody in the community to exclusively breastfeed for the first six months? Why not have mass media help spread this message to all women in the community? This would affect not only HIV but also infant mortality rates and other health outcomes. It’s fundamental, low cost, and could have high impact.
The book mentions that resources for HIV are often disproportionate to where they are most needed. What interventions do you think should be prioritized for funding in the next five years?
DH: Of course, male circumcision really could have a large impact at the population level. It should be seen, from a policy perspective, as a kind of mass vaccine campaign. So MC should obviously be a huge focus, and this has already been won on the policy level; most of the big organizations and donors are in support of it, but, as I mentioned, I think the way it’s being implemented is not always optimal. But ultimately the most important thing should be a focus on behavior change. If you have a lung cancer epidemic, you have to focus on smoking behaviors; otherwise, it’s ludicrous. Behavior change communications was accepted as a key focus for some time, but we seem to be going backward on that, which is sad.
Do you think moving away from standalone concurrency interventions is the right approach? How should countries and HIV programs deal with the issue of concurrency?
CT: It is clear to me from my time reporting on it and talking to Africans in all kinds of settings, that the concurrency issue is real, and it seems quite obvious from any historical perspective that what you’re seeing is a legacy of polygamy as it evolved into new forms. But I also feel that this debate about concurrency has gotten unnecessarily academic, and Westerners are shooting bullets at each other in peer-reviewed journals about what exactly concurrency is, and what the methodology is, etc. It is cyclical. The world focuses on sexual behavior as a key element of sexually transmitted diseases and then talks its way out of it for a few years, and then rediscovers it. That has been, in the end, destructive and confusing for Africans who are mainly living with the epidemic itself. What I would like to see clearly established as an unchallengeable principle of the response to HIV is that in the hardest places, it is spread by sex. I don’t know as a journalist exactly what levers NGOs can push in terms of bringing about changes in sexual behaviors, but I think that it is abundantly clear that when societies reduce the number of partners that people keep over time, then HIV goes down.
What in HIV should international organizations like PSI focus on to have the greatest impact on the epidemic?
CT: Don’t be scared from talking about sex and sexual behavior. If we lack the moral courage to focus on the key driver of this epidemic, the people who suffer are the victims of the epidemic, not us. We need to rouse ourselves to be brave and talk about these uncomfortable subjects if we are serious about trying to slow down the spread of this thing. I know it is sort of naturally slowing down on its own, and that will no doubt continue, but if we want to find a way to make a big dent in how rapidly HIV spreads through Africa in particular, we need to find away to talk about sexual behavior.