Dugger Nails It

I've been a bad, bad blogger since I took over the job as Education Editor at The Washington Post a few months ago. That makes feel me a bit sheepish about trying to pick up my game now. But Celia Dugger's excellent piece in the New York Times yesterday inspired me to dive back in. Here it is.
This picks up on themes my co-author Daniel Halperin has been pushing for years, including in a Times op-ed piece in 2008 pointing out the vast and growing inequities in global health assistance by big donors.
All of us who care passionately about the AIDS epidemic have to grapple with these issues. If the goal is letting people live longer, better lives, how best can we array the available resources while also pushing for more resources overall?

Testing the HIV Testing Mantra

Early in my Johannesburg years, I used to have regular coffee chats with Dr. Francois Venter, president of the Southern African HIV Clinicians Society. Over cappuccinos (we both had serious caffeine addictions), we'd talk about how to save the world from AIDS. More often than not, we'd scheme about how to get everybody tested for HIV. It seemed like a natural triple-word-score of AIDS progress. If everybody knew who was infected, stigma would go down. The sick would seek treatment. And everybody would be more careful.

.

Well, seems we were wrong, at least about that last part.

.

Dr. Venter and I were hardly the only ones mulling those issues at the time. The picture above shows Randall Tobias, the former Bush Administration Global AIDS Czar (before his fall from grace) getting an AIDS test to publicize the importance of the issue. Former President Clinton has talked up testing endlessly. So has Richard Holbrooke, and many, many others.

.

What we all missed was that while testing does indeed help people seek treatment, and likely eases stigma because the extent of HIV infection is clearer to all, there's little meaningful evidence that people who get tested act safer in the long run. In fact, the opposite may happen.

.

Several studies, both in Africa and among the U.S. and U.K. gay communities, suggest that measures of safe behavior often deteriorate for those who test negative for HIV. Not knowing your status, it seems, inhibits certain kinds of reckless behavior, such as multiple partners, visits to prostitutes and sex without condoms. Knowing for sure that you are NOT infected, meanwhile, can do the opposite. It can validate past behavior, including risky behavior. It's like a smoker finding out they don't have lung cancer... yet.

.

The good Dr. Venter gently broached this subject in a recent conference in South Africa, suggesting that the testing mantra is overdrawn. Kudos. The groupthink on this subject has gone on far too long. Kudos also to my co-author Daniel Halperin, who pointed out to me the limits of HIV testing a several years ago, allowing me to get off the bandwagon earlier than most. Here is his 2007 op-ed piece in the Washington Post about this.

.

Nobody, of course, is suggesting that getting tested for HIV is a bad thing. It's a good thing. But let's not confuse something that is good for the individual (who may now seek treatment) with something that has the power to slow the spread of AIDS on a broad, society-wide level. The list of those things, sadly, is rather short.

Craig Has Landed Back at the Post....

Regular readers of this blog (and my Tweets and Facebook updates) may have noticed that I vanished from cyberspace about three weeks ago. The reason was a fateful call from The Washington Post that has led to my becoming Education Editor, after a decade as a reporter there. No one is more surprised--or thrilled, or surprised that I'm thrilled--than I am. But the shift has been so abrupt that some explanation may be in order.

First, I'm still working on my book project with Harvard AIDS researcher Daniel Halperin, and given that I don't have to show up at the Post newsroom until my book leave ends in early September, we have three months to complete at least an initial draft of the manuscript. Second, my interest in all things about AIDS and Africa is undiminished. I still obsess about Zimbabwe, South Africa, Nigeria, and whether all the billions being poured into the AIDS War are being used well. This blog will continue to discuss those issues.

But my unexpected discussions with the Post's new Local Editor, Emilio Garcia-Ruiz, awakened something in me that I was trying to ignore: American newspaper journalism is in grave trouble, and I was on the sidelines in the battle to save it. I watched the Tribune Company hack two-thirds of the muscle out of the newsroom of The Baltimore Sun, my father's longtime professional home, and lay off my extraordinarily talented brother, Scott, from the Los Angeles Times (despite a run of good evaluations). So the personal stakes were certainly clear to me.

Yet even more I worried that the loss of our newspapers meant the loss of a shared narrative about our nation. The best papers are the daily diaries of their communities, and having lived and traveled in parts of Africa that lacked strong newspapers, I could see what happened when citizens and their leaders didn't agree on even the most basic elements of what was happening in their societies.

All papers, even the best ones like the Post, surely have failings but for decades they have been places where we meet, we talk, we chew over difficult issues, we exult in human achievement and lament human failing. Maybe cyberspace is becoming that, but from here it seems to created ever-more fractured conversations as it empowers new voices, diminishes others, and spins continually outward into new terrain. The center does not hold. Even the idea of the center--a place where straight-up news gathering is regarded as something akin to a calling--is feeling more quaint and antiquated by the day.

Offered the chance to rejoin a newsroom that's trying to save something so dear, I leapt at it with my usual manic fervor. That's why I've been out of touch for awhile. As one of my new editor colleagues said to me: "If we're going to go down, we might as well go down fighting."

Hell yeah!

That doesn't mean that the Post is in imminent peril. By most measures, the Post is the healthiest of the major American newspapers. Yet there's no ignoring that if we don't figure out how to make real money on the web, all newspapers are doomed.

I did, in applying for this job, gently mention to my new boss Emilio that I had virtually no background in either editing or education. But I also once knew nothing about Virginia politics, or D.C. politics, or AIDS, or any number of African nations. And I did already have a sense that schools and universities are so central to our societies that they should be a continuous source of great journalism, even if they have not always been so in the past.

As I began to assess my new team of reporters, it quickly became clear that the Post had a deep stable of talent ready to push harder and deeper into the subjects our readers care about. Probably the most difficult challenge we face will be mastering the new journalistic forms that the the web makes possible and, for those news organizations that survive this transition, ultimately demands of us.

So that's what's happening. I'm becoming an editor after 16 years as a reporter, foreign correspondent and (fingers crossed) an author. I can't think of anything right now that sounds more fun, or more important.

The Sounds of Spring

Over the last week my family and I have made our annual warm-weather pilgrimage up the hill, to our off-the-grid cabin in the hills of Otsego County, New York, up above Cooperstown. I am writing this on a laptop charged off our car battery, using an Internet signal coming invisibly from a cell tower miles away. We have not one but two iPods, and as of this weekend a battery-powered DVD player. This may not be exactly what Thoreau had in mind...

All the same, life in the woods in springtime offers revelations I can't imagine arriving any other way. There's nothing quite like venturing out with my children Cecilia, Andrew and Natalie to check their apple tree saplings as they grow buds, then leaves, then tiny red blossoms, still coiled tightly today but ready to burst forth. Yesterday my children caught their first neon-orange newt of the New Year, and then spent the next hour catching tiny flies to feed to it.

Yet it's the sounds that startle me with their springtime lust for life. There's the astonishingly loud, echoing pounding of the woodpeckers hunting for breakfast in the bark of old trees. This morning I heard the deep, rhythmic flapping of geese flying low over the metal roof of our cabin. And of course, this being near Cooperstown, we have the THWAPPP! of baseballs and softballs hitting leather gloves, or clinking off aluminum bats, as my two older children acquire a growing love for our National Pastime.

But it's at night, when human sounds quiet, when I feel totally at one with spring. There are owls hooting, nocturnal critters scurrying and the occasional coyote baying at the moon. And then, if I stand still, I hear a slow but sharp sound like the crinkling of paper, or a small waterfall maybe. It is tiny new plants, new life fashioned into green spears of fresh growth, forcing their way through last year's old dead leaves. Sometimes, in the light of morning, we can see the shoots of this new life stabbed right through the old.

The Globe Lives On...

It's nice to see The New York Times has decided not to shut down The Boston Globe after reaching deal with the unions. I guess that's good news. Yippee. But I can't shake the feeling that we're in a whole new phase of the destruction of the newspaper industry when we are cheering that one of the nation's oldest and best papers, based in the hub of an amazingly vibrant cultural and economic region, has earned a reprieve from the guillotine. We all know the blade remains sharp, and ready to drop on any one of us next week, next month, next year.

If the economy really recovers perhaps we can begin to understand how much of the recent wave of layoffs and newspaper closures is cyclical and how much is structural. Obviously it has been an evil combination of both until now. But I think we all know that the long-term prognosis is dire so long as print revenue keeps plummeting and web revenue stays so thin.

And I'm getting sick of the lazy assumption that we all were simply too stupid to adapt to the tidal wave as it loomed on the horizon. Just about the smartest journalist I have ever known-- Steve Coll, he of two Pulitzers, the New America Foundation and New Yorker staff writerhood--spent the late '90s and early '00s trying to see the future during his previous incarnation as the managing editor of The Washington Post. If he couldn't figure it out before it arrived, I'm not sure any human could have.

So what's left to do? I wish I knew. I hate the idea of walling off the news business behind the money of private foundations, no matter how well-intentioned. All money has strings, and in a way pure profit motive--money freely given in exchange for a service--is actually the most straightforward ethically. Is there a way to make money on the web? Can this idea about charging tiny amounts for each story work? It all depends on how much the public decides they value what we do. In that narrow way, maybe the scare over the Globe's possible death has been a wake-up call to us all. If our nation values its newspapers, they are going to have to decide they are worth saving, which means somehow paying for them again.

As Newspapers Wither, So Does Journalistic Innocence

For years, the surest way to get me to lose my reporter's cool was to accuse a newspaper (especially one I was writing for) of printing a story "just to sell papers." This irritated me not only because I'm a journalist, the son of a journalist and the brother of a journalist but because the people who ran newspapers were, so far as I could tell, pretty bad at trying to sell them. When was the last time you saw a story on Britney Spears or some new magical wrinkle cream on the front of The New York Times or The Washington Post, or even in their small-town equivalents? The hundreds of people I know in the newspaper industry did the job because it mattered, or they (we) thought it did.

We always delighted in challenging power, to use the old catch-phrase, comforting the afflicted and afflicting the comfortable. However much that may have satisfied the soul, it was not exactly a prescription for printing money. By and large, we simply were not populists. Newspaper publishers seemed to know this, and instead relied on non-journalists to make money, which was not terribly hard in the days when newspapers were the only broad-based source of real estate ads, classifieds and sports scores in any given city. The news, from a business point of view, probably always came second, and to the extent journalists were crucial to selling newspapers, it was the slow accumulation of credibility that was our most important contribution, not a single sensational story. But while the much-mocked "bean counters" made money, we were free to spend it by pursuing what we imagined were social goods: telling the truth, no matter how uncomfortable it often made the powers that be, or even our own readers. We were insulated. We were naive. We were innocent.

The wave of newspaper closings and layoffs has, I fear, begun to change that forever. The New York Times, of all entities, is threatening to close The Boston Globe, which was for decades one of the best around, and probably THE best for its market size. Meanwhile The Baltimore Sun, where my father worked for parts of four decades, and where both my brother and I spent time on our way to bigger places, has been gutted beyond recognition. Check out this terribly depressing account by my old Sun friend Dave Ettlin for the gory details. If I've got this right, The Sun's newsgathering power has declined by more than half from wave after wave of cuts. After you make cop calls or keep up with the Orioles and Ravens, and maybe attend a City Council meeting, what exactly do you have the horses to do? Having spent years overseas, in places that were short on serious, reliable sources of news, I can tell you that their absence undermined serious debate about just about everything.

So if we ever recover as an industry, I can't imagine we'll recover that essential spirit of reckless disregard for the economics of selling news. We all now know, in our guts, what it means when we don't sell papers. And while we've lost our innocence on this, there's little sign this obliviousness to the bottom line is built into the ethic of the webosphere. (About halfway down this David Carr column in the Times, see an appalling account of attempted news profiteering by a blogger at the Huffington Post.) Every click of a reader’s mouse generates data on what’s a hot topic that day. Simply having all that information operates as a kind of vast bio-feedback mechanism that makes it impossible to ignore the preferences of readers, for better or worse. No reader survey ever could come close to what web diagnostic tools tell newspaper editors every day about what might make their product sell better.

That doesn't mean you'll see stories about Britney or miracle skin cream any time soon on the front page of the Post or the Times. But the new world of free, easy media access has totally rearranged the incentives. A steady accumulation of credibility--of being right, or as close as possible, day after day after day--is worth less and less. The essential stodginess of newspapers, perhaps of serious news itself, seems to be a fatal flaw in an age of constant, rapid-fire sensation, stimulation, entertainment. The next time I hear somebody say, "They're just trying to sell newspapers," I will reply: "I wish."

The Fight for Sarah Obama's Soul

I'm no partisan. Heck I don't even vote. But I can tell you that traveling in Kenya over the past couple of weeks, it has been a delight to see how delighted Kenyans are about Barack Obama. Out in Luoland in Western Kenya, there are signs pointing to his family's ancestral home. After interviewing a Luo elder, one of his wives who works as a seamstress brought me some Obama cloth and shirts featuring his face on a traditional African pattern. At a hip party in Nairobi yesterday, where the menu include plenty of Smirnoff vodka and a bit of goat-head soup, one of the guests was wearing an Obama t-shirt that featured a solemn image of the president and the words "Making history." As I travel around, faces light up whenever I mention I'm an American.

I never sensed much anti-Americanism during my years kicking around the continent for the Washington Post, but I often got the sense that Africans didn't regard the U.S. government as consistently on their side. The main exception was in the petro-state of Nigeria, where George W. Bush's Texas oilman style went down well.

Obama's election has changed the emotional/political chemisty to an amazing extent. The Kenyan papers are trying to outdo each other in trying to get the scoop on a possible Obama presidential visit. And the fascination with all things Obama extends even to the soul of his sort-of grandmother, Sarah Hussein Obama, a Muslim who almost, but not quite, converted to Christianity over the weekend.

Sarah Obama is the third wife of Obama's grandfather, making her, in the family tree of the Luo ethnic group, a "grandmother," even if not Obama's exact, direct grandmother (who was, instead, the second wife of his grandfather. Got that?) Being a dutiful son of Kenya, President Obama calls Sarah Obama "Granny Sarah," as he should. (She is second from the right, bottom row, in the picture, looking resplendent in this image of Barack Obama's Kenyan family.)

The story, as told by Kenya's Nation newspaper, is that the Seventh Day Adentist church, which has sunk deep roots in Luoland over a century of energetic missionary work, managed to convince Sarah Obama to renounce Islam in favor of Jesus Christ. Her Kenyan relatives, however, stepped in before the baptism could take place. The Council of Imams and Preachers of Kenya endorsed her family's blocking maneuver in a statement yesterday: “Mama Sarah should not be forced by anybody to join Christianity since she is a Muslim. Conversion must take place in a voluntary manner,” a group spokesman said.

Seems reasonable enough to me, but I have a feeling this saga may not yet be over...

Canadians vs Somali Pirates: Who's Winning?

Hard to tell really. If you watch this video that a Canadian Navy public affairs team posted after a pirate encounter couple of weeks ago, you'll see Canadians with big guns and silly hats bravely capture Somali pirates, disarm them and make them walk the plank.

No, no, sorry. They don't walk the plank. They go free. The Canadians don't even confiscate the skiffs the pirates are using to terrorize international shipping. The Canadian Navy did much the same thing after an attack today.

No doubt there is some good reason for all this pirate coddling. But it's hard to fathom what it might be. Even Johnny Depp got spent a little time in jail when British naval authorities caught up with him at various places in the Caribbean, or was that Disney World? The Somalis, on the other hand, are free to keep it up until, apparently, they make the mistake of taking a handsome American captain hostage. All I can say is "Argh!"

A Must-Read Book: "Tulia"

One of the most-satisfying things about writing a book is that you have to read a lot of books, and think about them, along the way. I'm just now finishing the best book I've read in a long time: "Tulia: Race, Cocaine and Corruption in a Small Texas Town."
No doubt the better-read followers of this blog already have worked their way through this masterpiece, which was both a New York Times Notable Book of the Year and winner of the J. Anthony Lucas Book Prize. But I was overseas when it first came out in 2005 and had missed it. I can only say, "Wow!"
A book editor friend of mine recommended this, even though it has nothing to do with my normal preoccupations with AIDS or Africa. But it dives right to the heart of America's terrible racial history and its punishing present-day legacy in so much of the United States.
Author Nate Blakeslee chronicles the arrests of more than 40 supposed drug dealers, which amounted to a massive swath of the marginalized black community of a town of just 5,000 people. The evidence from an undercover narcotics officer was unusually thin and uncorroborated, but that didn't keep West Texas juries from doling out dozens--in one case, hundreds!--of years to these defendants.
Of course it all falls apart as the undercover cop turns out to be shady himself, and apparently a habitual liar. The most chilling part of the book, of course, is that most cases in our so-called drug war don't get anywhere near this much publicity, or scrutiny. It took a high-powered team of attorneys, and the pardon of an embarrassed governor, to eventually undo these blatant injustices. But how many injustices pass without notice beyond the routine reach of public scrutiny and good defense attorneys?

The Uganda Miracle That Was

The world has hailed Uganda's success on AIDS for so long that few have noticed that the glory days happened long, long ago. But Ugandans know. A chilling report on the epidemiology in Uganda, by Fred Wabwire-Mangen, stated bluntly last year (Here's a Powerpoint Version)that the declines in new HIV infections are over.

" 1. The previously heralded precipitous decline in HIV prevalence and incidence in Uganda stopped in 2002. HIV prevalence and incidence are now on the increase in Uganda

2. HIV-related sexual behaviours have deteriorated especially for men. There is evidence of: a rise in the number of life-time sexual partners and concurrent sexual partnerships; an increase in sex with non-regular partners, and a decline in condom use both for any sex and in the context of higher-risk sex."

Yikes!
A trio of Uganda AIDS experts tried to ring the alarm bells with articles in major Ugandan papers in January (here's a link to a copy of them). But I've sensed little energy around the issue on my visit here to Kampala, the national capital. Ugandans speak often of the AIDS epidemic in the past tense, and AIDS experts here are convinced that widely available treatment has taken the energy out of prevention campaigns. Now there's a dilemma to ponder: Is there any way to have good treatment and aggressive prevention programs at the same time?

The Rorschach Test

I'm on my way to Uganda to do some more reporting on the astonishing, and generally misunderstood, story of how this country emerged from devastating civil war in the mid-1980s to craft the most effective AIDS response in African history. It's a subject I've tackled before for The Washington Post. But for the purposes of book writing, I need to dig deeper, as well as feel the African sun on my skin and again marvel at the world's ugliest birds, which fly around Kampala, the capital.
Cynics often describe Uganda as Rorschach Test of AIDS: People see what they want to see. Some attribute the steep drop in new infection that began in 1989 (and ended in 1994) to condoms, others to abstinence. Some say good political leadership was the key, or maybe multi-sectoral approaches. Even Death, sometimes called the "D" of "ABC" prevention efforts, gets credit for the steep drop in AIDS rates.
I don't think much of this has held up to serious scrutiny in the years since scientists Rand Stoneburner and Daniel Low-Beer published their groundbreaking study in Science magazine in 2004. It showed conclusively that the drop in new infections tracked with major shifts in sexual behavior, away from multiple sex partners, casual sex and prostitution. Political, religious and cultural voices spoke together in those years, urging people to be more monogamous, or at least faithful to their spouses if polygamous. The resulting changes saved more than one million lives. And it all happened, and pretty much ended, before the wave of condom promotion that began in the mid-1990s and the abstinence programs that began a few years after that.
In any case, I'm hoping to have more to say in a few days. But my hunch is that Uganda's story is the opposite of a Rorschach Test. It was a moment of remarkable clarity, now lost and gone away. Those stupid blurry ink splotches, however, seem like they will be with us forever.

The Chinese: Africa's Salvation, or Doom?

This kind of simplistic question dominated about a decade worth of news coverage of rising Chinese influence in Africa. Both answers, of course, are wrong. Chinese incursions, both economic and political, upended the old order but the influence was neither uniformly benign, nor entirely malign. That ship carrying guns and bullets to Zimbabwe's embattled government certainly was a low point, but Chinese money and skill also built plenty of road, port and rail projects. Plus many Africans I interviewed were pleased with the straightforwardness of their dealings with Chinese companies. They were about profit, not about "saving" Africa.... as the West has been trying to do with varying degrees of success for nearly two centuries.
One correspondent who consistently avoided the salvation-vs.-doom trap is Lydia Polgreen, the excellent West Africa correspondent for the New York Times. Her story this week out of Guinea reminds us the Chinese-Africa relationship, like all relationships, is complex.
It also reminds us, as the Post's Karin Brulliard did last week with her dispatch from Zambia, that when things in the world go wrong, Africans generally pay the price--whether or not they had any role in causing the problem.

Should African Mothers With HIV Breastfeed?

Amid all the talk about the Pope and condoms the last few weeks, many people overlooked another intriguing development about AIDS in Africa. Health authorities in Mozambique are urging women with HIV to breastfeed their babies. Like many issues in the AIDS world, the logic is totally counter-intuitive. But given the other threats babies face in the poorest parts of Africa, the risk of getting HIV from breast milk is small compared to the risk that babies will die of other maladies that breastfeeding helps prevent.

The most obvious is the danger posed by infant formula itself in places that lack reliable sources of clean water or sterile feeding equipment. A couple of years ago, I wrote a story for The Washington Post about floods in Botswana that caused widespread water contamination, which led to the deaths of more than 500 babies and young children. In some places, two or three died in a single village. What an American team of investigators found was that well-intentioned efforts to provide infant formula to women with HIV had led to widespread abandonment of breastfeeding, even among women who didn't have HIV. A huge percentage of the children and babies who died during the floods were not breastfed. The push for the formula feeding came largely from Western medical authorities working at UNICEF, though the agency later reconsidered as evidence about the dangers of formula mounted.

Breast milk is not only inherently free of the kinds of contaminants that get into drinking water, it also has nearly perfect nutrition for a baby and antibodies that protect a child against all manner of disease. So while women with HIV who have access to reliably clean water, as in the case of some modern cities such as Johannesburg, should use formula, others mothers should abandon breastfeeding only with great caution.

In places where clean water is not available every single day, the best solution for mothers with HIV probably is breastfeeding ONLY for the first six months. Then breastfeeding should stop entirely and be replaced by other foods. Mixing breast milk that contains HIV with other food sources dramatically raises the risk of the HIV infection taking hold in the baby. The reason is that digesting the other food causes tiny intestinal ulcers that HIV can penetrate fairly easily. So let's hear it for the Mozambicans for applying the best available science to a difficult situation.

Farewell McGreal, Guardian's Man in Africa

For 20 years, there has been no journalist in Africa quite like Chris McGreal, the bulldog of Britain's Guardian newspaper foreign corps. Chris was everywhere, or had been everywhere, when Nelson Mandela cast his first ballot in 1994, when Hutus were slaughtering Tutsis in Rwanda, when Zimbabwe's long descent into hell picked up speed. Chris hustled. He was brave. He was tough. He took no shit. And, to top it off, he wrote pretty damn well too, better than most of us dared.
Check out his swansong today, whose only weakness is the inevitable, hackneyed headline "Out of Africa." Egad. I'm sure it's the fault of some editor somewhere. In any case, at a time when many great foreign correspondents have gone home, been laid off, or simply moved on to other parts of the world, I mourn Chris's move to the Washington bureau for the Guardian. Our understanding of our still-new president no doubt will be enriched, but our grasp of Africa certainly will suffer.

Global Recession Hits Africa

Terrific story on the front of today's Washington Post by my colleague Karin Brulliard, who took over as Johannesburg bureau chief after I left. I particularly like the lede, colorful, but sharp and to the point:

LUANSHYA, Zambia -- The global economic meltdown swept into this company town and took down the copper mine in January. It left in its wake a crisis measured in unsold tomatoes at the market, empty stomachs and desperate people lined up outside Chishimba Kambwili's pink house each morning.

Ah, Zimbabwe

There was a nice piece in the L.A. Times over the weekend comparing trying to report in Zimbabwe with similar challenges in war-torn Chechnya. Well-worth the read, with many nice touches by correspondent Robyn Dixon.
Wish I could write like this:

"The road to Gweru beckons, like a painting: a ribbon of pocked gray tar, flanked by jagged red gravel lines and wide green stripes of bush daubed on thick and wild. Nimble gray monkeys leap from red to green as you pass."

I fear it's too late for me to learn. Too much TV, not enough poetry, in my youth.

A Good AIDS Ad in Swaziland

Some readers of my Outlook piece in today's Washington Post about the AIDS problem in D.C. are asking what a good AIDS billboard would look like. Well, I thought this one from Swaziland was on point entirely. It will seem a bit preachy to some people, but it deals directly with the problem that accelerates the spread of HIV sexually. Sadly the far more prevalent billboards pushing condoms have been around so long, I'm not sure people see them any more. The small tag line at the bottom of this one is: "Casual sex is dangerous. HIV kills."
And below I'm re-posting a nice television ad from Mozambique. And here is a radio interview I did Sunday morning on WTOP radio in Washington.

Why Can't We Track HIV At Home?

I make a brief return to the Washington Post’s pages this weekend with an Outlook section piece about the AIDS problem in D.C. As I say there, and in a previous posting here, I think some of the important trends got lost in the furor after last weekend’s report about a 3 percent HIV rate in the city. And there’s not much evidence of an AIDS problem that’s actually getting worse in Washington, or one that resembles problem spots in Africa.
That said, there is something elusive about what’s happening in Washington. We simply lack the surveillance tools to know if, for example, there is a new spike of infection in the city. The report offers no evidence of one, but it also doesn’t offer much in the way of contrary evidence. Because HIV takes many years to develop in AIDS, and because the D.C. surveillance systems passively rely on reports rather than seeking out trends at sentinel testing sites as is common in Africa, we’re left guessing at the most important question: How many people are getting newly infected with HIV today?
In scientific terms, this is called HIV “incidence,” as opposed to the more commonly quoted “prevalence” that merely tracks how many people are alive with the virus, no matter whether they got it last year, or during the peak of transmission in the 1980s.
Amazingly, it was easy for me to find a pretty good estimate of HIV incidence for urban Uganda. Reasonably good studies of incidence exist for many other African countries. Yet it was impossible for me to get one for Washington, D.C.
As much as I’m wary of comparisons between AIDS epidemics in Africa and the ones here, I do think that some of the tools used to guide valuable programming there should be considered for deployment here. The new D.C. HIV/AIDS report is much better than anything we’ve had for the city before, but the risk is that because that data based on old infections, we still might miss the important trends today. If we are serious about a renewed commitment to knocking down the rate of new infections, we need to know when, where and how they are happening.

AIDS in D.C.: Getting Worse? No.

Kudos to my Washington Post colleagues Jose Antonio Vargas and Darryl Fears for helping turn the spotlight on the unnervingly high HIV rate in our nation’s capital. This is a place very close to my heart. I covered D.C. politics for several years before going to Africa, and my wife and I still own a home on Capitol Hill to which we will be returning later this year.
But I am a bit uneasy with the way D.C. officials (Mayor Adrian Fenty pictured to the right) seem to be portraying what’s happening there. The 3 percent HIV rate certainly is cause for concern, but the comparisons to rates in African countries are misleading.
Here's the quote that caught my eye: "Our rates are higher than West Africa," said Shannon L. Hader, director of the District's HIV/AIDS Administration. "They're on par with Uganda and some parts of Kenya."
Those African rates are national ones, not one for a geographically compact city like Washington, D.C. If you compared to core urban rates in Uganda and Kenya they are substantially higher than what D.C. is showing. That’s even more true at the epicenter in Botswana, South Africa and Swaziland.
More importantly, the numbers of NEW AIDS cases in Washington appears to be falling fairly steadily, and has been for several years according to both last year’s AIDS report, and the new one officially released today. Check out page 22 in the 2007 report. AIDS deaths are steeply down as well.
How could this be? People with AIDS aren’t dying at such a high rate anymore, at least not in places like the United States where effective treatment with antiretroviral drugs is universally available. In places with effective treatment, the number of people LIVING with HIV will keep going up for years even if the numbers of people getting HIV is going down. In that scenario, a rising rate of people with AIDS is good news, not bad.
To my eye, the most important elements of these reports are their potential ability to guide an effective response. Not surprisingly, gay men have high infection rates. But the rates among African Americans are eye-openers and remind us of the need for more effective prevention strategies. Condoms and HIV testing are not enough.
Mayor Fenty’s push to block transmission by infected mothers to their babies is urgent. Let’s hope, however, he doesn’t shy away from discussing the sexual behaviors—especially multiple, concurrent partnerships—that drive HIV so efficiently.
Even more broadly, let’s not mistake our new awareness of the AIDS problem in D.C. with being a problem that’s truly new, or truly getting worse. I’ve watched how sloppy portrayals of the epidemics in Africa have led to poorly targeted responses. Our nation’s capital shouldn’t make the same mistakes.

The Real Problem With Female Condoms

Few HIV prevention tools have generated more hype and less demonstrated success in Africa than the female condom. The Chicago Tribune reports in a blog today about a new one approved by the FDA that is made from a different material (synthetic rubber instead of polyurethane) and hence is cheaper to make. For those who want to use the female condom, this obviously is good news.
But who are these people? In four years in Africa, I never met a single woman who said she regularly used this device. The cheaper, easier and vastly more plentiful male condoms had at least become routine (if not always consistently used) for bar hookups or encounters with sex workers. But the female condom has not yet caught on. The Tribune article blames this on price. My gut is that different problems are at play: Those who have tried them say they are uncomfortable and also squeak during sex. One woman compared it to stuffing a garbage bag into her body. The Tribute article doesn't address these issues, though other reports suggest that the newer generation of female condoms are indeed less squeaky, if not less like bags. (Here's a nice piece from the NYT on newer female condoms: http://tinyurl.com/2vf2gn)
But remember that a woman using a female condom is still taking a stand, and risking a fight or abuse from her husband or boyfriend, because he surely will know that it's there. Many will perceive this as a sign of distrust, which has been a key barrier in keeping male condoms from being used more widely, and hence more effectively, in long-term relationships. In the end, are the dynamics so different between male and female condoms?
No one doubts the need to give women more control over their sex lives, especially in African societies where they don't traditionally have much. And we've all heard story about faithful wives getting HIV from their unfaithful husbands. But is the best answer a new product?
Let's remember that the core issue here is the nature of loving relationships, and the disastrous disruptions in traditional sexual rules wrought by colonialism and its aftermath. This is surely a tricky subject, but in societies where multiple sexual relationships are widely accepted, maybe more energy needs to go into making women feel like they have the right to demand mutual fidelity from their husbands or boyfriends. Or better yet, more energy could go toward helping men see that having lots of sex partners is deadly, as South Africa's Soul City soap opera recently has tried to do. Even more direct is this add from Mozambique. It's in Portuguese, but the message is clear enough...

Too Scary for Words

I wish I hadn't read this piece from Martin Wolf at the Financial Times: http://tinyurl.com/cmrlma. The implications for Africa and the fight against AIDS are profound. The idea that the West (or China, or Bill Gates) is going to swoop in and save the continent, or put tens of millions of people on life-long drug regimens, seems even less plausible today than it was a year ago. We must enter an era that prizes approaches derived from Africa, and that spends money as wisely, frugally and effectively as possible. One lesson of the past year: The money pit is not bottomless. Solutions must be sustainable.

Is PEPFAR Really So Great?

Dr. Joia Mukherjee, the medical director for Partners in Health, writes in the Boston Globe today about the need to fully fund the new, expanded PEPFAR, the big anti-AIDS program pioneered by President Bush. While I agree that an investment of that scale makes sense, it's not clear to me that PEPFAR, as currently conceived, is the best vehicle to do this. Couldn’t we find a better way to spend $48 billion on improving the health of Africans?

A few points:
1. This idea that PEPFAR has put 2.1 million Africans on “life-saving drugs” is simply not true. The program’s numbers, and those of most similar programs, are notoriously tricky. In addition, the best meta-analysis says that half of all Africans put on antiretroviral drugs have fallen out of those programs after 2 years. Many, if not most, are dead. And let's not forget that ARVs, though miraculous, are not cures.

2. The other, oft-cited stats are inputs, not outputs. Money spent, audiences supposedly reached, etc, are flimsy measures of success. New HIV infections are falling in some African countries, but there's no obvious relationship between PEPFAR money and falling infection rates. Perhaps the steepest drop since PEPFAR began came in Zimbabwe, which is not a PEPFAR country. Many of the biggest PEPFAR recipients, meanwhile, have not done nearly as well. Wasn’t Bush’s goal to “turn the tide” on the AIDS epidemic? Has this happened? (My take on PEPFAR last year http://tinyurl.com/awagpl).
3. There's meager evidence that PEPFAR has succeeded at preventing many new infections. Bush deserves real credit for getting the politics, and money, rolling toward widespread treatment. But in prevention programs, PEPFAR got stuck in distracting debates about condoms vs. abstinence.
4. The focus on treating people with AIDS has, no doubt inadvertantly, drained energy and money away from other similarly worthy goals. As my book project co-author Daniel Halperin wrote in the New York Times last year, as AIDS funding has skyrocketed, vital efforts on clean water, breastfeeding and family planning have stagnated or worse. Some PEPFAR money has spilled into basic health, most famously in Rwanda, but if basic health is the goal, is this program the best way to pursue it?

Now for some suggestions:
1. If we are going to put $48 billion into PEPFAR, let’s spend it much better, with a renewed emphasis on prevention programs that work. That means expanded services for male circumcision, much more effort to break up sexual networks by promoting partner reduction. Obviously the push for wider, more accessible treatment remains vital.

2. If we’re serious about saving African lives and improving African health, let’s invest intelligently in African health systems, not merely buy AIDS drugs, or send over expensive U.S. doctors, or build clinics focusing on a single disease. Let’s help build medical schools, and even better, nursing schools. Let’s work harder on medical system brain drain. And let’s make real investments in making drinking water clean, encouraging breastfeeding and making modern contraceptives (and not only condoms) easily available for everyone.

If we do these things, we’ll save and improve a lot more lives, no matter what the budget ends up being.

What do you think? Hit “Comments” below.

Dr. Francois Venter, Treatment Activist, Responds......

Here's a reply by Dr. Francois Venter, president of the Southern Africans HIV Clinicians Society and an old friend, to my "AIDS Cure: Good... AIDS Prevention: Better" posting yesterday.

From Dr. Venter:

"Maybe not (totally) crazy - I am scared that the biomedical stuff won't provide the solution fast enough, and that a partial biological prevention solution is decades away.
But the cause:effect is easy to measure with biological interventions. The prevention interventions are so woolly that for someone like me who needs things preceisely described it needs very careful boxing. Add to this that prevention studies notoriously measure surrogates like behavioural change, rather than the real thing we're interested in - new HIV infections - makes it hard for empiricists to take it seriously. I don't dispute the mysterious decrease in infection rates above [in Uganda and Zimbabawe]- I just don't understand how the behaviour change (and I'm still unsure that partner reduction is the explanation, although agree it seems to be the most likely) was effected. The question remains: What behaviour do we need changing? and in some way, the second question is harder: How do you do that?"

If there are other thoughts out there, I'm happy to post them here as well. I'd like this to be a conversation....

AIDS Cure: Good... AIDS Prevention: Better

There has been a lot of buzz today about the renewed call to find a cure for AIDS. And let me say, clearly and unequivocally, that I can’t think of anything better. There is a real danger, in an era when antiretroviral drugs are so effective at controlling the disease, that we forget that a cure would be much, much better, even transformative. So, bravo.
But….. I always worry that these biomedical solutions, real or imagined, drain energy and attention from the crying, urgent need to intelligently deploy the prevention tools we already have at our disposal, or to develop new, better ones. (Please see my ongoing posts on “AIDS Prevention 2.0”) The medical model--the idea that enough money to enough scientist in enough labs can solve any problem--is so appealing to our way of approaching the world, and yet the dividends for the African AIDS epidemics have so far been meager.
Even more deeply, we tend to assume that more money equals better results. And while that is often true, it’s worth remembering that the two most important success in AIDS prevention in sub-Saharan Africa came with little money, or Western interference. Those of course were Uganda in the late 1980s and early 1990s, then again in Zimbabwe in the late 1990s and early 2000s. The first saved at least 1 million lives by PREVENTING new infections. The second saved at least 600,000 lives the same way. In both cases, shifts in sexual behavior were the key. In those two countries alone, the number of saved lives exceeds the total number of people on ARVs throughout Africa.
Now I accept that there are real challenges in converting those experiences into new programming. Zimbabwe, in particular, has conditions nobody would want to replicate elsewhere (My story on the Zim situation: http://tinyurl.com/2j5kvd).
But isn’t it clear that we should be working like hell to answer those challenges? We must figure out what elements of the Uganda/Zim successes can be used elsewhere. In the meantime, let’s hope a cure gets closer too.
Think I'm crazy? Please hit "Comments" below and tell me why....

Zim Disaster Gets Worse: Tsvangirai Hurt, Wife Killed

As if the Zimbabwe disaster didn't have enough to break your heart, now Morgan Tsvangirai has been hurt in a car accident that, according to some sources, also seems to have killed his wife, Susan Tsvangirai. Let's hope those sources are wrong. (Picture here is file art from 2003).

I didn't know Susan in my years covering Zimbabwe for the Post, but I knew Morgan Tsvangirai reasonably well, or as well as reporters know public figures who they see occasionally. He never struck me as the best strategic thinker potentially available in a nation of super-bright, super-educated people, but I never doubted his devotion to the cause. There are some ugly incidents in his party's past, as there are for most political movements in Africa and elsewhere, but mostly I sensed a basic decency about Tsvangirai. Even if I'm wrong about this, the man suffered for his convictions, even before this accident.

I remembered visiting him at his house in Harare, a few days after Mugabe's thugs beat him and 50 other MDC activists into a bloody mess in March 2007. The stiches were still visible in the patch of missing hair on his head. He was surrounded by some friends, relaxing in the garden, trying to figure out a way forward in political dynamic more complex than even attentive outsiders could grasp.

I'll be among those sending my good wishes out to Tsvangirai, and to the Zimbabwean people, and praying that truly better news starts flowing out of there soon.

AIDS Prevention 2.0, part 2

Lord knows UNAIDS was slow on the uptake in recognizing the importance of male circumcision as a prevention tool. The long silence on the issue was even more surprising given that its founding leader, Peter Piot, was noting the epidemiological power of circumcision more than 20 years ago, in a 1988 paper he authored for Science. But since the powerful reports of the second and third circumcision trials a couple years back, in Kenya and Uganda, UNAIDS has worked to redress its past oversights. They now have taken another step forward, joining several other partners in a big, fancy new website devoted to disseminating good information on the issue. Check it out at: http://malecircumcision.org/
I wrote a few days ago about the concept of AIDS Prevention 2.0. The gist was: What things have we overlooked, or deployed badly, in our response to the AIDS epidemic in Africa during the first quarter-century of furious work? By any standard, male circumcision meets my critieria. The original evidence began perking up in 1988, about the time Piot noted it in his Science paper, but the idea languished despite the efforts of people like Robert Bailey, Bertrand Auvert and my co-author for the book project, Daniel Halperin. Only in the past couple of years, after three studies put circumcision's protective effect at more than 60 percent (probably beyond any vaccine imagined), has the conventional wisdom on this issue turned. Yet is it easy for boys or men to get circumcised in the places where HIV is raging in Africa? With few exceptions, it's not. Those wanting the service done safely (or mothers wanting it for their sons) still find it expensive and logistically complex. Waits for appointments can range into the months. Some of those places, such as South Africa and Botswana, also have financial and institutional assets that are the envy of the continent and would make rolling out such programs relatively straightforward.
Let's hope the new website is part of a broader effort to finally move forward on this powerful research, especially given that most Bantu societies already have circumcision as a tradition within their culture. Some activists think circumcising men is not a good idea, or an affront to human rights, but shouldn't the men most at risk for getting HIV, and passing it onto their partners, have a right to the procedure if THEY want it?
(See my story on the issue among Luo in western Kenya: http://tinyurl.com/8twodo.)
Please let me know what you think by hitting "Comments" below this post.

Freshlyground Co-Founder Moves On

For those who have enjoyed the South Africa Afro-pop band Freshlyground, it's sad to see that one of the founding members, keyboardist Aron Turest-Swartz, has decided to move on (see gentle announcement of "new band member" here: http://www.freshlyground.com/). I met Aron several years back writing about the band's remarkable, and remarkably unintentional, knack for crossing South Africa's still strict racial lines (http://tinyurl.com/ccotrq). He was so mellow, so Zen-like, that I had trouble at first believing he was a rock star. The best part is, so did he. The only time he lost that persona was during the stage performances of their biggest hit, "Doo Be Doo," (for the uninitiated, much cooler than the title sounds: http://tinyurl.com/dml4v7), when Aron would come out from behind the keyboard and dance like a madman, complete with a few Zulu kicks. The crowd always went wild.
Luckily, the band's creative core, and especially dazzling lead singer Zolani Mahola, are still there, so I don't expect a dropoff in quality as the freshlyground begins work on its fourth album. And happily, Aron seems happy to spend more time with his wife and their young son after years of greuling, nearly constant travel. But I'll miss Aron's vibe, and I'll miss those Zulu kicks!
If you are a fan, or just want to shout-out to Aron, please hit "comments" below.

Is Jail Best for Darfur Crimes?

It's certainly hard to feel bad about Sudan's Prez al-Bashir getting indicted by the International Criminal Court. There's no real doubt about his role in the horrendous assault on his own nation's citizens. If that isn't worth jail time, I can't imagine what is. Here's the take by my Washington Post colleagues: http://tinyurl.com/bkndvw.

To all this, I offer one reservation, best outlined in this story last year by Stephanie Nolen of Canada's Globe & Mail (http://tinyurl.com/baxltr), about how the international justice movement gets in the way of actually getting an evil despot out of power. Would Charles Taylor, the best example of international justice in Africa so far, have stepped down when he did if he knew he was eventually going to end up in jail, rather than in a bungalow in the Nigerian tourist town of Calabar? I see no easy resolution to this tension. It's clear that this stuff has been on Mugabe's mind, and those of his top advisers, as they have held on so tenaciously as Zim has gone from bad to worse to catastrophic to outright hellhole. I'd rather the old man spend the rest of his life in the Ritz Carlton if it meant Zimbabweans could begin their recovery free of his influence.

(For my take on the shortcomings of international justice in Sierra Leone, see http://tinyurl.com/accd7c).

What do you think? Is justice for one man, however evil, worth the possible price of slower political resolutions to Zimbabwe-type disasters?

Drink Away the Recession Blues

On a (much) lighter note, Robyn Dixon of the L. A. Times, whose coverage of Zimbabwe has been the ballsiest anywhere, showed her range recently by catching a trend toward high-quality, value-oriented South African wines amid this disastrous economy. She even caught President Obama sipping the stuff. http://tinyurl.com/c5fnx5. It's a great read.
(Disclosure, I'm friendly with Robyn, the winemaker she wrote about Eben Sadie. Plus my brother, Sam Timberg, imports South African wine for a living. How's that for a trifecta conflict?) In any case, read away, or drink away, or both....

For my minor offering on the subject of South African wines and the perils of global warming, check out: http://tinyurl.com/czk5sf. (Wrote this before Eben and I were friends).

AIDS Prevention 2.0

Here's an idea I'm hoping will animate most of what we do on this blog: The AIDS Prevention strategies of the past have either failed, or topped out in terms of their ability to control the epidemic. This is especially true in sub-Saharan Africa. If condoms (or HIV testing, or "positive attitude" posters) were going to reverse the tide, it would already have happened in many places. If treatment was going to do it, new HIV infections would be going down quickly in Botswana, where ARVs are approaching universal levels. Sadly this hasn't happened. We need new strategies, or to better deploy old ones.
I have ideas on what might work. But I'd like to hear from the blogosphere: Out of the tools not yet deployed, or under-deployed, what should get attention now?
There's a moral obligation, I think, to have an intellectually rigorous answer to this question. That's what AIDS Prevention 2.0 should be about. As long as the average South African teenager has a 50 percent chance of catching HIV in his/her lifetime, none of us can walk away feeling like we've made enough of a difference.
So, ideas?
Hit the "comments" button at the bottom of this post to join the conversation.

New Pepfar czar?

Who knows this guy Mark Kline, the possible new PEPFAR Czar? http://www.chron.com/disp/story.mpl/metropolitan/6286401.html
Does he get prevention? Is he an improvement on Mark Dybul? Yes? No?
The answer could hardly be more important.....
Other names tossed about, according to the Houston Chronicle, "Dr. Eric Goosby, President Clinton’s AIDS policy director; Dr. Jim Yong Kim, a Harvard professor and former World Health Organization AIDS chief; Dr. Nils Daulaire, former president of the Global Health Council; Dr. Wafaa El-Sadr, a Columbia School of Public Health epidemiologist; and Warren Buckingham III, PEPFAR’s director in Kenya."

Multiple Concurrent Madness?

Helen Epstein's teriffic "The Invisible Cure" (http://www.invisiblecure.com/) has helped push the conversation toward the essential role played by multiple concurrent partnerships in spreading HIV, especially in Africa. I don't sense a lot of serious debate about Helen's essential point. It's clear that men and women who keep more than one sex partner in a single week or month are more likely to get HIV, and to transmit it to others, including their monogamous husbands or wives. It's a point also at the core of the ideas put forth by my friend Daniel Halperin (who is the co-author on our forthcoming book "Dr. Livingstone's Children: Why We Are Losing the War on AIDS, and How To Win").
What has proven more nettlesome is translating that insight into action. The Ugandans famously did it in the late 1980s and early 1990s, but then forgot how to do it as the big AIDS money rolled in, and perhaps also as that society normalized into a more-settled postwar era (http://tinyurl.com/d7u8qe). The Zimbabweans also did it, with the help of massive economic collapse and outmigration that made keeping multiple sex partners a luxury few could afford (http://tinyurl.com/2j5kvd). But the dilemma has been, and continues to be, how do create these sorts of changes in societies not coming out of a civil war, or not going through a historic economic and social collapse?

These issues dominated a revealing conference I attended in Gaborone, Botswana in late January, and sponsored by the Harvard AIDS Prevention Research Project, UNAIDS and the World Bank. The group struggled to find a single, dominant coherent message that could be rolled out across southern Africa, a region that (aside from Zimbabwe) has been notoriously poor at talking directly about the sexual behaviors that spread HIV particularly fast there.
I've been keeping tabs on the conversations that flowed out of that conference, and the effort to draft a solid, concise document that can be distributed around the region. My old friend Francois Venter, president of the Southern African HIV Clinicians Society, blasted the original effort in a blistering blast email. His point, in short, was: Everybody is sick of being told what to do (condoms/HIV testing/etc). If you are going to come forward now with another idea, it better be rooted in rock-solid, demonstrable science, with clear guidance on how to turn it into effective programs.
On this, I mostly agree. The science has to careful, the arguments rigorous and well-explained. But I'd like to think that, thanks to Helen and others, that even Francois would agree that the most urgent questions in AIDS prevention today has to be: How can we help change the sexual behaviors that are most dangerous? As a first step, don't we have a moral responsibility to make clear what these are?
I've spent dozens upon dozens of hours in bars/shebeens all over southern Africa talking about this stuff. And inevitably I end up flipping my notebook over and drawing a simple diagram of a sexual network, with my interviewee in the center in an expanding spiderweb of interactions. Not once has somebody failed to express surprise. A quarter century into the world's response to the epidemic in African, shouldn't everybody in these hardest-hit nations be familiar with this stuff. If they aren't, whose fault is it?

The good/bad news about vaginal microbicides

I join everybody in applauding the news that the microbicide people are making progress in their quest to find a better female-controlled HIV-prevention device. But no one yet has answered the deeper and harder question: How do you get people to use it?
Elizabeth Pisani nails the happy side of the development announced last month at the CROI Conference in Montreal: http://www.wisdomofwhores.com/2009/02/10/significant-progress-in-hiv-prevention/
But at least as valuable is this piece by the gang at CADRE in Johannesburg, where they have watched the rise and fall of many of the supposed solutions to the AIDS crisis. Take a look at their reservations about microbicide research: http://www.cadre.org.za/files/Parker%20Colvin%20Microbicides%20Durban%20Conference%20A267%20low%20res.pdf
I fear that microbicides, and the one-a-day prevention pills that also are showing signs of technical success, amount to just building a better condom. Sure they stop HIV, but only if people use them almost constantly, with all sex partners, in every interaction. Microbicides certainly have the advantage of more female control, though I'm skeptical that men won't know that their sex partners suddenly are inserting a new substance in their vaginas. I can recall interviewing couples in Durban a couple of years back about Microbicide use during trials, and the men definitely could tell the difference. In most cases, they liked the extra lubrication, which might be a secret marketing advantage for microbicides IF you can get people to start using them.
In any case, the technological problems will not be the hardest ones to solve for Microbicides. As with most everything having to do with AIDS in Africa, the solutions are going to have to mesh with cultures almost totally unfamiliar to the Westerners in charge of the AIDS war.
What do you think?

Welcome

Welcome to Craig Timberg's personal blog. Here you will find links to my favorite stories that I've written for the Washington Post, about wars, famines, and dictatorships, as well as rock bands, gold pirates, guys who blow up ATM machines and a Nigerian who built a concrete 737 on the roof of his house. But my work these days is focused on the AIDS epidemic in Africa, which by my reckoning is going disastrously despite the world's unprecedented financial and political commitments to the problem. I'm on leave from the Post for a year while I write, along with my co-author Daniel Halperin, "Dr. Livingstone's Children: Why We Are Losing the War on AIDS, and How to Win."
Daniel is an epidemiologist and medical anthropologist, as well as a veteran of the political battles over AIDS, within the Bush Administration and more recently on a world stage as an oft-quoted expert from the Harvard AIDS Prevention Research Project. (http://www.harvardaidsprp.org/daniel-halperin.html).
I'll use this space to update everybody on our work, and I'll sprinkle in some interesting issues and discoveries along the way. Please keep reading. AIDS already has been around for a century. But we've probably never been closer to figuring out how to bring it under control.