Friday, March 27, 2009

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.

Wednesday, March 25, 2009

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.

Tuesday, March 24, 2009

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.

Sunday, March 22, 2009

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.
video

Friday, March 20, 2009

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.

Monday, March 16, 2009

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.

Thursday, March 12, 2009

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...

video

Tuesday, March 10, 2009

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.

Monday, March 9, 2009

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.

Saturday, March 7, 2009

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....

Friday, March 6, 2009

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.

Thursday, March 5, 2009

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.

Wednesday, March 4, 2009

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).

Tuesday, March 3, 2009

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.

Sunday, March 1, 2009

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?