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.

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.