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Different Culture Warrants Different Approach
Hill Lecturer Hopes 'Dilemmas' of AIDS in Africa Will Spur Renaissance

By Carla Garnett

Photos: Ernie Branson

On the Front Page...

In many crucial ways, AIDS in Africa is different than AIDS in the United States. So said Dr. Malegapuru William Makgoba, president of the Medical Research Council of South Africa, who delivered the second annual James C. Hill Memorial Lecture, "The HIV/AIDS Pandemic: An African Dilemma" on May 15. The differences, he contended, present a number of problems unique to the continent and require different approaches to prevention and treatment of the disease.

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"I particularly chose the word dilemma," Makgoba began, "because it brings a sense of risk, a sense of reality, a sense of uncertainty, a sense of intrigue and a sense of excitement and challenge — all of which characterize the endeavor of scientific research."

The picture he then painted of HIV/AIDS in Africa is far worse than even the direst predictions of a few years ago, when it was confirmed that sub-Saharan Africa had more cases of HIV than any other region in the world. Life expectancy — which had risen to the 70s from the mid 40s of earlier decades — has plummeted again in nations such as Botswana and Zimbabwe, Makgoba reported. South Africa, where Makgoba hails from, currently has one of the fastest growing HIV epidemics, according to the World Health Organization. That country alone is home to an estimated 4.7 million to 5.3 million people who are HIV positive, with 1,700 to 2,000 more people becoming infected every day. Every year, Makgoba said, about 60,000 HIV positive babies are born.

Dr. Malegapuru William Makgoba of South Africa gives the Hill Lecture.

"Africa, particularly sub-Saharan Africa, is engulfed by the HIV/AIDS epidemic," he declared. "Almost all the socioeconomic improvements of post-independent Africa are being reversed if not wiped out by this epidemic."

Disease Differences

Complicating Africa's (and the rest of the world's) response to the "explosive" nature of the epidemic's spread, Makgoba pointed out, is that the disease looks a lot different in Africa than it does in the U.S. and other developed nations. That's why approaches to AIDS that have worked in "northern" regions may not be as effective in sub-Saharan nations. He asked the audience to consider several unique features of HIV/AIDS in Africa:

Unlike in this country, where HIV-positive men for a long time outnumbered HIV-positive women (although infection rates now are growing faster among U.S. women than men) during the epidemic's early period, women in Africa are infected more than men there; specifically, younger women (including teenagers and other women of early childbearing ages) and older men are affected more.

While Americans battled the various social stigmas ("it's a 'gay' problem" or "only IV drug abusers can get it") that accompanied HIV/AIDS here in the early years of the epidemic, Africans are struggling with their own social mores and expectations, according to Makgoba. Although the first cases of the disease were among homosexual men, the epidemic in Africa has primarily affected the heterosexual population. About 74 percent of 219 African women ages 16 to 44 who were surveyed said they depend on their partners for financial support; half of them do not believe they have the right to ask their partners to wear a condom during sex; and about 25 percent of them fear violent reprisal from their partners if they refuse to have sex. The prevalence of rape in Africa is three times the U.S. rate: 240 rapes per 100,000 in Africa versus 80 per 100,000 here.

A former visiting scientist with NCI in the late 1980s, Makgoba is welcomed back to NIH by NIAID director Dr. Anthony Fauci.

In South Africa, approximately 35 percent of HIV-positive mothers who are breastfeeding will pass the virus to their newborn infants. "Those children who manage to avoid infection face the prospect of being orphaned," Makgoba said. In the U.S., perinatal transmission has been virtually eliminated with the use of AZT and other therapies.

Threat to the Future

In Africa, the mortality pattern from AIDS is shifted more toward young people, he noted. That has forced African society to face what is potentially its most devastating dilemma.

"Today, the plague only exists in the subconsciousness of the descendants of Europeans," Makgoba asserted, "while it boggles the consciousness of every African parent and child. The new African leadership has to stare and be witness daily to the deaths of young, gifted Africans. The youth of any nation is its future. The dilemma here is investing in education in the midst of great human losses."

Also, in Africa, the spread of the disease is intimately linked with the continent's burgeoning economic success and the opening of some African countries' borders to commerce. Migration and the migrant labor system are keys to transmission as is the epidemic's association with major transport routes (56 percent of truck drivers reportedly are HIV positive). In addition the epidemic grew far faster than the region's initial response, Makgoba said, due in part to delayed reaction by the political leadership in many African nations.

"National denial seems to be entrenched in African society," he lamented.

When compared to America, Africa also has different patterns of transmission, higher rates of infection, the presence of different opportunistic infections and higher frequency of sexually transmitted infections that facilitate transmission.

A Role for NIH

Still, Makgoba stressed, "these different factors are no license for quackery, discredited, pernicious and dissident ideas, unethical practices or unscientific experimentation." While the HIV/AIDS pandemic could be considered only a cruel setback to a continent that has consistently improved its socioeconomic conditions over the past 30 years, he said the health crisis should also be viewed as an opportunity.

"The future of science lies in three areas — ethics, communication and attending to societal concerns," he predicted. "Will the HIV/AIDS epidemic define the African Renaissance in terms of innovations, morality and ethics? I believe Africa and its science will contribute to the knowledge base."

In that area, Makgoba said the U.S.— and the National Institutes of Health, in particular — can offer invaluable assistance to Africa by continuing to open its medical research enterprise to foreign investigators for the purpose of learning and sharing.

"You have an important role in mentoring," said Makgoba, an internationally recognized molecular immunologist who himself was an NIH visiting scientist from 1986 to 1988 in the National Cancer Institute. "One of the things you learn when you come to NIH is the integrity and excellence of science. There are not many other places you can learn those."

Let Africa Be Africa

He also cautioned would-be helpers who want to impose other nations' standards of ethics and research on Africa.

"You want to respect the partner with whom you are engaging in research," he noted, discussing the current ethical debates about providing to Africa treatment options that have not passed U.S. efficacy or safety tests, and about obtaining informed consent from potential participants in U.S. clinical trials that could take place in Africa. "Empowering a patient empowers the investigator."

Despite the sobering snapshot of HIV/AIDS in Africa and the forecast of the all-uphill battle ahead, Makgoba was able throughout his lecture to point to several ways that scientists and nonscientists can work together against the pandemic — the most important way being to keep information flowing.

"The need for science to be understood by the public, the need for scientists to communicate better, the need for the public to make choices about what science has to offer in their daily life, the need for the public to participate and shape the scientific process, the need for science to integrate the wealth of information have never been greater than today," he concluded.

Fauci opened the lecture with a brief remembrance of his friend, the late Dr. James C. Hill, who served as NIAID deputy director from 1987 to 1995. This year marks the second year for the lecture given in Hill's memory.

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