Why AIDS keeps spreading in Africa

Messages about how to prevent HIV have been spread to all corners of Africa. AIDS education programs take place in schools in Kenya, churches in Uganda, workplaces in Botswana, and even bus stations here in Ghana. Yet the stark numbers in a new United Nations report suggests these efforts are failing to persuade millions of Africans to change their sexual behavior.

The UN AIDS Epidemic Update 2004, launched to mark Wednesday's World AIDS Day, estimates about 5 million people over the past year contracted the virus that causes AIDS, and predicts another 5 million will do the same next year. Most of those people - 3.1 million, or 63 percent - are here in Africa.

Awareness levels around the world are higher than they've ever been, but so is the pace at which the virus spread, according to the report. The real hurdle, say observers, is translating awareness into behavior change, and the effort often runs up against longstanding and strongly held cultural values.

"If the same market researchers who are selling Coke were charged with selling safer sex, they'd probably have thrown up their hands by now because it's a much more complicated thing," says Neill McKee, coauthor of the book "Strategic Communication in the HIV/AIDS Epidemic."

Here in sub-Saharan Africa some of those cultural stumbling blocks include male dominance, a reluctance to talk openly about sex, and a tradition of polygamy that today manifests itself in tacit acceptance of married men having multiple sexual partners. African men who have become disempowered through a history of colonialism, racism, and poor economic prospects are unwilling to give up the power they hold over women, says Suzanne Leclerc-Madlala, head of anthropology at South Africa's University of KwaZulu-Natal.

"I don't think we're putting enough emphasis on changing men's behavior," says Ms. Leclerc-Madlala. She says a key solution is for male African leaders - whether politicians, sports figures, or traditional rulers - to take a stand, admit publicly that men's behavior is a problem, and urge men to change.

"The prevention strategies are missing the point. Women do not have the economic power or social choices over their lives to put the information into practice," said Kathleen Cravero, deputy executive director of the UN joint program on AIDS, during a press conference in London last week. "We tell women to abstain when they have no right. We tell them to be faithful when they cannot ask their partners to be faithful. We tell them to use a condom when they have no power to do so."

Research into whether young people in sub-Saharan Africa are putting into practice the so-called "ABC" principles - abstain, be faithful, or use a condom - shows, at best, mixed results. The country often singled out as Africa's biggest AIDS-prevention success story is Uganda, where HIV infection rates have dropped to 4.1 percent from a peak of 13 percent in the early 1990s. Research has attributed some of this decline to programs that succeeded in persuading young people to delay their first sexual experiences and to increase condom use. But elsewhere in Africa, condom use is increasing only in some countries, and the proportion of men and women engaging in extramarital sex is not declining.

The new UN report points to "gradual, modest declines" in HIV prevalence in some urban areas of Kenya and Ethiopia but cautions: "It is much too early to claim that these recent declines herald a definitive reversal in these countries' epidemics."

Simply knowing how HIV is transmit- ted wasn't enough for Julius Amoako, a Ghanaian man who tested positive for the virus two years ago. He believes he caught it from his girlfriend. "I thought HIV was a thing for people who are prostitutes or gay, not someone like me," he says.

"People, especially the youth, don't think the disease is there among them," says Samuel Benefour, senior program officer with Family Health International, a US-based development agency. Mr. Benefour runs a behavior-change communication program in the Manya Krobo and Yilo Krobo districts, about 50 miles north of the Ghanaian capital, Accra.

A significant chunk of on-the-ground HIV education worldwide is done by volunteers like Emmanuel Awaitey. Mr. Awaitey goes door-to-door here in Abanse, a densely populated strip of a town stretched out along the main road through Manya Krobo district. On a recent day, he approaches a courtyard where two young women are preparing lunch and doing laundry and asks them what they know about HIV. He spends half an hour talking with the women. It's a time-consuming process, but it's face-to-face work like this that Benefour wants to see more of.

Some HIV-prevention efforts are turning more attention to giving people life skills that empower them to say no to unsafe sex. Until recently, the main activities of the Ghana Social Marketing Foundation (GSMF) have been selling condoms and spreading the safer-sex message through mass media. It has plastered more than 300,000 AIDS awareness bumper stickers on the country's taxis and tro-tros, the mini-buses that provide much of the urban and long-distance transport here.

Targeting the country's transport hubs as a vector for the spread of HIV led the foundation to work with the female hawkers who scrape out a living selling food and drink at the tro-tro stations. These women are often financially dependent on men, making it hard for them to refuse sex, especially when it comes with the promise of some cash.

"We realized a way to control (the spread of HIV) is to increase the empowerment of women," says Rudi Lokko, GSMF chief of operations. Instead of simply teaching the hawkers about HIV prevention, GSMF has started training them in business skills and helping them access microcredit.