The war on AIDS is now three decades old, but it’s been years since the media paid close attention to developments in the fight against HIV. So it’s perhaps not surprising that little of the latest research on the history of HIV has penetrated the public consciousness. Did you know, for instance, that geneticists have identified 1908 as the (most likely) year in which HIV made the leap from chimpanzees to humans? Or that HIV made that leap in a remote equatorial forest in southeastern Cameroon, before making its way south to Leopoldville (now Kinshasa), and then radiating out to other parts of the world?
These are just a few of the discoveries revealed in “Tinderbox: How the West Sparked the AIDS Epidemic and How the World Can Finally Overcome It” (Penguin Press), by the Washington Post’s Craig Timberg and epidemiologist/medical anthropologist Daniel Halperin. Timberg and Halperin advance the argument that Western colonial powers unwittingly sparked the AIDS epidemic by sending people into remote parts of sub-Saharan Africa, where chimps had carried the simian version of the virus for hundreds of years without spreading it to humans. The co-authors also highlight the critical role of male circumcision in controlling the spread of HIV, and why Western attempts to stem the epidemic (through condom distribution and abstinence campaigns) been less effective than many homegrown African initiatives.
In the following Failure Interview, Timberg discusses the history of HIV, as well as the successes and failures in the longstanding fight against AIDS, and what worries him most about the future.
How long has HIV been around?
The strain of HIV that has killed ninety-nine percent of everyone who has died of AIDS [HIV-1 group M] jumped from the chimpanzee population to the human population about a hundred years ago.
How do we know that HIV is as old as it is?
Viruses have their stories coded in their genetic structures, and if you can get two pieces of virus and see the ways in which they are similar and the ways in which they are different, you can make reasonable assumptions about how many waves of mutation they would have to go through to be as different as they are.
The scientists who have done the best research on this worked from a well-known piece of HIV that came from 1959 in what is now Kinshasa. They then found a second piece of virus in a blood sample from 1960 and what they discovered is that they were remarkably different. When they figured out the number of mutations it would have had to go through to find what they call a common ancestor, they recognized it had to have happened between 1884 and 1924.
How did the virus move from chimpanzee to man?
The dominant theory is that somebody caught a chimpanzee that was infected with the simian version of HIV, and in the process of butchering it cut his hand, whereby blood from the chimp flowed into the blood of the human. The chimpanzee equivalent of HIV that was found in the area identified as the birthplace of the virus is virtually indistinguishable from the strain that kills most humans.
What got the epidemic moving among humans?
There were several important factors. The chimpanzee version of HIV was found in a remote forest, and until colonialism brought change to that part of Africa there weren’t any people there. Suddenly you had porters being force-marched into parts of the forest where people didn’t go before, and steam ships going up the rivers. Diseases need a certain number of humans to sustain progress, and you also need a degree of human density more generally, like you have in a city of significant size. We know from the historical record that in colonial Congo during the end of the 1800s and early part of the 1900s there was the spread of sexually transmitted diseases—gonorrhea, syphilis and chlamydia—up and down steamship routes on the rivers. It’s now clear that HIV was moving along these same paths.
Another factor is that HIV spreads much more easily in societies where people have more than one sexual partner at a time. Parts of Africa that were predominantly polygamous featured a culture in which it was not unusual for both men and women to have more than one sexual relationship in an ongoing way. That ended up being crucial in allowing HIV to spread.
The other factor that eventually became consequential is that HIV spreads much more easily in places where men are less likely to be circumcised. In the Congo Basin and much of Africa most men are circumcised, but when you move into East Africa they don’t circumcise and you get HIV rates that are five, ten, or fifteen percent, as opposed to one or two percent in Congo. Likewise, the ethnic groups in southern Africa historically did circumcise, but with the onset of westernization and urbanization it fell out of fashion. So in the parts of Africa where male circumcision rates are low you get these explosive HIV epidemics.
Talk about the impact of circumcision on the spread of the virus.
HIV is actually relatively hard to spread. In the average relationship a man and woman can have sex hundreds of times and not necessarily spread HIV between them. But not being circumcised changes those odds in a way that ends up being consequential. Men who have foreskins are 70-75 percent more likely to get HIV.
The Western world was slow to pick up on the connection between HIV’s spread and male circumcision. After the initial research suggested there was a connection it took more than a decade before you got the second wave of research, where they took three-thousand males and circumcised half of them and then measured how quickly they acquired HIV or didn’t acquire HIV. When we finally got around to doing that kind of experimentation the research findings were so incredibly bright that they had to shut down all three of the medical trials early, because the men who were not circumcised were getting HIV so much faster than the ones who didn’t. It became unethical to keep those experiments going. But it shouldn’t have taken the world a dozen years to put together that kind of research. It seems to me that if AIDS had been less politicized and the conversation had been less clouded by people’s ideology, we would have moved more swiftly toward policies that would have led to less HIV spreading around the world.
Which parts of the world have the highest HIV rates nowadays?
The places in the world that have the highest HIV rates are in southern Africa: Botswana, Swaziland, and parts of South Africa have HIV rates where more than 20 percent of adults are infected. Gay men in the United States and Europe still get HIV at much higher rates than straight men and women in those same parts of the world. There are also quite a few places where you have high HIV rates among men who use heroin and other kinds of injecting drugs, particularly in cities in the Americas and Europe and Southeast Asia. So what you have are pockets of high HIV in different communities in different places. You need to understand how HIV spreads in order to combat it in a sensible way. You can’t have [a] one size fits all [approach].
Is there a country that has done a remarkably good or bad job of combatting the epidemic?
Whenever you get into ranking how people are doing you need to break apart the pieces, because a society can do really well at treating people who have the virus, and quite badly at preventing them from getting it in the first place. The reverse can also be true. You can be really good at preventing people from getting it and truly horrendous at getting drugs to people who are sick. Some counties are good at one or the other and some are bad at both. I’m trying to think of a country that is good at both, but I’m not sure I can.
Uganda, famously, was good at preventing HIV during the late 1980s and early 1990s and is now pretty good at treating people, but those things weren’t contemporaneous. Botswana became incredibly good at treating people beginning around 2002, but has not been as good at preventing HIV. South Africa was famously horrendous at treating people but now is pretty good, and not so good at prevention.
The prevention piece ends up being much more subtle and arguably even counterintuitive in that places where you’ve had heavy investments of foreign money (from the United States and the United Nations and the Gates Foundation) have not done that well with prevention. The Bush Administration program, PEPFAR, was a game changer when it came to treating AIDS, but really struggled in effective strategies to prevent HIV from spreading.
The most effective responses have come from societies themselves. In Uganda and other nations you’ve had singers singing about AIDS, religious leaders preaching about it, politicians talking about it, and members of a society having conversations with one another. The big outside donors were focused on other things. In the book we talk a lot about condoms being aggressively pushed by the donors and that had less success than you might have guessed. Then there was the later fixation during the Bush years on abstinence programs, which had less success than proponents would have hoped for. The intuitive thing—we’re living amid a sexually transmitted fight and we need to make changes in our sexual behavior—hasn’t come very effectively from the outside. It appears to be a hard message to transmit across cultures.
Since you mentioned Uganda, can you talk about “zero grazing,” [1987-1992] which seems to have been a message that Christian churches could get behind—monogamy—and one that traditional African households that practiced polygamy could embrace too.
It was a program promoted in Uganda and the term zero grazing literally refers to what’s left of the grass when a goat is tied to a post, because it can only go so far from its post. It eats all the grass it can reach and leaves a zero shaped mark in the field. What it meant metaphorically was: Stay to your primary sexual relationships. There’s a reason why the Ugandans relied on metaphor, because a lot of Uganda was still polygamous. It you had a big social initiative that left twenty percent of the nation feeling they were being shunned, that would be a big problem. So the zero grazing message was ingenious because for the people who were validly monogamous, it was: Stay with your boyfriend, girlfriend, husband or wife. For a polygamous man it was: Stay with your wives. So the zero grazing campaign ended up being remarkably effective across a very broad swath of Ugandan society, and you saw the biggest and best documented drop of HIV anywhere in Africa.
But at the same time, the most famous singer in Uganda [Philly Lutaaya (1951–89)] was dying of the disease and talking about it. He went around the country saying: Look at me. I’m dying, but you don’t need to die. I got this because of sexual behavior. And if you continue to have three girlfriends at a time or three boyfriends at a time, you are going to get sick too. That message ended up being remarkably effective during the years when zero grazing was the main focus of AIDS policy in Uganda.
Does the West still believe the West knows best in terms of fighting HIV and AIDS?
Generally, yes. It’s been awfully hard for Western policy makers to consistently listen to what Africans have had to say about the epidemic affecting their own societies. I’m a little bit sympathetic in the ways in which Western policy makers come on strong, because in some places there was huge denialism. There were presidents who said there was no such thing as AIDS or that HIV doesn’t cause AIDS. You run up against that enough times and it is only natural to get a bit passionate and maybe a bit strident. But I think the record shows that the donors eventually called the shots in every country where they made big investments in AIDS policy. So Western instincts were followed and Western sensitivities respected, and African instincts were not followed and African sensitivities not respected.
Where are we in the fight today?
Treating AIDS has been a huge success. There are many people alive who would not be alive today if Western donors hadn’t put so much money into this. It’s something I’m very proud of as a taxpayer—that we made that kind of investment. On the prevention side of the ledger, Western investment in keeping HIV-positive mothers from giving it to their babies has been effective. And at this point there is pretty significant investment in making safe and voluntary male circumcision services available.
Most of the failures have to do with the prevention side of the equation and the inability of Western donors to talk in compelling ways about sexual behavior. And as a secondary effect, the distracting nature of the way that big, well-funded Western programs drained energy away from conversations about sexual behavior that were growing up organically—or would have grown up organically—if we had tread more lightly.
What do you worry about in terms of the future?
The West in particular is a little too focused on drugs for AIDS right now. Despite the fact that recent research makes it clear that people who are well treated are less likely to spread HIV to others, I think that approach of pushing out more and more drugs is being seen as something of a panacea. The places that have the best treatment programs in many cases don’t have meaningful drops in the spread of HIV, and that is because of risk compensation: People who wear seatbelts drive faster and people who wear sunblock probably are more likely to sit out on the beach all day. So while I’m happy to see anybody treated who we can possibly treat, we’re going off track if we think all we need to do is get drugs out to as many people as possible.
The other thing I worry about is that there has been this very persistent backlash against candid conversations about the way that sexual behavior plays into the spread of HIV. That strikes me as a real disaster for the people who are living in places where the AIDS epidemic is worst. If it was hand shaking that gave you this virus, we would talk very candidly about how often you should shake someone’s hand and how many hands you should shake. But because of our inherently conflicted nature and feelings about sexual behavior more broadly, we seem to struggle to have conversations about the role between sexual behavior and disease uncluttered by moral imperatives or the fear of sounding moralistic. Having a basic scientific conversation about this seems to be awfully difficult. That has a problem in fighting the epidemic and there is every reason to believe that will continue to be a problem in the future.