LILONGWE, Malawi — If this small nation, with a per capita income of less than $3 a day and a life expectancy of 53, offers a hopeful model for fighting the scourge of AIDS in Africa, then large and relatively prosperous Uganda shows how quickly progress can run off track.
LILONGWE, Malawi — If this small nation, with a per capita income of less than $3 a day and a life expectancy of 53, offers a hopeful model for fighting the scourge of AIDS in Africa, then large and relatively prosperous Uganda shows how quickly progress can run off track.
Secretary of State Hillary Rodham Clinton saw Malawi’s more promising example Sunday as part of an eight-nation African visit. Last week in Uganda she highlighted an alarming rise in infection rates there after years as a leader in preventing the spread of HIV and AIDS. About 23 million people in sub-Saharan Africa are believed infected, and the U.N. estimated AIDS-related deaths at 1.2 million in the region in 2010.
“I am here because I am worried,” Clinton said Friday, during a tour of a health center near the Ugandan capital Kampala that treats women with HIV and AIDS.
“In recent years, the focus on prevention has faded and new infections are on the rise again,” Clinton said. “Uganda is now the only country in sub-Saharan Africa where the rate is going up instead of down.”
The number of Ugandans with HIV doubled between 2004 and 2011, from 1.2 million to 2.4 million. A more blas attitude about AIDS among Ugandans is one explanation, and a more socially and religiously conservative approach to the epidemic from the government of Yoweri Museveni may be another.
By contrast, Malawi has a higher infection rate, but a more progressive approach to countering it. Clinton said little about the epidemic during a one-day visit here Sunday. But her very presence as the first American secretary of state to visit Malawi was a mark of regard for the new government of President Joyce Banda, a women’s rights activist who has backed aggressive HIV prevention programs.
Clinton toured a girls’ educational summer camp run by the Peace Corps, where the curriculum includes sexual health and birth control. Later Clinton’s party bumped down a long dirt track to a U.S.-sponsored milk production cooperative where farmers can also be tested and treated for HIV.
U.S. officials say about one in 10 Malawians are infected with HIV or have AIDS, a crippling figure.
But the rate has fallen nearly 13 percent over five years and innovative prevention and treatment programs extend through much of the country. Malawi has cut mother-to-child transmission of the virus, condom use is widely accepted and a male circumcision program once unthinkable in such a traditional society is now oversubscribed.
U.S. officials point to a huge change in public attitudes and awareness over the last decade. In 2002 Malawi suffered the worst famine in 50 years, caused in part by the absence of farmers too sick to work or caring for sick relatives.
“The government is committed,” said Ritu Singh, who heads HIV and AIDS work in Malawi for USAID. “They understand this is a problem and they understand this is affecting their people.”
The challenges remain vast, even leaving aside Malawi’s poverty. Per capita income is about $900, more than half the population is dependent on outside aid and U.S. donations fund the majority of Malawi’s annual health budget.
Cultural norms contribute to transmission, including an acceptance of multiple sex partners, polygamy and rituals such as sexual “cleansing” of recently widowed women, said Beth Deutsch, a longtime U.S. government HIV specialist in Malawi.
Condoms are not a hard sell generally. But condom use carries a stigma for married couples and others in trusted relationships, even though those relationships may not be monogamous, Deutsch said. The availability of condoms where they are needed is a major challenge.
Uganda has many parallel difficulties, but until recently was widely praised for a national effort to put prevention and treatment ahead of even deeply held cultural aversion to frank public discussion of sexual behaviors and homosexuality.
Success in treating infection, much of it funded by more than $1.6 billion in U.S. aid over the past six years, has allowed even very poor Ugandans to live normal lives. But that success has had unintended consequences; it has reduced the perception of risk and made a positive diagnosis a source for badly needed general medical care, AIDS advocacy groups say.
Clinton said she had discussed the backslide with Museveni, a close U.S. partner in counterterrorism and African security missions, and she made a point of praising Ugandan activists who opposed efforts to criminalize homosexuality.
The 2009 draft legislation proposed the death penalty for anyone convicted of “aggravated homosexuality”. The bill stalled in parliament, but a milder version was reintroduced by a member of Museveni’s party.
Although the HIV infection is mostly spread through heterosexual sex in Africa, AIDS groups said the proposed anti-gay law sets back prevention efforts by driving risky homosexual sexual behavior underground.
“It is critical for all Ugandans— the government and citizens alike — to speak out against discrimination, harassment, and intimidation of anyone,” Clinton said in presenting a human rights award to a coalition of activist groups. “That’s true no matter where they come from, what they believe, or whom they love.