Wars take second place to new killer

Fela Anikulapo-Kuti was the undisputed king of Nigerian music, a gifted artist with millions of fans worldwide. He was also a political activist who spoke up for the rights of his people and never hesitated to criticise his country's corrupt leaders. Years of imprisonment and torture failed to break his spirit or still his voice.

What silenced him where nothing else could was AIDS. Fela died from the disease in 1997, at the age of 58.

Edwin Cameron is a South African High Court judge, a white homosexual who represented conscientious objectors when they were prosecuted by the former apartheid state. This week he identified himself publicly, in a speech to the International AIDS conference in Durban, as "an African living with AIDS," one of the "forbidding statistics of AIDS in Africa".

Unlike millions of other Africans, however, Cameron can buy health and vigour - for a time. His medication costs $400 a month, in a continent where 290 million people live on less than $1 a day. "I am here because I can pay for life itself," he said.

Tinashe was an AIDS "orphan" I visited in a slum in Harare three years ago. Not yet four years of age, he scratched listlessly at the lesions on his legs and arms. His father, eyes sunken in their sockets, lay nearby in his crib. The boy's mother was already a memory, taken by the virus she bestowed on her son.

Three years ago Tinashe was one of more than 500,000 children in Zimbabwe who had lost their mothers to AIDS. Irish nuns did what they could for him, and for dozens more victims living in one-roomed shacks in the slum, with nothing more than a bottle of aromatherapy oil and a few prayers. Today, Tinache is just a statistic, one more blameless victim of the scourge that is Zimbabwe's biggest killer.

There are so many facets to the AIDS crisis in Africa that it is difficult to know where to start. With statistics, perhaps, which tell us dryly that AIDS now kills two million people a year in Africa - 10 times more than war.

The disease has created some 12.1 million orphans on the continent, most of them prey to abuse, neglect and a short life of illness and crime. South Africa, supposedly one of the more advanced countries in the region, has 4.2 million people infected with HIV, the largest number of any country in the world. One in four South African women between the ages of 20 and 29 are infected with the virus.

In all, AIDS has killed about 31 million people, 90 per cent of them in the developing world. Life expectancies have dropped by 20 years and more in the worst-affected countries, and decades of steady progress have been reversed.

But statistics do not convey the horror. AIDS sufferers, especially poor AIDS sufferers, die a horrible death, their flesh and innards consumed by painful and invasive afflictions. Even before the final stage of full-blown AIDS, sufferers like Tinashe experience a sort of premature "death", overcome by lassitude and losing all interest and involvement in the world around them.

In the West, meanwhile, the problem has been contained. Changes in sexual practice, especially in the homosexual community, and the more widespread availability of condoms reduced transmission rates more than a decade ago. Most importantly, pharmaceutical companies developed new drugs, or drug cocktails, which allow sufferers to live, relatively healthily, with AIDS for many years.

So why has the issue re-emerged on the international agenda at this time? Why has the West - belatedly, guiltily - started making positive noises about Africa's AIDS crisis?

One reason is that the US and other wealthy nations have finally woken up to the global implications of the disease. The world is unstable enough without being further unsettled by the massive spread of AIDS, which is already causing serious social problems in many developing countries.

In the seven states of southern Africa, for instance, at least one adult in five is living with HIV. The disease has spared no category of society. Relentlessly, the delicate threads of African society are unravelling. In Zambia there was a 13-fold increase in deaths among healthcare workers in the 1980s, largely due to AIDS. An estimated 860,000 children in sub-Saharan Africa lost their teachers to AIDS last year, according to the latest UNICEF Progress of Nations report.

And what if this pattern is repeated elsewhere in the developing world? India already has the second-largest number of HIV-infected people and the disease is menacing Cambodia, Burma, Thailand and other Asian countries.

In addition, scientists are only too aware that no cure has yet been found for AIDS. The battleground of disease control is a constantly shifting one, and AIDS/HIV is no exception. New strains are constantly emerging to challenge the efficacy of existing treatments.

Dr Mike Meegan, an Irish scientist working in Kenya, warns that unless doctors "break the back" of the disease, mutated forms that are highly resistant to treatment are likely to develop.

Complacency has grown among the sexually active populations in Western society and there is anecdotal evidence of some high-risk groups returning to the practice of promiscuous, unprotected sex. New figures which show that the number of HIV cases in San Francisco has risen for the first time in over a decade has reinforced these concerns.

BUT the attention at this week's AIDS conference in Durban has been firmly fixed on the drug companies. Firms such as Glaxo Wellcome made over £2 billion over the past two years from anti-AIDS drugs that only Western health systems can afford. UNAIDS, the United Nations' specialist body dealing with the disease, has trumpeted a new deal with the drug firms which will slash the prices of some drugs to the developing world. But this still leaves the cost of such treatments well beyond what the world's poor can afford.

In any case, this is not a viable solution. Making anti-retroviral drugs available to the poorest citizens of sub-Saharan Africa would be akin to offering them heart transplants: there are so many other things to get right with their health services before this level of sophistication can be approached. For a start, low-cost drugs to treat infections such as TB or pneumonia would greatly increase the quality of life of AIDS sufferers.

Dr Meegan, in his work with pastoral groups in East Africa, sets more store on witchcraft, traditional practices and peer group pressure in fighting the disease.

Prevention, as ever, is better than cure. The picture here, even in Africa, is not all bleak. Uganda, once the worst-afflicted country for AIDS, has halved its HIV rates since the early 1990s through strong prevention measures. In Lusaka, the capital of Zambia, surveys show that premarital sex is losing popularity, while male sexual abstinence is rising. In Brazil, where over half a million people are living with HIV, condom use has increased 10-fold, according to UNAIDS.

However, tradition and religion generally conspire to obstruct this progress. The Western churches preach abstinence, but refuse to advocate the wearing of condoms during sex.

In many rural, male-dominated African communities, women's sexual initiation comes early and sometimes forcibly. Reproduction plays a central role, as children are needed to help with farming and to support their parents in their old age.

As in the West, male promiscuity is common, but in Africa this takes more reckless forms. As I was told in Zimbabwe, men are unwilling to use condoms: "They say it's like eating a sweet with the paper on."

Ignorance is still widespread, as the UNICEF report shows. In Mozambique, three-quarters of teenage girls were unable to name a single way to protect themselves from the infection. More than half the young people surveyed in 15 countries did not know that someone who looks healthy can be infected with HIV and transmit it to others.

Astoundingly, this week's international AIDS conference, the 13th such annual gathering, is the first to be held in a developing country. South Africa's President Thabo Mbeki has again caused controversy with his assertion that it is poverty - and not the human immuno-deficiency virus - that causes AIDS. There is dissident scientific support for this view, which is rejected by the vast majority of scientists.

Mr Mbeki may not be right, but there is some truth to what he is saying. Poverty breeds ignorance, susceptibility to illness, even promiscuity where people are living in cramped conditions, and all of these factors have contributed to the spread of AIDS in Africa.

For Dr Meegan, it all comes down to sex. "Plainly speaking, they have far more sex in Africa than in the rest of the world. And unless they change, Africans will be obliterated."