The Invisible Cure: Africa, the West, and the Fight Against AIDS (review)

This well-researched, wide-ranging, and passionate book addresses the issue of why so many donor-funded HIV/AIDS programs in eastern and southern Africa have failed. Epstein links this failure both to misunderstandings about why the HIV virus has spread so rapidly in this region and to the inertia and blanket treatment provided by many HIV prevention programs, developed by western experts and exported to Africa. This argument is not a novel one, but the question of why prevention programs have not worked is timely, particularly as the rollout of antiretroviral programs, hugely funded by donors such as the United States, is currently receiving a great deal of attention. As Epstein points out, such treatment programs, though laudable and necessary, will not halt the epidemic. Epstein offers insights into the complex epidemiology and sociologies of HIV/ AIDS and a subtle analysis of particular AIDS policies and projects. She writes about projects and communities throughout eastern and southern Africa, but her focus is on Uganda and South Africa.

Shaped by stereotypes about sexual promiscuity and high-risk behaviors, many AIDS prevention programs in the 1980s and 1990s focused on targeting high-risk populations and behavior through the promotion of condoms. The effect was that most people considered AIDS to be other people's problem. Epstein's argument is different. Drawing upon studies showing that the average African does not have more sexual partners over a lifetime than people in other continents, she suggests that the reasons for the rapid spread of HIV in parts of Africa lie in the nature of sexual networks rather than in individual promiscuity. In many African societies, she argues, sexual concurrency—having a sexual relationship with a small number of people at a time—is common. Concurrent relationships might overlap for months or years, or even, in the case of polygamous marriage, for a lifetime, and partners do not usually want to use condoms in such long-term relationships. They link people in a web of sexual relationships that create ideal conditions for the spread of HIV. Epstein points out that concurrency networks have been encouraged by colonial and postcolonial histories of labor migration, by deepening poverty and social inequality, and by the growth of transactional sex (in which sexual relationships are tied up with the exchange of material support), particularly in urban contexts where women survive economically through having sexual relationships with men. Gendered inequality, violence, and patriarchy exacerbate women's exposure to HIV through these networks.

Epstein argues that one reason for the now generally accepted decline in Uganda's HIV rate starting in 1992 was because the Ugandan government early on addressed the culture of concurrency by promoting the message of "zero grazing" (meaning "avoid indiscriminate and free-ranging sexual relations"). Partner reduction, she suggests, was a major factor behind the fall in the incidence of new infections in parts of Uganda during the 1990s. The other key factor in Uganda's relative success was, she argues, something less tangible: a sense of solidarity, compassion, and mutual aid bringing Ugandans together to address HIV/AIDS. This sense of the epidemic being everyone's problem was facilitated by the government's messages, but it was also motivated by people's shared experiences of suffering and by social networks providing care to AIDS patients and their families. Unfortunately, this early success has not been repeated by more recent AIDS prevention policies in Uganda. Driven by political, economic, and religious national and international agendas, these programs' focus shifted from "zero grazing" to condom promotion in the late 1990s and then, starting in 2003, to abstinence promotion, which, Epstein contends, has had little impact on rates of infection. Her anger at the "multimillion dollar bureaucracy" behind this control of HIV/AIDS policy-making is tangible.

Epstein's interest in Uganda's HIV/AIDS epidemic goes back to her discomforting...