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GlobalPost's John Donnelly and a team of reporters investigate what experts are calling a 'turning point' in the global fight to reduce HIV infection rates. Successes in southern African countries have produced valuable lessons on effective approaches to fight AIDS, lessons that need to be learned in US cities where infection rates remain persistently high — particularly among African-Americans. Meanwhile a political confrontation looms in Washington over critical funding which could threaten gains already made.

In Tanzania, HIV at a crossroads

The US will launch a series of HIV prevention strategies to test whether an AIDS-free generation really is possible. Will this be a breakthrough moment?

IRINGA, Tanzania – This ridge town is a stopping point for truckers headed to Malawi, Zambia and the Congo, and for migrant farmers on their way to harvest potatoes and tender tea leaves. Here at this crossroads lies the epicenter of AIDS in Tanzania, an intersection where scientists hope to unlock the secrets of stopping AIDS.

In Iringa and in three other sites in Africa, the United States and its African partners will be launching a combination of coordinated HIV prevention tools and strategies in the coming months that will test what President Obama and Secretary of State Hillary Clinton have been telling the world: An AIDS-free generation is now possible because the tools to prevent HIV infection are at hand.

No one yet knows whether they are soothsayers or false prophets. The trials may reveal the way ahead, or they may fall flat and leave the AIDS fight in a state of dangerous limbo.

The window of opportunity is small. Donors have started to cut back on AIDS funding. Most developing countries are still contributing relatively tiny sums of money. Success could mean more funding; failure could mean less. Life for millions hangs in the balance.

Off the traffic byways of Iringa, HIV flourishes in the murky and risky world of men looking for sex far from home and women looking to make a living in an economy that offers few options.

“The time for small steps is now over. This will be the big bang.”
~Jessie Mbwambo, researcher, Muhimbili University

Still, there is guarded optimism that the scientists will find some success in their prevention trials. Smaller trials have shown the immense promise of various tactics when tried alone, notably the vaccine-like preventative effect on transmission when someone starts taking AIDS drugs, as well as the life-long protection afforded to many due to male circumcision. The trial designers believe if they can effectively stitch these programs together, the multiple approaches put them on the road to a Holy Grail: the numbers of HIV infections tumbling down.

For so long, the brains behind the fight against AIDS have sought a route to reverse a disease that flourishes for so many reasons, ranging from taboos of talking about sex to behaviors that have created high-risk populations whose Russian Roulette-like acts get them infected and then they infect others. Now many hope that this time by using several tools are once, they can change behavior and other some layers of protection, putting the worst of AIDS behind them.

Just one decade ago, experts from the CIA to the World Health Organization feared that AIDS would infect more than 100 million people, becoming a runaway epidemic and crippling countries. But the world, led by the United States, responded in a massive way and expanded treatment from tens of thousands to millions of people, leading to slight decreases in the past five years in the numbers of people living with HIV in countries from West to Southern Africa, where the epidemic has hit the hardest. 

Is the world now at the next turning point in the history of AIDS? Is this a moment when AIDS, not countries, becomes crippled? Doubters are many. But many also believe new prevention tools and ramped up campaigns to protect newborns and women will help them finally outmaneuver a virus that has killed millions for decades. 

“We need to put together all these things more than we have in the past,” said Brian Rettmann, the Tanzanian country coordinator for the US global AIDS program known as PEPFAR, the President’s Emergency Plan for AIDS Relief. “We’ve seen the global epidemic rate come down, but we don’t know what is figuring into that.”

‘The big bang’

Said one of the principal investigators of the Iringa combination prevention trial, Jessie Mbwambo, a researcher at Muhimbili University in Dar es Salaam: “The time for small steps is now over. This will be the big bang.”

In sub-Saharan Africa, where more than 23 million people — or two-thirds the global total — are HIV positive, the strategies to prevent HIV transmission have gone through major changes in the last five years, dating to clinical trials in 2007 that showed male circumcision reduced chances of infection by at least 60 percent. 

In remote areas of south-central Tanzania, near the Malawi border, large-scale male circumcision campaigns were under way last month, with some of the demand sparked by women forcing men and boys to go. In the town of Makambako, USAID-funded workers were teaching sex workers about “kitchen gardens” and how to take care of livestock, two alternative — and safer — employments. Others in town visited trucker hangouts to encourage safe sex and HIV tests.

These efforts, now done separately by various contractors, will be forged together for the pool of trial participants so that anyone receiving any HIV prevention tactic can be offered all of the tactics. It will be kind of like entering a supermarket of HIV prevention, with checkout clerks not giving away just one free handout, but multiple gifts at a time. 

“To combat HIV/AIDS you need to combine strategies,” said Robert Mahimbo Salim, the Tanzania government’s regional medical officer in Iringa, after visiting a male circumcision campaign near Tanzania’s border with Malawi. “We need to do more counseling and testing for HIV, put more people on treatment, and now get more men to be circumcised. Iringa has three times the national prevalence of HIV. It’s a very big problem.”

Kennedy Mdegelwa, 16, puts his hand on his head at the Tamwat Hospital in south-central Tanzania during surgery for circumcision. Afterward, he said that he didn’t feel much pain.

(John Donnelly/GlobalPost)

Fervent supporters of male circumcision

Sitting across from him, Hally Mahler, the director of a USAID-funded male circumcision program in Tanzania run by Jhpiego, an affiliate of Johns Hopkins University, said that those who work on male circumcision campaigns almost always become fervent supporters of the procedure because of its impact. Jhpiego has helped circumcise roughly 100,000 men in Tanzania in the last 30 months. In a six-week campaign ending in June, the group oversaw the circumcisions of 25,840 adolescents and men.

“You drink the Kool-Aid,” she said, explaining that clinical trial results have made believers even out of the most hardened cynics. AIDS modeling, she said, has made their work tangible: “You have 100 people in the waiting room (to be circumcised) and you count every six of them and that’s how many HIV infections are averted because of circumcisions.”

For Mahler, a high-energy mother of two who has been working in Tanzania for six years, the expansion of male circumcision in Tanzania amounts to “creating a whole new social movement.” Driving the demand, she said, are women encouraging their male partners to be circumcised for both hygiene and HIV prevention reasons.