Debrework Zewdie

"If we don't correct the mistakes that we've made [in the fight against HIV/AIDS in Africa], we are not going to win the war," predicted Debrework Zewdie, director of the Global HIV/AIDS Program for The World Bank, on February 23 to a packed audience in Snyder Auditorium. The mistakes, made early on in the epidemic, included unfocused and inadequate funding, as well as the perpetuation of the erroneous belief that HIV/AIDS would be a short-term problem.

"Africa's future is not preordained," she said in her talk, "AIDS in Africa: Actionable Solutions," co-sponsored by the student group Africa Health Forum and the Harvard School of Public Health AIDS Initiative. "Everything depends on how we respond to the HIV/AIDS epidemic today."

Governments in countries heavily affected by HIV/AIDS must implement what Zewdie called "The Three Ones:"

"If we all got together and agreed that these are the best things we could do, we would make progress," she said. "I see no excuse for not doing the third 'One' immediately."

Zewdie pointed to three sub-Saharan countries--Madagascar, Senegal, and Mali--that have low infection rates, and said that she hopes they will remain that way. The African continent is not monolithic, she said, but made of many cultures, varied geography, and vulnerable groups. What works to prevent the transmission of HIV in one country may not work in another. But all regions of Africa need well-funded, coordinated prevention programs, plus access to treatment.

Before joining the Global HIV/AIDS Program at The World Bank, Zewdie managed the AIDS Campaign Team for Africa, a coordinating agency of The World Bank set up to support African countries. Earlier, she took on the role of leader of the team responsible for the billion-dollar Multi-Country HIV/AIDS Program for Africa, which in part raised money to provide flexible and rapid funding to African countries that needed to jump-start their HIV/AIDS prevention and treatment programs.

Zewdie said that researchers must strive to understand, delineate, and address the major drives of disease transmission, while policymakers need to have the courage to recognize that transmission is primarily among vulnerable groups whose members need protection. Zewdie pointed to the expansive spread of HIV among sex workers and others with multiple sex partners, as well as transmission among uncircumcised males across a wide swath of central Africa. In Ghana, for example, the prevalence of HIV/AIDS among sex workers is 80 percent, compared to five percent among the general population.

"We have to ensure that funding is broadly commensurate with the proportion of infection attributable to vulnerable groups," she said. Public health professionals should help government leaders talk openly about sensitive issues related to cultural and sexual practices. Researchers also must selectively assess the biological impact of prevention approaches to make sure they remain effective.

The fight against AIDS not only saves lives, she said, but also helps the economic health of the country in which people live and work. According to studies funded by The World Bank and other agencies, South Africa alone faces lower productivity levels, slower economic development, and reduced per capita over the next few years as a result of its burgeoning number of HIV/AIDS cases, she said.

"We need to increase harmony among donors at the country level, work together on joint annual reviews, build common implementation units, and pool funds," Zewdie stressed. It is only through providing long-term political and funding commitments that dilapidated health care systems in Africa will improve, she said. 

--PHC