From the New England Journal of Medicine, March 6, 2003
In only two decades, the epidemic of human immunodeficiency virus (HIV) infection and AIDS has progressed from being a medical curiosity to its current status as a global killer, changing the family structures, economic development, and even the security of many countries in the developing world. Tony Barnett, professor of development studies at the University of East Anglia in the United Kingdom, and Alan Whiteside, director of the Health Economics and HIV-AIDS Research Division at the University of Natal in South Africa, have written a book that examines the social and economic effects of the HIV-AIDS epidemic, failures in responding to the epidemic, and what must be done to combat the epidemic. Appropriately, Barnett and Whiteside devote considerable attention to Africa, the home of most of the world's HIV-infected persons. Although disorder, social inequalities, exploitation, and poverty are common throughout sub-Saharan Africa, the authors note that the underlying risk factors for the spread of HIV in this region vary according to country. For example, they maintain that corrupt governments and war gave rise to the epidemics in Uganda and the Democratic Republic of Congo, whereas more gradual economic and social changes created a high-risk environment in Tanzania. In the Republic of South Africa, the authors trace the origins of the epidemic in large part to the legacy of apartheid. The need for black workers in mines and factories owned by white persons created a culture in which men left their families to find work and then turned to local prostitutes for sex. The authors also cite the remarkable claim that the apartheid government employed HIV-infected men for the purpose of infecting female sex workers. Beyond the sheer numbers of infections, the effects of the epidemic in the most severely affected countries can be measured by its effects on families, economies, and governments. Barnett and Whiteside give poignant examples of families consisting of children and their grandparents and households where more money is spent on funerals than on medical care. Orphaned girls are often vulnerable to sexual abuse, and orphaned boys forced to serve as soldiers. The loss of adult workers further affects the already weak economies of poor countries. The loss of farmers may lead to the sale of their lands or cultivation of crops that are easier to grow. In businesses, HIV infection increases absenteeism and health insurance costs. In addition, companies may lose their customer base and are forced to write off the debts of customers who have died. African governments may no longer be able to meet their development targets and must cope with the loss of much of their own workforce. One unfortunate irony of the epidemic is that the large numbers of deaths among children and young adults actually allow governments to save money by spending less on education and pensions. Although the large amount of demographic and economic detail provided in the book may not be of interest to most readers, some facts are particularly compelling. For example, in Botswana, the country with the world's highest prevalence of HIV infection, life expectancy for a child born in 2000 has dropped from an anticipated 70 years in the absence of AIDS to only 39 years. Botswana is a relatively wealthy African country because of its diamond industry. However, among employees of Debswana, the diamond company that accounts for a third of Botswana's gross domestic product, HIV seroprevalence is almost 29 percent. In Zambia, a country where the epidemic is almost as severe as in Botswana, the number of teachers who die annually from AIDS now exceeds the number of teachers graduating from all training colleges each year. Unfortunately, the authors note, knowledge and observation of the African HIV-AIDS epidemic have not been translated into appropriate action. They argue that effective prevention efforts will need to move beyond focusing on biomedical and behavioral interventions to changing high-risk environments. The latter goal will require political leadership and multisectoral approaches that extend beyond health agencies. The successes of Uganda in prevention are cited as goals for other countries. In their acknowledgments, the authors thank the staff of KLM Airlines because sections of the book were written on KLM flights and in the KLM lounge in Amsterdam. Unfortunately, the sorts of problems that might result are apparent in the book. These problems range from errors of fact (Pneumocystis carinii is carried by birds, and HIV infects the Sykes monkey) to simple oversights, such as the inclusion of figures that are not referenced in the text. The authors also reveal their backgrounds in economics rather than clinical medicine by failing to define terms that are unlikely to be understood by noneconomists (e.g., "Gini coefficient" and "parastatal middlemen") and making misleading statements about medicine ("Some clinicians prefer to step up the treatment gradually with single drug therapy"). The book is further marred by truisms, such as "Mortality rates crucially affect life expectancy indices" and "The further you look into the future, the less certainty there is." The reader is left wishing that the authors had spent less time on airplanes and more time consulting with a medical editor. Although AIDS in the Twenty-First Century will primarily be of value to persons interested in health economics and international development, even the most casual reader will be struck by the global tragedy of AIDS and the likelihood that the epidemic will progress from bad to worse. Harold W. Jaffe, M.D.Copyright © 2003 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.

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