Madagascar's low incidence of HIV / AIDS
Madagascar seeks to maintain low HIV rate
Spike feared as island becomes less isolated
By John Donnelly, Globe Staff | November 20, 2004
ANTANANARIVO, Madagascar -- This island nation off the southeastern coast of Africa poses one of the world's great AIDS mysteries.
Madagascar faces a great risk for an increasing HIV epidemic because of its unusually high rates of sexually transmitted diseases, and because many adults acknowledge having sex with multiple partners. Yet the HIV prevalence rate in Madagascar was estimated at 1.7 percent at the end of last year, according to UNAIDS, extraordinarily low compared with southern Africa as a whole.
Some specialists say the Indian Ocean insulates Madagascar from southern Africa, where nine countries have double-digit rates of HIV prevalence, including two with nearly 40 percent prevalence among people ages 15 to 49. Some say another protective barrier is that nearly 100 percent of boys are circumcised before puberty; in many nations, circumcised men have a far lower rate of HIV than uncircumcised men. Others think that the AIDS epidemic is still relatively young in Madagascar or that the estimates are incorrect.
But most worry that the low HIV rate will not last for long.
"Madagascar hasn't had all the movement of people that southern and eastern African has had," said Wendy Githens Benazerga, head of health projects at the US Agency for International Development in Madagascar. "It's been fairly isolated from the outside world, and the old socialist regime kept its economic growth low."
She said the more open economic and trade policies of President Marc Ravalomanana, which encourage outside investment, "is a very positive thing, but it also gives a possible opening toward more HIV transmission."
A few pockets of the country already are reporting high rates of HIV prevalence, including an estimated 16 percent of adults in the Ifanadiana district in the southeast.
Several studies have indicated that the country's rate of sexually transmitted infections, or STIs, are among the highest in the world. A study published last year found that 77.5 percent of sex workers in the capital, Antananarivo, and 73.5 percent of sex workers in Tamatave had at least one curable sexually transmitted disease.
In addition, a study in 2000 of men and women in the Ejeda region in southwestern Madagascar found that 26 percent had syphilis. A third study in the tourist destination Nosy Be in the far northwest found that of the young people with STIs, 82 percent were incorrectly treating themselves; only 2 percent were cured.
STIs, especially syphilis, chancroid, and genital herpes, provide openings for HIV transmission because the ulceration and inflammation gives viruses an easier pathway to enter cells.
Dr. Francis Ndowa, a specialist on sexually transmitted infections at the World Health Organization, said in an interview from Geneva that Madagascar could be headed for an explosion of HIV infections unless prevention efforts expanded rapidly.
"I don't know why HIV prevalence is so low now," Ndowa said. "It may be a question of introducing the infection. Once it is in there, though, I think there would be a catastrophic rise in HIV. You have to look at the profile of Madagascar's STIs. Those who have them are mostly young, sexually active people. It may be an island, but they need to put in place some active prevention strategy before HIV takes off."
Madagascar has started initiatives to encourage young people to adopt safer behavior, educating them about HIV transmission and encouraging prompt treatment for STIs. President Ravalomanana has spoken out several times to warn people against the spread of the disease and has created a Cabinet-level department to fight AIDS.
One program, funded by USAID and the Bill & Melinda Gates Foundation and run by Population Services International, or PSI, has essentially created a network of youth-friendly health clinics in urban areas. Each doctor who joins the program receives training on how to treat STIs, as well as how to counsel teenagers and encourage them to get tested for HIV.
After little more than a year, 186 doctors and 123 clinics belong to the program, called Top Reseau, French slang for the "best network." It's a fast start for the program, but it is in only six cities and covers a small percentage of the country, whose population exceeds 15 million.
Under the program, doctors agree to charge a lower fee for young people and they give discounts for partners of those with STIs for an exam at a Top Reseau clinic.
Off a busy street in the capital, Dr. Rakotoniaina Raniriharisoa Voahirana said her business has boomed in the year since she joined. She said teenagers, who had made up 30 percent of her practice, account for nearly 70 percent now. She said the Top Reseau sign, and reputation, draws them in.
"People are starting to become afraid of AIDS here," the doctor said in her tiny one-room office. "They should be. Madagascar is so poor that if we don't really fight it, we will be lost. We are very, very late in this fight."
Outside her office, some AIDS workers from PSI had attracted a crowd of young people. One woman, Rianala Rasohonjataro, a PSI educator, used a wooden model of a penis to show how to properly put on a condom. Many in the crowd laughed, but everyone kept watch during the demonstration.
Andritahina Eddy Martin, 20, said he was glad to learn more about how to use condoms, but acknowledged he used them only "when I've met someone new who I don't trust. If I know the person, then I won't use one."
The PSI educators said Martin was not unusual in that he was willing to listen, but not necessarily ready to change his behavior. Martin said he has two girlfriends at the moment. Neither he nor his girlfriends, he said, had been tested for HIV, and he was not sure he would be.
"It's not so easy a decision," he said, before turning his eyes to the condom demonstration.
Text © Copyright 2004 The New York Times Company
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