Why Madagascar's HIV rates are low

from the Guardian

The Guardian is running an International Development Journalism competition. This is an excerpt from one of the semifinalists. - Kale

by Aline Reed

An unusual activity is taking place on a stretch of wasteland to the east of Madagascar's capital, Antananarivo. A group of children is peeling bananas and stuffing them in their mouths as fast as they can. That they are hurrying is understandable. The assembled boys and girls come from the nearby slums of Ankazomanga, where the average family has six or seven children. As in any large family where food is scarce, children soon learn that the quickest gets the most to eat.

What's unusual here is that each boy and girl is being timed and, although they may not realise it, eating bananas is intended to protect them from becoming infected with HIV.

As such, the banana-eating competition is part of a much wider race. One that has millions of lives at stake as well as the reputations of the 189 world leaders who signed up to the eight Millennium Development Goals. Goal six includes a commitment to halt and begin to reverse the spread of HIV/Aids by 2015. With six years to go, the latest UN chart shows "no progress, a deterioration or a reversal" in sub-Saharan Africa.

It is the region where progress is most urgently needed. Last year, a third of all new cases of HIV infections and a third of all Aids-related deaths occurred here. The Global Fund alone has invested almost US$3bn in combating Aids, TB and malaria. For the children of Ankazomanga, however, the greatest protection was given to them as a birthright.

Madagascar has amongst the lowest rates of infection in HIV-blighted sub-Saharan Africa. The government's latest estimate is that 0.14% of men and women aged over 15 are HIV positive. Compare this to the 26% adult infection rate in Swaziland and a question emerges. Why?

It's generally agreed that Madagascar has its geographical isolation to thank for its low rate of HIV infection. A secondary factor, however, is the widespread practice of male circumcision. The World Health Organisation (WHO) is now investigating advocating circumcision after a series of trials funded by the US National Institutes of Health revealed a 60% reduction in risk of HIV infection.

It's been estimated that, if full coverage were achieved, male circumcision could prevent two million people from becoming HIV positive in sub-Saharan Africa in the next 10 years.

Catherine Hankins, associate director of the policy, evidence and partnerships department at UNAids, adds a warning note, "Male circumcision does not provide complete protection against HIV. Men and women who consider male circumcision as an HIV preventive method must continue to use other forms of protection such as male and female condoms, delaying sexual debut and reducing the number of sexual partners."

On the ground, this message continues to be at the heart of HIV prevention work together with investment in testing and treatment. By taking an HIV test in public, Madagascar's President, Marc Ravalomanana, has shown commitment exists at the highest level. But his government's description of HIV and Aids as a "feeble presence" in its latest UN update strikes an unfortunate note of complacency. There is growing evidence to suggest that Madagascar is on the brink of an epidemic of its own.

The island's first line of defence has been breached. The 250 mile sea that divides Madagascar from Mozambique has provided a natural barrier to the disease that has overrun the mainland. Net migration has been close to zero for many years, but recent government initiatives to counter the country's crippling poverty is bringing an influx of foreign workers.

High rates of syphilis suggest that HIV could spread quickly. In July last year, the government was forced to declare a state of emergency in Fort Dauphin, when 17,000 people contracted syphilis. A local mine which attracted international workers and prostitutes alike to the town is thought to be the centre of the outbreak.

Syphilis, at least, can be contained and treated in circumstances like these. HIV cannot. "Mini-epidemics" have already been observed with HIV infection rates amongst adults rising to 1.1% in the city of Sainte Marie and 0.8% in Morondova. According to UNAids, Madagascar's young people could be the key to averting catastrophe just as they are believed to be behind the decline in HIV prevalence in eight sub-Saharan countries. For the children of Ankazomanga, though, HIV prevention comes in an unusual form.

Fun is not a major feature of life in Ankazomanga. Hunger, disease and absolute poverty are. So the banana-eating competition is enough to draw a crowd of over a thousand of the slums' inhabitants. Once it's completed, young men take their places for a "pousse-pousse" race. These carts are usually used to carry goods to market. Today, they are moving so fast that the home-made banner marking the winning line is a blur to participants, but it reads "unsafe sex is risky for HIV/Aids".

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