Every morning, as in a carnival magician's trick, the simple white waiting room changes into a kaleidoscope of color and sound as women in bright robes fill it with chatter and children. About half of the 80 women a day who come to this STD clinic in Dakar, Senegal, work in the world's oldest profession. Anne is typical: Thirty-seven years old with seven children, she needs the three or four dollars that men pay her for sex. Anne, who spoke on condition that her real name not be used, sometimes encounters customers who balk at wearing a condom. "There was a time when I would go on with those men," she says. "But not now."
Why not? Because to keep the government card that lets her ply her trade legally, she must get tested every month for STDs and every six months for HIV, making her all too aware of the consequences of unsafe sex. She and the other sex workers receive copious education and counseling about health -- and how to leave prostitution. The clinic even has a classroom. This innovative program is part of why this West African nation has one of the lowest rates of adults infected with HIV of any African country south of the Sahara: less than 2 percent.
Western news reports about AIDS often portray Africa as an undifferentiated disaster zone of poverty, death and government mismanagement. Indeed, since the hardest-hit African countries have more than a fourth of their adults living with HIV, AIDS is on track to surpass every African catastrophe of this century, including periodic famines and the Rwandan genocide. But Senegal's aggressive prevention campaign stands as a counterpoint of hope. Last December, the Society of Women Against AIDS in Africa held its seventh international conference in Dakar and presented Senegal's president, Abdou Diouf, with an award for the country's prevention efforts. Pierre Mpele, president of the Society of AIDS in Africa, which joined in giving the award, said it was designed "to show that efforts against AIDS are not useless."
Indeed, Senegal's largely unsung success story shows that foresight, pragmatism and energy can surmount profound poverty and keep at bay even the world's leading infectious killer. When it comes to education and prevention -- the human side of AIDS work -- "we don't need to come up with some supertechnological secret weapon," says Peter Piot, MD, director of the United Nations Joint Program on AIDS, UNAIDS. "The answers are already in Africa."
Senegal lies on the westernmost edge of Africa, a country roughly the size of Nebraska with 9 million people. It is the original home and capital of Afro-pop, and that vibrant, eclectic music reflects the true soul of the country. Here, fisherman throw nets off wooden boats hand-painted with lively patterns and goats meander through city streets and bleat off balconies. Even teenagers with baseball caps lay out their prayer mats and bow down to Allah, as more than 90 percent of the population is Muslim.
Yet Senegal is poor, with a gross domestic product of just $600 per person. Many homes still draw their water from wells, and many children play in clothes that go so long between washings that their vivid colors turn brownish-gray. Beggars crippled by polio roam the streets. Malaria is widespread. A new disease could easily flourish here.
That was Senegalese microbiologist Souleymane Mboup's fear back in 1984. The virus was known to be prevalent in central and East Africa, but what about West Africa? Mboup, now a leading scientific expert on AIDS in Africa, wanted to conduct surveillance studies. Many African governments, pandering to AIDS stigma and offended by what they viewed as racist suggestions that the disease originated in Africa, discouraged scientists and public-health authorities from even discussing, let alone studying, AIDS. In Senegal, however, "We never came under that kind of pressure," Mboup says. "We were very lucky to have politicians who listened to us."
This set the pattern for Senegal's success. In 1987, when the country had a mere 45 reported AIDS cases, Senegal launched a national prevention education campaign. The country had already secured the blood supply, one of the first African countries to do so. Now, it set about enlisting unlikely allies to promote safer sex.
The danger of aggressive opposition from mosques or churches was not lost on the architect of Senegal's HIV prevention program, Ibrahima Ndoye, MD. Working with NGOs (nongovernmental organizations) Ndoye convened two national meetings, one for Muslim imams and another for Christian priests and pastors. "We said that they can preach fidelity and abstinence," recalls Ndoye, a lanky man who seems to be in perpetual motion, like a human windmill. "But permit us -- NGOs and the government -- to promote condoms. We came to this modus vivendi: No organization should be a barrier to the others."
That formula works. In numerous interviews, Senegalese citizens confirm that, especially in big cities, they constantly hear about AIDS prevention. It's on the radio and television, discussed in primary and secondary schools and, yes, even reinforced in their houses of worship. True, the Catholic Sida Service gives out condoms only to its married clients. But on posters and in counseling sessions, the service tells people to use rubbers if they aren't faithful. In Senegal's bustling market, a young cloth merchant named Paco describes the AIDS ed he receives in his mosque. "Condom is vulgar," Paco explains. "So the imam tells us to wear a sock."
Senegal's prevention program can't claim all the credit. HIV has been slower to penetrate West Africa in general, and Senegalese culture, with its Islamic influence, is less open sexually than other countries. And Senegal is not a magnet for refugees fleeing civil wars or migrants seeking economic improvement, like the harder-hit Ivory Coast and South Africa, so the virus may not be entering the country as quickly as in other places.
But HIV certainly doesn't lack for opportunities. Paco, for example, has 23 siblings because his father has four wives -- the maximum allowed by the Koran. And Paco himself has two children out of wedlock, which is hardly surprising given the fact that more than 40 percent of young Senegalese men report having casual sex. But in a recent survey more than 60 percent of such men said that they used condoms with their most recent casual sex partner -- almost three times more than in AIDS-devastated Zimbabwe. Perhaps the most telling statistic is that in 1988, 800,000 condoms were distributed in Senegal, while by 1996, that figure had soared to 7 million. The rate of STDs such as gonorrhea and syphilis has decreased. The signs point to effective behavior change.
Moustapha, a wiry 43-year-old who sells newspapers, candy and other sundries from a little street shed, thinks the government has done a lot for prevention. But he argues it has done "rien" -- nothing -- for people like him living with the virus. That's not quite true. In fact, Moustapha is a recipient of his government's new program to subsidize antiretrovirals; health officials also provide drugs for some opportunistic infections, such as tuberculosis, free of charge to PWAs. Still, many people with HIV feel that the government is so focused on prevention that care remains a distant second priority, and that the AIDS stigma remains widespread.
Some complaints stem from the frustration of knowing there are effective treatments that few can afford, even with the government's new program. Compared to many Senegalese, Moustapha is well off; his small shop is thriving. Yet his share of the bill for a cocktail of Crixivan and two nukes eats up almost 30 percent of his monthly income. His wife, who helps run the shop, is also HIV positive -- but treatment for both of them "would be too expensive," Moustapha says. He doesn't say how they made the choice of who would get the drugs.
Such stories explain the blunt perspective of Babacar Wade, a founder of Oasis, one of the country's few organizations for people with HIV. Asked what Senegal needs, he immediately answer, "More medicine." He's not kidding. Sida Service is proud of the pharmacy that provides drugs its clients can't afford, but this "pharmacy" is a solitary cabinet in a corner, and it contains no protease inhibitors.
Beyond medicine, people with the virus want a seat at the table. Moustapha says the government only turns to PWAs when it wants window dressing at conferences and public events. But as is common across Africa, very few Senegalese PWAs are willing to be publicly identified. Moustapha, for example, has told no one in his family except his wife, and she too has told no one but him. Even Mboup, the scientist who started his research on AIDS so early and has worked to combat AIDS stigma all along, admits, "If I had it, I'm not sure I would tell my family."
It's curious that Senegal still has so much AIDS stigma, given how vigorously its public health leaders have fought the virus. Take, for example, what happens to prostitutes who test HIV positive. Are their sex-work licenses revoked? "No," answers Ndoye. "We think that would be very dangerous, because it would drive prostitutes underground." Instead, women who test positive are counseled about why practicing safer sex is in their own best interest: With a weakened immune system, picking up an STD from a john could be fatal. As a result of this enlightened approach, STDs, including HIV, have diminished among Senegalese prostitutes over the last few years.
When it comes to the country as a whole, a projection a few years back estimated that by 2003, 3 percent of the country's population would be infected. That same estimate reckoned that by now, the country would have just above 2 percent positive. But the actual rate of 1.77 percent, says Ndoye, "shows that our effort is working."