By the almost exclusive emphasis on behavior modification, AIDS research and policy for sub-Saharan Africa implicitly incorporate the assumption that behavior explains the differences in HIV prevalence between African countries and rich countries without examining its implausible conclusions. How much sex are we talking about that would produce, in the absence of other factors, prevalence of HIV in Botswana that is over fifty times that of the United States, eighty times that of France and 1,000 times that of Cuba? It was not until 1999 that the central tenet was tested; a study published by UNAIDS showed no correlation between rates of sexual behavior and prevalence of HIV.

There are significant levels of unprotected multipartnered sex in the United States and Europe, as evidenced by serious epidemics of other STDs, such as herpes-2 and chlamydia. In spite of the level of unprotected sex, there has not been a heterosexual epidemic of AIDS in the rich countries. Among otherwise healthy, well-nourished people in industrialized countries, heterosexual transmission of HIV is relatively rare--about one in 1,000 contacts between an HIV-positive female and an HIV-negative male, and about one in 300 contacts between an HIV-positive male and an HIV-negative female.

Since the African epidemic is heterosexual, it is clearly different from that of the West, a fact that was noticed by South African President Thabo Mbeki. He had the temerity, as some Western scientists viewed it, to ask how conditions of poverty in Africa affect the development of HIV/AIDS. It was a very conventional epidemiological question, well within the bounds of standard research. His question was treated, however, as heresy by at least a vocal minority of mainstream scientists, who seemed to regard any inquiry as beyond his prerogative. Spurned by the mainstream, Mbeki turned to scientists on the fringe of AIDS research who were eager for an audience. South Africa lost valuable time in addressing the AIDS crisis as the government vacillated and explored dead ends.

Mbeki's question, however--how does poverty influence AIDS in Africa?--is neither inappropriate nor unscientific. The environment in which any infection is transmitted in poor countries is very different from that of the United States and Europe and is strongly influenced by poverty, malnutrition, bad water and poor access to preventive and curative care. The standard epidemiological approach to understanding disease is characterized by Louis Pasteur's comment: "The microbe is nothing, the terrain everything." In other words, pre-existing health conditions play a key role in susceptibility to disease. We should expect HIV/AIDS to develop differently in rich and poor countries, just as do tuberculosis, pneumonia, measles and nearly all other infectious diseases.

Ironically, mainstream biological science has the answers to Mbeki's questions, but the specialized and conservative nature of biomedical research inhibits any one scientist from coming forth with the solution, or perhaps even acknowledging it. Most social science has failed to incorporate biomedical data into its analysis, in spite of the obvious fact that HIV and AIDS are biological conditions. What has been missing is an interdisciplinary approach that incorporates biological and social data into an analysis of the social context of HIV disease in Africa.

Sex tends to be distracting, for researchers as much as for the general public. The sexual transmission of HIV diverted attention from the broader epidemiological environment in which a heterosexual epidemic developed in sub-Saharan Africa. Both rich and poor countries are characterized by high rates of unprotected multipartnered sexual activity. Populations in poverty are also characterized by malnutrition, parasite infection and lack of access to medical care and antibiotics for bacterial STDs, which are important co-factors for transmission of HIV. To acknowledge the synergistic relationship among malnutrition, parasite infestation and infectious disease is not to say that AIDS itself is a nutritional disease. Nor does it deny that HIV is sexually transmitted in Africa and causes AIDS. It merely subjects STDs, including HIV/AIDS, to the same methodology employed in the study of other infectious diseases, however transmitted.

Even a brief survey of economic conditions in sub-Saharan Africa in the years in which the AIDS epidemic began reveals an extremely compromised health environment. From 1970 to 1997, sub-Saharan Africa was the only world region to experience a decrease in food production, calorie supply and protein supply per capita. In ten countries (including Zimbabwe, Kenya, Uganda, Zambia and Malawi), protein supply fell by more than 15 percent. Eighteen of the nineteen famines worldwide from 1975 to 1998 were in Africa, and 30 percent of the total population of the region was malnourished. Refugees from internal and external conflicts crowded into unsanitary camps where food rations were deficient in necessary nutrients. Sub-Saharan Africa is not the only region in which malnutrition is associated with HIV/AIDS. Among all low- and middle-income countries, HIV prevalence is strongly correlated with falling protein consumption, falling calorie consumption, unequal distribution of national income and, to a lesser extent, labor migration. Almost all of sub-Saharan Africa is tropical, with a very high prevalence of parasite infection, including malaria, schistosomiasis and various intestinal and skin ailments.

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