There is a large body of mainstream biomedical literature that documents the mechanisms by which malnutrition and parasite infection undermine the body's specific and nonspecific immune response. Protein-energy malnutrition (general calorie deficit) and specific micronutrient deficiencies, such as vitamin-A deficiency, weaken every part of the body's immune system, including the skin and mucous membranes, which are particularly important in protecting from STDs, including HIV. Parasite infestation plays a dual role in suppressing immune response. It aggravates malnutrition by robbing the body of essential nutrients and increasing calorie demand. Moreover, the presence of parasites chronically triggers the immune system, impairing its ability to fight infection from other pathogens.

Poverty not only creates the biological conditions for greater susceptibility to infectious diseases, it also limits the options for treating disease. Infection with other STDs is an important co-factor for transmission of HIV; genital ulcer diseases in particular, such as chancroid, provide an entry point for HIV. Such painful bacterial STDs are relatively uncommon in rich countries because of the availability of antibiotics. In Africa, South Asia and Latin America, however, even when poor people have access to healthcare, the clinics may have no antibiotics to treat bacterial STDs that act as co-factors for AIDS. These are among the conditions we have to consider in poor countries, and they are standard variables in epidemiology.

Treating African AIDS as a special case caused by a hypersexualized culture obviously reinforces racist stereotypes and pessimism over Africa's future. It also pushes AIDS policy to an almost exclusive reliance on behavior modification and condom use and away from general health and nutrition, and it gives us little preparation for similar epidemics that are now incubating in South Asia and Latin America. Some parts of India already have substantial epidemics; one out of every nine HIV-positive people in the world is Indian. Nascent or concentrated epidemics throughout Latin America, in combination with deteriorating economic conditions, produce conditions as propitious to HIV as those in Africa ten years ago. By 1997, after several years of high unemployment, the prevalence of HIV in Buenos Aires was already what it had been in Zambia ten years earlier. At least a quarter of Latin Americans and Caribbeans cannot obtain 80 percent of their minimum calorie requirement even if they were to spend their entire income on food, and almost half the population of the region lives in poverty.

Social conditions in Latin America aggravate the population's vulnerability to HIV/AIDS. As in Southern Africa, highly concentrated land ownership forces millions of workers to migrate for work, internally or internationally, increasing risk of HIV and other STDs through new sexual liaisons, including prostitution. Forty million children in Latin America live on the street; they eat from garbage cans, and many of them sell sex to survive. Sex tourism has shifted from Asia to the Americas, with children as the primary targets of an Internet-based industry. Considering the extent of poverty and the immunological effects of that deprivation, an AIDS epidemic of African magnitude is possible in parts of Latin America. Throughout the region, the preponderance of new cases has shifted from upper to lower income and from men to women and children. Based on the demographics of those recently infected, Latin American AIDS is already "Africanized."

The policy implications of understanding the broader causes of the AIDS epidemic in Africa are reason for both optimism and pessimism. Reducing HIV transmission requires health education, availability of condoms and also a broad assault on malnutrition, diarrheal diseases and parasitic diseases, including malaria and schistosomiasis. To treat those already infected will require upgrading the health services infrastructure and expanding health education. The steps that are necessary for both prevention and treatment of HIV/AIDS are the same as for addressing the other health and development needs of poor countries.

Identifying those needs is relatively easy, but they have not been adequately addressed in the past--not by the governments of poor countries or by their bilateral and multilateral aid partners. Even that dismal acknowledgment, however, should be balanced by a recognition of how relatively inexpensive some solutions are. Vitamin A supplementation sufficient to prevent blindness and other deficiency diseases for one person for an entire year costs less than one condom. A year's supplementation with vitamin A, iron and iodine costs less than ten condoms. To fortify the food supply with iron to prevent anemia and increase disease resistance and work capacity costs about 20 cents per person per year. Attending to broader health concerns is not as expensive, or as hopeless, as it might seem. There are also serious weaknesses in a prevention plan that relies exclusively on provision of condoms, even with health education. It does not address women's lack of power in sexual relationships, nor the irrelevance of condoms to most people after a few beers. Strengthening immune systems will help to protect people from some of the consequences of unsafe sex and from other infectious diseases as well. What it will take to prevent HIV transmission and to treat people with HIV/AIDS is no less, but no more, than what has been needed all along in sub-Saharan Africa and other poor regions. It would have been cheaper to provide the infrastructure, the nutrition, the education and the medicines before HIV/AIDS, but it is still a bargain calculated in both compassionate and cost-effective terms.

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