Book Review

AIDS in Africa

N Engl J Med 1994; 331:619September 1, 1994

Article

AIDS in Africa
Edited by Max Essex, Souleymane Mboup, Phyllis J. Kanki, and Mbowa R. Kalengayi. 728 pp., illustrated. New York, Raven Press, 1994. $160. ISBN: 0-7817-0110-4

When the definitive history of AIDS research in Africa is written, many of the 70 contributors to this 728-page book will feature in it prominently. The book includes chapters on the biology of retroviruses, including the simian pathogens, the epidemiology of the human immunodeficiency viruses (HIV) and human T-cell lymphotropic viruses in Africa, clinical aspects of retroviral diseases, preventive measures, and the socioeconomic impact of AIDS. It concludes with a country-by-country analysis of the current situation with respect to AIDS. It represents an enormous effort and provides a valuable resource.

Some of the weaknesses of the book are inherent in multiauthored works. The chapters vary in length, amount of detail, and timeliness of references; although some chapters include references through 1993, others cite works published only up to 1991, three years before this book's publication. Some chapters discuss subjects of limited field importance in great depth, whereas others cover more important subjects more superficially. For example, the chapter on AIDS-associated cancer discusses molecular mechanisms of pathogenesis and is 2 1/2 times as long as that on opportunistic infections. At the same time, there is no separate chapter on HIV-associated tuberculosis, undeniably one of the most important public health consequences of the AIDS epidemic in Africa. There is sometimes overlap between chapters, such as the repeated discussion of HIV type 2 infection. Although a chapter is devoted to case definitions, discussion of the purposes and methods of surveillance for HIV and AIDS is sparse. Country-specific details are often outdated.

The strengths of the book include the broad range of subjects covered, including counseling, issues related to women and children, strategies for the prevention of HIV and AIDS, ethical and legal issues, and the socioeconomic effects of AIDS in Africa. The authors show, for those who need convincing, that AIDS is having a devastating impact on a continent whose resources are already stretched by poverty and rapid population growth, with damage extending beyond the health sector to the socioeconomic development of already fragile societies.

Who will read this expensive book, and what alternative works are there? According to the editors, their objectives were to facilitate research, treatment, and intervention throughout Africa and to contribute to the understanding of AIDS in general. The book will promote knowledge in the industrialized world about AIDS in Africa. Its cost and emphasis on the details of research will place it beyond reach for most on the front line of AIDS work in Africa, and the editors and publishers should consider how they might make it accessible to African colleagues in the field.

I can think of no alternative work covering AIDS in Africa in this depth; for those interested in the subject, the supplement to the journal AIDS entitled AIDS in Africa: The First Decade and Challenges for the 1990s (Peter Piot et al. AIDS 1991;5 Suppl 1:S1-5) provides many useful review articles. AIDS in the World: The Global AIDS Policy Coalition (Jonathan Mann, Daniel J.M. Tarantola, and Thomas W. Netter, eds. Cambridge, Mass.: Harvard University Press, 1992) takes a more global view and attempts to describe the pandemic and society's response. Few books have addressed the care of patients with AIDS in resource-poor areas, a subject that merits much more attention; AIDS in Africa: A Manual for Physicians (Peter Piot et al., eds. Geneva: World Health Organization, 1992) is one of the better attempts.

In his preface, Max Essex describes the commitment of a Zairian author concerned about completing his chapter despite his personal insecurity during the civil unrest. I reviewed this book while Rwanda's agony was destroying one of Africa's finest infrastructures for research on AIDS; at the same time, hope and dignity flourished in the new South Africa. Perhaps one book cannot adequately cover a disease as complex and dynamic as AIDS in a continent as heterogeneous as Africa; this excellent book represents an important effort.

Kevin M. De Cock, M.D.
London School of Hygiene and Tropical Medicine, London WC1E 7HT, United Kingdom