Book Review

The African AIDS Epidemic: A History

N Engl J Med 2006; 355:1182-1183September 14, 2006

Article

The African AIDS Epidemic: A History
By John Iliffe. 214 pp. Athens, Ohio University Press, 2006. $55 (cloth); $24.95 (paper). ISBN: 0-8214-1688-X (cloth); 0-8214-1689-8 (paper).

“A History Up to Now” might have been a more accurate subtitle for this intriguing book by British historian John Iliffe. It would have emphasized that the story of the AIDS epidemic in Africa is still in the making. Iliffe's analysis of the sociopolitical aspects of HIV and AIDS in the context of African history reminds us that disciplines other than the biomedical sciences can provide us with insights that are equally pertinent, though different, just as photographs (which are not included in the book) can convey the meaning of AIDS more effectively than any clinical description. A comprehensive summary of the epidemiology of HIV and AIDS in Africa is provided, with chapters devoted to its biology and origins, its emergence in western equatorial Africa, and its extension to the east, south, and west. An unusual strength of this book is its diverse and exhaustive literature review, which brings together in a single-author work a wide range of material from different disciplines.

Iliffe begins by asking why Africa has been so disproportionately affected by HIV and AIDS. In early chapters describing origins and epidemiology, he argues that time was the critical factor — Africa was affected first, unaware of the menace and thus ill-prepared to respond. To be fair, Iliffe also discusses other social and biologic reasons for the continent's vulnerability, including demographic characteristics (fewer women than men in many urban settings); massive migration by men seeking work, as in the South African mines; sex-based inequalities that make women vulnerable, sometimes pushing them into trading sex for money or goods; high rates of other sexually transmitted infections, especially genital herpes; and the absence of male circumcision.

It is with Iliffe's interpretation of the importance of timing that I disagree. Granted, countries affected later had a theoretical opportunity to take preventive action. However, there is little evidence that many did so, and the most heavily affected countries of southern Africa were affected later than others. In the Democratic Republic of Congo, for instance, the epidemic has been present longer but has stabilized at a relatively low level by African standards. In the April 8, 2006, issue of Lancet (“Has Global HIV Incidence Peaked?”), Shelton and colleagues used the term “perfect storm” to refer to the unique gathering of conditions in Africa that drove high-incidence epidemics, especially in the southern part of the continent. Africa is unique and will likely remain so in its severe, generalized epidemic of HIV and AIDS.

In subsequent chapters, Iliffe addresses the response to HIV and AIDS by the international community, by the affected societies themselves, and by that modern phenomenon so amplified by the HIV and AIDS pandemic: nongovernmental organizations. These organizations have often been the only source of help, comfort, and care for those afflicted. The author has reviewed a whole literature and range of experience that biomedical researchers would otherwise never access, and he poignantly describes the extraordinary impact of the disease and its mortality rate on households and societies.

In this book, HIV and AIDS are captured in the context of social and economic crisis in Africa. Too often, Western observers attribute Africa's woes to the impact of HIV and AIDS, ignoring the fact that the epidemic emerged in parallel with a decline in public health and clinical infrastructure and a general worsening of poverty. Sometimes the text gets overly dense and long, as Iliffe tries to gather too many different strands of African reality from too many countries; meaningful generalizations cannot always be made. However, the peculiar politics of HIV and AIDS in South Africa are clearly described.

Iliffe accurately depicts the global response, the role of the World Health Organization, the events leading to the establishment of the Joint United Nations Programme on HIV/AIDS (also known as UNAIDS), the recent increases in funding, and recent efforts to deliver antiretroviral therapy to Africa. As is true in other disasters, silver linings can be found, and Iliffe closes on a more positive note than one might have thought possible given the early history of the epidemic.

Other books describe some of this history more anecdotally, give more insight into individual characters, or discuss the global politics of HIV and AIDS more deeply. Iliffe's review is scholarly, combines biomedical as well as societal perspectives, and is sympathetic to and insightful about Africa and its peoples. It is a valuable contribution that reminds us how much we have learned about HIV and AIDS from this uniquely captivating, troubled continent.

Kevin M. De Cock, M.D.
World Health Organization, CH-1211 Geneva, Switzerland