There is greater frankness today about development policy failures in Africa. It was reflected in President Barack Obama’s speech in Accra, Ghana on July 11 when he stated: “Development depends on good governance. That is the ingredient that has been missing in far too many places for far too long.” And it is also seen in President Jacob Zuma‘s surprising declaration to the South African Parliament on October 29 for the need to “respond with urgency and resolve” to the “devastating impact of HIV and AIDS” on the nation.
It has taken many years for a South African president to speak frankly to his fellow citizens of the need to convert “knowledge into behavior change.” Unlike his predecessor, Thabo Mbeki, who refused to acknowledge how HIV was actually transmitted, Jacob Zuma now encourages South Africans to learn their HIV status and “take informed decisions to reduce their vulnerability to infection.” While estimates of new infections in South Africa are an astounding 750,000, they are also climbing relentlessly in Nigeria where latest annual estimates are put at 370,000.
In January 2006, the Bill & Melinda Gates Foundation made a large grant to support the Research Alliance to Combat HIV/AIDS (REACH), a collaborative program between Northwestern University and the University of Ibadan, Nigeria. Survey research has been completed in 12 communities in four Nigerian states on two projects: the social and cultural factors that influence vulnerability to infection and the willingness, or inhibition, regarding the use of testing and care facilities. A third pilot project on adolescents and HIV prevention was started when preliminary findings showed the high vulnerabilities of, and insufficient attention being devoted to, this age group.
This month, teams of REACH researchers will return to the twelve communities to report on the research findings. These studies could not have been conducted without the active cooperation of local authority figures: government, traditional and religious. In spring 2010, comprehensive reports of the three projects, along with policy recommendations, will be made available in Nigeria and internationally.
The four Nigerian states in which the REACH research was conducted—Oyo, Lagos, Cross Rivers and Benue—have prevalence rates of 2.2, 5.1, 8 and 10.6 percent, respectively. Understanding the reasons for these disparities requires probing the economic, cultural, normative and other factors involved. Even with this information, inducing the necessary remedial action must overcome great barriers.
One of the notable achievements of this era has been the provision of billions of dollars annually so that millions of HIV-infected persons worldwide can receive anti-retroviral drugs. However, a report just published predicts that unless there are drastic changes in infection rates, tackling AIDS and its consequences in poor countries could cost $35 billion annually in two decades. Since sub-Saharan Africa still accounts for two-thirds of persons infected with HIV, much more vigorous efforts are needed to curb transmission of the disease in the continent.
President Zuma told South Africans that “knowledge will help us to confront denialism and the stigma attached to the disease.” That is no easy charge after decades of disinformation and distrust. I was confounded in a tour of our research sites in Nigeria earlier this year when a man in one community complained that, as a result of drug treatment, it was now difficult to know who was infected and therefore whom to avoid. In that remark, knowledge, stigma, and behavior were tightly interwoven. Unwinding them to facilitate effective and humane action will require enhanced collaboration, at the level of communities, among government, social, religious, business and academic actors.
Richard Joseph is Principal Investigator of REACH.
 Donald G. McNeil, Jr., “Panel warns that without new direction, epidemic will remain out of control at 50,” New York Times (November 2, 2009).
 For a strategy of wider testing and earlier drug treatment in Washington, DC and the Bronx, whose prevalence rate of about 5 percent is close to the Nigerian average, see Susan Okie, “Fighting H.I.V., a Community at a Time,” New York Times (October, 27, 2009).