By Susan Allen, M.D., M.P.H.

Over the last 20 years, HIV emerged as the #1 cause of death in African adults, and the Rwanda genocide became the most concentrated mass murder in recorded history. Though one catastrophe surfaced slowly and inexorably while the other smoldered for years before exploding in 1994, the lessons learned are similar. In both situations, the international community has combined moral bankruptcy with a spectacular display of incompetence. Genocide masterminds continue living in Michigan, Minneapolis and Boston, brazenly planning the final extermination of the Tutsi. Students of law, diplomacy and international development are astoundingly sanguine about this, as though our current abdication of responsibility today is mitigated by the centuries of unprincipled idiots who preceded us. If medicine operated this way we’d still be treating syphilis with arsenic.

Unfortunately, medicine has lost the moral high ground in Africa through missed opportunities and misappropriation of resources. In the last five years we have spent 20% of the US bilateral foreign assistance budget putting 2.5 million Africans on anti-retroviral treatment (ART), while twice that number of new HIV infections occurred. We tested 50 million Africans for HIV without acting on the evidence and common sense: rather than—transmission happens between two people. Had we tested Africans as couples, a prevention strategy proven to be effective in multiple publications since the early ’90s, we could have averted more HIV infections than we are now treating, and at a fraction of the cost.

And HIV is not even the greatest challenge facing Africa today; poverty is. While the US spent more than $20 billion treating 15% of the 22 million Africans with HIV, we contributed <$400 million to family planning. Explosive population growth is one of four major determinants of poverty in Africa, and the only one squarely in our medical domain. If we had spent $20 billion on testing couples and providing them with contraception, we would be seeing tangible benefits now. Instead, Africa’s population has grown by >25% in the last ten years and is now almost 850 million.

The international community also spent $1.5 billion on an International Criminal Tribunal for Rwanda, with an average of $18 million per case. This was symbolic, but not strategic. In the last two years alone we have allowed at least two alleged genocide perpetrators to enter the United States, despite their inclusion on the Homeland Security watch list. Each of them will now cost hundreds of thousands of dollars to investigate and deport to Rwanda.

We are capable of much better than this.

1986–1990

In 1986, one year after the first HIV antibody test kit was licensed, a serosurvey of 3800 antenatal clinic visitors in Kigali, the capital of Rwanda, showed 29% of healthy pregnant women were antibody positive (1). That same year, Yoweri Museveni took power in Uganda, Rwanda’s northern neighbor. Among Museveni’s best soldiers were Rwandan exiles, children and grandchildren of those who had fled massacres of Tutsi in Rwanda in 1973 and 1959 and who had helped overthrow Uganda’s famous despotic leader Idi Amin in 1979. Among them was Paul Kagame, who became chief of intelligence in President Museveni’s new government and later led the forces that stopped the 1994 Rwandan genocide.

From 1986 to 1990, the “Projet San Francisco (PSF),” named after my faculty home base at UCSF, followed HIV+ and HIV− women recruited from the antenatal clinic survey (2). We hoped that HIV would be like hepatitis B—that the presence of antibodies indicated immunity rather than chronic infection. As 5% of HIV+ women died each year, this hope waned, and we focused on early diagnosis and treatment of opportunistic infections (3). The first to die was Josephine, a quiet widow and mother whose story was told on one of the first AIDS quilts shown in San Francisco in 1987.

PSF secured long-term NIH funding in 1987 and accumulated evidence that >90% of adult deaths in Kigali were due to HIV. Our message to study participants evolved as we realized that most people with positive antibody tests were chronically infected. The women in our study asked for our help in educating their spouses about HIV and condom use, and we began to offer free testing to the husbands. We were as surprised as they to discover that one in eight couples had different HIV test results, a phenomenon we christened ‘discordancy’ (4). By 1990 it was clear that men’s participation in HIV prevention was crucial, and though condoms were at that time virtually unknown in Rwanda, we were encouraged to see that couples we counseled learned to use them. They did not use them perfectly, but HIV transmission in discordant couples was reduced from somewhere between 15–25%/year to 3–7% (5).

That same year, 1990, was also the year of the invasion of Rwanda by predominately Tutsi previously exiled to Uganda. Facing pressure from competing Ugandan tribes for grassland and water for their cattle, and having their status as refugees cemented by Uganda’s decision to deny them citizenship, these Rwandan exiles who had helped Museveni overthrow Amin, and later Okello, took up arms to reclaim their ancestral lands in Rwanda. The timing coincided with pressure from the West on Rwanda’s military dictator, who had seized power in a coup in 1973. North American and European diplomats were tying financial aid to development of multi-party democracy, and the Rwandan Patriotic Front, as the armed movement was known, established a political party and used their occupation of the northern part of Rwanda along the Ugandan border as negotiating leverage to keep a place at the multi-party table.

Within days of the October 1990 invasion, several thousand Tutsi residing in Kigali were arrested and herded into the soccer stadium. They included the husbands of two Projet San Francisco nurses. Professor David Weissbrodt of the University of Minnesota Law School and Amnesty International (AI) met with the nurses in my home and offered to have their husbands’ names included in AI’s letter writing campaign. He was clear that this could backfire: Idi Amin had selectively shot prisoners mentioned in letters from Al. The nurses courageously opted to have their husbands names included. Several tense weeks later, both husbands were released, skeletal and traumatized, but alive.

1991–1994

Meanwhile on the medical front given the high prevalence of HIV in women of childbearing age, and the pivotal role of their husbands in HIV prevention efforts (6), we received another NIH grant to establish a parallel cohort of the husbands of our antenatal recruits (7). Our male interviewers included a Tutsi father of five, and a Hutu former military leader who had been dishonorably discharged for blowing the whistle on the President’s son’s marijuana plantation in the Nyungwe tropical forest. Some of our study participants were military men from the main camp, 500 meters from our clinic. We received news from them about the continued fighting at the Uganda-Rwanda border. This complemented the information we had from the hospital surgeons, and from the truckloads of bodies that were deposited daily at the hospital morgue across the street from our clinic. Curiously, some of the soldiers reported being sent to the front lines with no ammunition, at the same time routine screening of the wounded in the surgical department showed an approximate HIV prevalence of 80%. A rumor circulated that the army was getting rid of HIV+ soldiers by sending them selectively into battle unarmed. Not surprising, given that, one general in that same army had said to me that burning prostitutes was the solution to AIDS.

Each Rwandan had an identity card that listed them as Hutu, Tutsi, or Twa, a system that had been established by Belgian colonialists. Upwards of half of Rwandans were thought to be of mixed ethnicity, but they inherited their official identity from their father. The Belgians had found it convenient to govern through the existing clan structure, which was similar to feudal Europe with a ruling class of rulers and a peasant class of Hutu agriculturalists. In many parts of Rwanda, the warriors were Tutsi cattleherders. In the northwest, both warriors and peasants were Hutu. The Belgians preferred to administer Rwanda through the Tutsi, whom they characterized as ‘superior’ to the Hutu by virtue of their height and fine features. The Belgian imposition of a new Tutsi administration in the northwest set the stage for much of the inter-ethnic hostility that would follow.

Rwanda became independent from Belgium in 1959, when a Hutu-dominated government took power. From 1973–1994, the President of Rwanda and most of his government were Hutu from the northwest, and they set rigid ethnic quotas that effectively prevented Tutsi from acquiring education and employment. In 1989 I began to receive requests for lists of HIV+ cohort participants and their ethnicity, part of a smear campaign to blame the Tutsi for the HIV epidemic. We had deliberately not recorded ethnicity so we were able to protect our study participants. The labor ministry, however, required regular reporting of employee names and ethnicity. Many non-governmental organizations like ours kept our Tutsi employees ‘off the books’.

In 1992, in the wake of small scale killings that we would later recognize as ‘warm-ups’ for the 1994 genocide, we debated whether to seek continued research funding for Projet San Francisco, or to close it down in light of the deteriorating political situation. We decided to press on. NIH renewed our grant for another five years, with the focus shifting to the study of heterosexual transmission in discordant couples. We established a couples’ testing center and began to promote couples’ testing on the radio (8). Our peppy advertisements were heard between increasingly virulent anti-Tutsi programming, which had become so toxic that I banned the radio at the project and in our three-family home. Several of our staff began to display openly extremist tendencies, haranguing the Tutsi employees and taunting them with their imminent demise. Two Tutsi nurses came to me to discuss the problem, but they begged me not to fire the offenders for fear of retaliation. I moved the most dangerous of the extremists, a data entry clerk, into my office with strict instructions not to leave her post. We maneuvered as best we could so that couples seeking testing would not feel intimidated.

In 1991 we produced a video in Kinyarwanda, the local language, entitled ‘Responsibility’ with a series of vignettes modeling desirable HIV prevention behaviors for married men. The film became unusable after 1994 when we learned that audiences recognized several actors as genocide perpetrators.

By early 1994, several Americans had moved into our home as it was no longer safe outside the capital. My eldest son Ryan was 13 months old and I was five months pregnant with my second son Kieran. I had agreed to go to Zambia for two weeks in March to help set up a new HIV project. As Zambia’s capital, Lusaka, was not safe at that time, I left Ryan with his father at our house in Kigali.

On April 6, 1994, the President of Rwanda was returning from another round of UN-brokered negotiations in neighboring Tanzania. The talks were aimed at implementing a transitional government with participation of opposition political parties, and a timeline for elections. The President’s entourage of northerners knew that they would lose elections-the parties representing a potential alliance of opposition groups had more constituents. Government leaders been able to infiltrate each opposition party with an anti-Tutsi faction, and to unify them against ‘the enemy’. Between 1993–1994, the government had succeeded in enumerating every house in the country-almost 8 million people-and defining them as Tutsi, moderate/opposition party Hutu, or extremists loyal to the current party. Lists were drawn up and instructions prepared that detailed who would die, who would give the orders to kill, and who would be forced to participate in the killing. The President’s supporters became more extreme, and he found himself caught between them and the international community that insisted he sign on to the transitional plan. The extremist newspaper had even published in March that the President would die if he went along with the UN plan. On April 6, after exhausting all attempts to delay, the President agreed. On his return to Kigali, it is widely believed that his own men shot his plane down and blamed it on the Tutsi. This provided the spark needed to launch the genocide.

Upon hearing that the plane was shot down, I was able to get through to our house by phone and learned that everyone was pinned down by shooting. I flew to Nairobi hoping to find a flight into Kigali to help with the evacuation, but I could not find a willing pilot. Three days later, I received word from the U.S. State Department that the group from my house, including my infant son Ryan and his father, had made it overland to Bujumbura, Burundi, and would be evacuated to Nairobi by U.S. military transport. (Six years later, I received a bill from the State Dept for $247 for Ryan’s evacuation.)

Eleven of us, expatriates and family from the project, waited in Kenya for several weeks, vainly hoping that Rwanda would calm down and we could return. We tried everything we could think of to reach the PSF staff, and miraculously the project phone worked until May 5. Each day or two, I would call and speak with Froduald, our Tutsi gardener, who would update us on which staff had been killed. Nyandwi, our Hutu guard, was sneaking Froduald food and information. The NIH was pressing me for a plan, and since we could not return to Rwanda I made a decision to relocate the Project to Zambia. In the course of helping a colleague in Lusaka, I had met senior people at the Ministry of Health and was able to obtain their permission for us to come. The NIH kindly set a precedent by allowing my grants to transfer from Rwanda to Zambia (Figure 1). We rented a building, hired Zambian counselors and nurses, and set up a couples’ testing center patterned on the Kigali model. As the weeks went by, we were able to find and relocate several surviving Rwandan staff and their families to Lusaka. I returned to the U.S. in July, and my son Kieran was born August 8. The RPF had by then taken over most of Rwanda and stopped the genocide, and in September I left the boys in the United States and went to Kigali to see what remained of the project and staff. In two weeks I found only seven survivors, 10% of the staff. All had horrific stories to tell about hiding for days under piles of corpses, witnessing the murder of their families. … My UCSF colleagues advised me to give the staff simple tasks to combat post-traumatic stress. The project clinic and lab had been decimated by mortar fire, so we began to clean up and organize patient files. Our house had been looted and there was nothing of value left except my old Suzuki jeep. A departing American had wisely taken the distributor cap (an idea he got from the movie “The Sound of Music”). I was able to give the car to our driver Alphonse, who resurrected it and kept it running for another 10 years.

1995–1999

As we built up the project in Zambia and waited for Rwanda to recover, we placed radio ads encouraging couples to get tested at our research center in Lusaka. In honor of the colleagues we lost in Rwanda, we gave the Lusaka project the same name—‘Projet San Francisco’. The prevalence of HIV was even higher in Lusaka than it had been in Kigali, and we soon confirmed that 20% of cohabiting couples were HIV discordant (9, 10). We did not realize that, just as we had fled to Zambia, so also had many senior leaders of the genocidal government that had been overthrown by Paul Kagame and the RPF. One of them, Jean de Dieu Habineza, had been Minister of Social Affairs in the genocidal government. In May of 1995, he came to our Lusaka project and asked questions of the expatriates, Rwandans, and Zambians. Several hours later, a phone call came, our German nurse Andrea vonLieven answered, and the caller said “Close your project and go back to America or we will kill all of you.”

We were forced to temporarily close the project while the Zambian police investigated the death threat. Between us, we lobbied all of our Embassies: the United States and Republic of Ireland (me), Germany (Andrea), and Belgium (Alain deGroot, who had been born and raised in Rwanda and had worked with us for five years in Kigali). The encouragement of the diplomatic corps, combined with expanding intelligence about the scope of the ‘Rwandan problem’ in Lusaka, led the Zambian authorities to arrest 18 Rwandans suspected of participation in the genocide. Three of these, Georges Rutaganda, Jean Paul Akayesu, and Clement Kayishema—a doctor—were the first in the world to be handed over to the UN International Criminal Tribunal for Rwanda (ICTR) and convicted of war crimes.

Unfortunately, though Rwanda requested that the others be handed over to stand trial in Kigali, the UN intervened citing ‘jurisdictional primacy’, and the remaining 15 detainees were released. Two weeks later, after spending day and night with an armed bodyguard and carrying a handgun myself, I took my boys, then aged 18 months and almost three, back to the United States. I deeply appreciated everything the Zambian police had done, and I trusted our bodyguards implicitly. I knew they were as angry as I was about the order to release the Rwandans. It was clear, though, that we had run out of options. All things considered, it seemed wiser to be realistic about the risks and remove the project from the line of fire.

On the HIV front, 1998 was a turbulent year. After receiving the highest score in an NIH technical review of new HIV clinical trial sites in Africa and having two large trials of perinatal HIV prevention approved for funding in Lusaka, we were suddenly accused of being a racist organization and ordered to close by the Zambian Ministry of Health. All accusations of racism in Zambia are investigated by the intelligence services. Our project was well known to them as a result of our work on the Rwandan case, and their investigation quickly exonerated us of racist charges. We were able to re-open in June 1999 after a seven-month hiatus, but by that time the perinatal trials had been relocated to other countries, and we had to downsize considerably. On the plus side, we were able to refocus on pathogenesis studies of heterosexual transmission, which were expanding rapidly following my April 1998 marriage to renowned virologist Eric Hunter (11, 12).

By 2000, with NIH funding, we had been able to enroll the largest single-site discordant couple cohort in the world in Lusaka (13), and we were rapidly accumulating precious samples from donors and recipients in male-to-female and female-to-male HIV transmission pairs. As in Rwanda, Zambian discordant couples adapted rapidly to condom use and transmission rates dropped to 7%/year after joint counseling (14). We had managed to find interim funding from UNFPA in Rwanda, but this was limited to service delivery with no research component. The number of surviving staff in Kigali had grown to 17, including those who returned to Rwanda from Zambia in the wake of the death threats.

HIV testing remained limited to research projects, blood screening services, and a few small voluntary HIV testing centers like ours. The ‘service sector’ did not view HIV testing as a viable prevention strategy, despite the evidence from our group and others that (15):

  • Most African adults are in cohabiting unions
  • Most sexual encounters are between cohabiting partners
  • Most HIV transmissions occur between cohabiting partners
  • Testing couples promotes effective risk reduction

It was not until single dose intrapartum Nevirapine was found to reduce perinatal HIV transmission by 40% that HIV testing received attention, but only as a means of identifying pregnant women who needed Nevirapine. In 2001, we obtained funding from the World AIDS Foundation to pilot test couples’ volunary counseling and testing (CVCT) services in four antenatal clinics in Lusaka and Kigali. We were able to show that CVCT was feasible, popular, and effective in promoting condom use. We lobbied heavily for the inclusion of male partners in antenatal clinic HIV testing, pointing out that this would mutually reinforce prevention of heterosexual and perinatal HIV transmission.

In Rwanda we have managed to leverage the evidence and establish CVCT as a standard of care (16). Paul Kagame, leader of the forces that stopped the genocide, eliminated ethnic indentity cards, and abolished the death penalty is felt by many to be a visionary President and an able diplomat and administrator. He heard the argument for couples’ testing in 2003, specifically that >90% of new infections in Rwanda were acquired from spouses and two-thirds of those could be prevented by joint testing and counseling. He endorsed CVCT and instructed his Ministry of Health to make it happen. By 2009, all the counselors in the government clinics had been trained to counsel couples, and more than half of the cohabiting couples in the capital city had been tested. In October of 2009, we received a five-year grant to expand CVCT nationwide. Rwanda being Rwanda, and the Kagame government being what it is, this will happen efficiently. Unfortunately, Rwanda remains the only country in Africa to implement CVCT nationally.

Zambia is still a work in progress. An estimated seventy percent of new HIV infections in urban Zambia are acquired from cohabiting partners in ‘discordant couples’ who do not realize that one partner is HIV+ and the other HIV− (17). In Zambia, CVCT reduces transmission in discordant couples by half to two-thirds. The benefits of CVCT in couples with two HIV− partners are also substantial through reduction of new infections acquired from extramarital sexual partners. Lastly, CVCT prompts reductions in other sexually transmitted infections, including gonorrhea and syphilis, and is associated with increases in long-acting contraceptive use and corresponding decreases in unplanned pregnancies among couples with HIV. When both partners know both HIV test results, they know what to do, and they are motivated to do it.

Couples’ HIV counseling and testing has enjoyed long-standing support from the Government of the Republic of Zambia, but international donors have not been supportive. The lack of resources and implementation plans have prevented the expansion of the testing program. Six years after the 2003 endorsement by government, only 8% of the capital’s couples have been jointly tested, and CVCT services are not yet offered in over 90% of the urban health centers outside the capital city.

Since the inception of the U.S. President’s Emergency Plan For AIDS Relief (PEPFAR) in Zambia, 881,700 pregnant women and 640,400 other adults have been tested for HIV (www.pepfar.gov). Although more than 80% of these adults were married, and half of those who were HIV+ had HIV− spouses, fewer than 2% were tested with their spouses, and an estimated 240,000 discordant couples are thus unaware of their status. Unfortunately, the grant we have to provide CVCT in Lusaka, which constituted 0.3% of the annual Zambia PEPFAR budget, was cut this year while treatment budgets were increased. Even after we showed that couples’ testing in antenatal clinics was feasible and popular in the capital city in 2001, the PEPFAR perinatal prevention programs refused to entertain testing husbands until 2008, when the Minister of Health wrote a letter explicitly authorizing us to provide these services. To this day CVCT remains relegated to weekends.

In 2009, our project received a five-year grant from the US Centers for Disease Control to become a Center of Excellence that provides CVCT training to other African countries. To date we have hosted envoys from 18 countries at our sites in Rwanda and Zambia, and have sent technical assistants to seven countries. The annual budget of this grant, which could help African countries prevent more than half of all new adult HIV infections, is 0.012% of the annual PEPFAR budget. At higher levels in Washington, couples’ testing is not taken seriously, evidently because Africans are viewed as promiscuous and unwilling or unable to change their sexual behavior. Interestingly, research consistently show that Africans are more sexually conservative than Americans, and both men and women report fewer partners (DHS in Africa and NCHS in the USA). Our African physician colleagues who have spent time in the U.S., or with Americans in Africa, confirm that Americans have a far more lenient attitude towards sex than Africans do. In 23 years of living and working in Africa, I would certainly second that observation. Unfortunately, the evidence has not been enough to overcome unfounded prejudices, pharmaceutical company interests, or the influence of internists who want the focus to remain on treatment.

There is a similar misplaced fatalism when family planning in Africa is discussed: what is the point of providing contraceptives when African men and women are firmly pronatalist? Our experience confirms that when effective contraception is provided, Rwandan and Zambian couples will use it and the incidence of pregnancy declines (1823). In Rwanda, use of hormonal contraception was associated with longer survival in HIV+ women (22). Most recently, a survey of Zambian and Rwandan couples seeking HIV testing showed that half did not want more children. One in three of those chose to have an IUD or Jadelle implant inserted after post-test counseling (unpublished data). These two methods are relatively unknown in most of Africa, but our preliminary results confirm that there is high demand for user-independent methods that can prevent pregnancy for 5–10 years. Given Africa’s explosive population growth (Figure 2: the average African woman bears five children, the highest total fertility rate in the world), and the critical role this plays in perpetuating poverty, a combined focus on prevention of HIV and unplanned pregnancy in couples is needed.

We have recently presented data from our cohorts showing lower transmission rates in discordant couples with HIV+ partners who initiate ART therapy for clinical indications (P.Sullivan et al, IAS conference, Capetown 2009). Others have used these data to promote the concept of “test-and-treat” to eradicate HIV from Africa by treating all 22 million HIV+ Africans to render them not contagious. We vigorously disagree with this proposition for practical reasons. Initiating and maintaining 2 to 3 million Africans on ART costs $4–$5 billion per year since 2004. The entire U.S. bilateral foreign assistance budget was $20 billion/year in 2008. Assuming all HIV+ Africans could be identified and treated (which we have failed to do even in North America and Europe), ‘test and treat’ would require that the US double its Foreign Service budget and allocate 100% of it to ART in Africa. In today’s economic climate, the chances of this happening are vanishingly small. The cost of preventing one transmission in a discordant couple using ART is $5943/year; this money would be better spent preventing 10–20 new infections though couples’ testing (Figure 3). Moreover, given the PEPFAR budget ceiling, each asymptomatic HIV+ person treated solely to reduce contagion is one ill HIV+ person who will die without ART. This attempt to reconcile prevention and treatment by combining them is not evidence-based, realistic, or achievable.

The essential role of African Rights, the only human rights organization to undertake systematic investigations and reporting of Rwandan war criminals in exile, cannot be overstated. Rakiya Omaar, a British-educated lawyer of Somali origin and director of AR, was in Rwanda during the genocide and wrote ‘Death, Despair, and Defiance”, which remains the definitive scholarly work on the 1994 genocide and includes a history and political analysis as well as eye witness testimonies. AR has contributed in one way or another to most of the arrests that have occurred to date worldwide, including those in Zambia and the U.S. I had ordered 40 copies of Rakiya’s book and distributed them to all the Ministries, Embassies, and UN agencies in Zambia, and this proved to be a critical source of information.

Per www.ictr.org as of October 2009, the genocide investigation has produced:

  • 47 completed cases
  • 26 cases in progress
  • 4 awaiting trial
  • 11 accused, at large
  • $18 million per case

The ICTR stopped issuing new indictments in 2006, though their mandate to finish the ongoing cases and to pursue the indictees who are still at large, has been extended to 2011. Why the international community would continue to support such an unproductive mechanism remains a mystery, but at least the narrower mandate allows previously blocked bilateral arrangements to be pursued.

Of the 15 suspects arrested and released in Zambia in 1995, at least two subsequently entered the USA. One of them—Jean Marie Vianneg Mudahinyuka, alias “Zuzu”—is now in a prison pending deportation to Rwanda, and the other is one of several dozen cases reported to Homeland Security’s Immigration and Customs Enforcement Human Rights Violators Unit. The precedent for the deportation mechanism is Enos Kagaba, who entered the U.S. via Zambia and was arrested and deported to Rwanda in 2005 (Figure 4). He remains the only alleged genocide perpetrator to be deported or extradited to Rwanda by any western country.

Though it is encouraging that U.S. Immigration is taking an interest in Rwandan genocide perpetrators residing in the U.S., our border has proved to be disappointingly permeable. Several high-level genocide perpetrators have succeeded in obtaining visas and entering the U.S. despite extensive reports provided to the U.S. State Department and Homeland Security. It requires a great deal more time and money to deal with them once they have entered the U.S. than it does to prevent them from entering. Most of them enter the U.S. from Southern Africa—in particular Malawi, Zambia, and Mozambique. It is more efficient to facilitate their arrest in these countries, particularly since in November of 2009, Rwanda joined the British Commonwealth, and fellow Commonwealth countries in Southern Africa no longer require separate extradition agreements. Unfortunately none of the relevant U.S. government agencies are willing to fund this effort.

Pursuing Rwandan killers has been both frustrating and exhilarating. On the one hand, how could the world react in such a disorganized fashion to what had been clearly called a genocide? Was ‘never again’ just an empty phrase? How could law enforcement in Zambia, a poor southern African country of 11 million, be so much more effective than the UN (or for that matter the US) in apprehending war criminals? How could a handful of people working for non-governmental organizations be responsible for the coordination and momentum needed to get the first genocide perpetrators to the International Criminal Tribunal for Rwanda? Why, despite a clear track record of success, does African Rights struggle to find funding, while the ICTR, an emperor with no clothes if ever there was one, receives millions of taxpayer dollars each year? Why are diplomats satisfied with empty symbolism, and why are they so averse to tangible accomplishments? I wish I could pursue a doctorate in political science: “Accountability in international relations: translation of M&M from medicine to diplomacy.”

CONCLUSION

The next 10 years should be the decade of evidence-based decisions and actions that are strategic rather than symbolic. Resources for HIV should shift from treatment to prevention and be combined with family planning. Justice for Rwanda should be served, not only for the peace of mind of survivors, but for the security of the children of Rwanda and for our own conscience.

ACKNOWLEDGEMENTS

I would like to thank Ray Schinazi, Professor of Pharmacology at Emory University and his wife Lynn, for founding the Genocide Prevention and Justice Foundation (GPJF), which raises funds for Rakiya Omaar and African Rights to conduct investigations of alleged genocide perpetrators in exile. GPJF is also fundraising to help us complete our documentary “Killers Among Us”. If you would like a copy of the 9-minute trailer of Killers, please email sallen5@emory.edu. If you would like to purchase a copy of “Death, Despair, and Defiance” please email sallen5@emory.edu or go to www.rzhrg.org and select ‘Genocide prevention’. All proceeds to the GPJF.

Footnotes

REFERENCES

1. Allen S, Van de perre P, Serufilira A, et al. Human immunodeficiency virus and malaria in a representative sample of childbearing women in Kigali, Rwanda. J Infect Dis. 1991;164:67–71. [PubMed]

2. Allen S, Lindan C, Serufilira A, et al. Human immunodeficiency virus infection in urban Rwanda. Demographic and behavioral correlates in a representative sample of childbearing women. JAMA. 1991;266:1657–63. [PubMed]

3. Lindan CP, Allen S, Serufilira A, et al. Predictors of mortality among HIV-infected women in Kigali, Rwanda. Ann Intern Med. 1992;116:320–8. [PubMed]

4. Allen S, Serufilira A, Bogaerts J, Van de Perre P, Nsengumuremyi F, Lindan C, et al. Confidential HIV testing and condom promotion in Africa. Impact on HIV and gonorrhea rates. JAMA. 1992;268(23):3338–43. [PubMed]

5. Allen S, Tice J, Van de Perre P, Serufilira A, Hudes E, Nsengumuremyi F, Bogaerts J, Lindan C, Hulley S. Effect of serotesting with counselling on condom use and seroconversion among HIV discordant couples in Africa. BMJ. 1992;304:1605–9. [PMC free article] [PubMed]

6. Seed J, Allen S, Mertens T, Hudes E, Serufilira A, Carael M, Karita E, Van de Perre P, Nsengumuremyi F. Male circumcision, sexually transmitted disease, and risk of HIV. JAIDS. 1995;8(1):83–90. [PubMed]

7. Roth DL, Stewart KE, Clay OJ, van Der Straten A, Karita E, Allen S. Sexual practices of HIV discordant and concordant couples in Rwanda: effects of a testing and counselling programme for men. Int J STD AIDS. 2001;12(3):181–8. [PubMed]

8. King R, Allen S, Serufilira A, Karita E, Van de Perre P. Voluntary confidential HIV testing for couples in Kigali, Rwanda. AIDS. 1993;7:1393–4. [PubMed]

9. Bakari JP, McKenna S, Myrick A, Mwinga K, Bhat GJ, Allen S. Rapid voluntary testing and counseling for HIV. Acceptability and feasibility in Zambian antenatal care clinics. Ann N Y Acad Sci. 2000;918:64–76. [PubMed]

10. McKenna SL, Muyinda GK, Roth D, Mwali M, N’gandu N, Myrick A., Priddy FH, Hall VM, von Lieven AA, Sabatino JR, Allen S. Rapid HIV testing and counseling for voluntary HIV testing centers in Africa. AIDS. 1997 Sep 11;(Suppl 1):S103–10. [PubMed]

11. Trask SA, Derdeyn CA, Fideli U, Chen Y, Meleth S, Kasolo F, Musonda R, Hunter E, Gao F, Allen S, Hahn BH. “Molecular epidemiology of human immunodeficiency virus type 1 transmission in a heterosexual cohort of discordant couples in Zambia.” J Virol. 2002;76(1):397–405. [PMC free article] [PubMed]

12. Derdeyn CA, Decker JM, Bibollet-Ruche F, et al. Envelope-constrained neutralization-sensitive HIV-1 after heterosexual transmission. Science. 2004;303:2019–22. [PubMed]

13. Chomba E, Allen S, Kanweka W, Tichacek A, Cox G, Shutes E, Zulu I, Kancheya N, Sinkala M, Stephenson R, Haworth A. the RZHRG. Evolution of Couples’ Voluntary Counseling and Testing for HIV in Lusaka, Zambia. J Acquir Immune Defic Syndr. 2008;47(1):108–115. [PubMed]

14. Fideli US, Allen SA, Musonda R, Trask S, Hahn BH, Weiss H, et al. Virologic and immunologic determinants of heterosexual transmission of human immunodeficiency virus type 1 in Africa. AIDS Res Hum Retroviruses. 2001;17(10):901–10. [PMC free article] [PubMed]

15. Allen S, Meinzen-Derr J, Kautzman M, Zulu I, Gao F, Haworth A. Sexual behavior of HIV discordant couples after HIV counseling and testing. AIDS. 2003;17:733–40. [PubMed]

16. Allen S, Karita E, Chomba E, Roth DL, Telfair J, Zulu I, et al. Promotion of couples’ voluntary counselling and testing for HIV through influential networks in two African capital cities. BMC Public Health. 2007;7:349. [PMC free article] [PubMed]

17. Dunkle KL, Stephenson R, Karita E, et al. New heterosexually transmitted HIV infections in married or cohabiting couples in urban Zambia and Rwanda: an analysis of survey and clinical data. Lancet. 2008;371:2183–91. [PubMed]

18. King R, Estey J, Allen S, et al. A family planning intervention to reduce vertical transmission of HIV in Rwanda. AIDS. 1995;9(Suppl 1):S45–51. [PubMed]

19. Allen S. International data. J Acquir Immune Defic Syndr. 2005;38(Suppl 1):S7–8. [PubMed]

20. Allen S. Why is fertility an issue for HIV-infected and at-risk women? J Acquir Immune Defic Syndr. 2005;38(Suppl 1):S1–3. [PubMed]

21. Mark KE, Meizen-Deer J, Stephenson R, Haworth A, Ahmed Y, Duncan D, Westfall A, Allen S. Contraception among HIV Concordant and Discordant Couples in Zambia: A Randomized Controlled Trial. Journal of Women’s Health. 2007;16(8):1200–10.

22. Allen S, Serufilira A, Gruber V, Kegeles S, Van de Perre P, Carael M, Coates T. Pregnancy and contraception use among urban Rwandan women after HIV testing and counseling. Am J Public Health. 1993;83(5):705–10. [PMC free article] [PubMed]

23. Allen S, Stephenson R, Weiss H, Karita E, Priddy F, Fuller L, DeClercq A. Pregnancy, Hormonal Contraceptive Use and HIV-related death in Rwanda. Journal of Women’s Health. 2007;6(7):1017–27.


Articles from Transactions of the American Clinical and Climatological Association are provided here courtesy of

American Clinical and Climatological Association

Source: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2917146/

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