On a back street in one of Antananarivo's seedier neighborhoods, Saholy clutches at the hood of her blue jacket, pulling it down against the light rain. She steels herself for more verbal abuse from her fellow street walkers plying their trade on the corners.
Saholy is 39, a single mother of three teenagers, a prostitute ashamed of her life and, for the last couple of years, a weapon in Madagascar's war on AIDS. Several nights a week, she dons a blue uniform and white badge and tries to convince prostitutes to have only protected sex and get regular medical checkups.
"The other sex workers insult us and try to drive us away because we are interfering with their work," said Saholy, who does not want to be identified further for fear her children will learn what she does. "We leave but keep coming back. Eventually they listen to what we have to say."
Madagascar has the lowest HIV rate in sub-Saharan Africa, with less than 1 percent of its people infected. Yet this island is waging one of the most aggressive campaigns against AIDS on the continent — a model for how to prevent HIV and improve basic health care at the same time.
"On HIV and AIDS, Madagascar is the only country in Africa that is getting it right," said Dr. Hugo Templeman, a Dutch AIDS specialist in South Africa who advises Madagascar President Marc Ravalomana on fighting AIDS.
AIDS seen as Africa's biggest problem
Other African countries are making some headway against the disease — the number of new infections in Uganda and Kenya has dropped after widespread public campaigns, for example. But 80 percent of Africans still see the spread of AIDS and other diseases as the continent's single biggest problem, according to a Pew Global Attitudes Project survey based on 57,000 interviews in 10 countries.
Madagascar's all-out attack on AIDS comes from the fear that HIV will arrive along with a more open economy and an influx of foreign workers. Foreigners come every year to work in the vanilla plantations and in new ventures such as a mining project recently launched in once-remote Fort Dauphin.
The island has been protected so far largely by its isolation, but it has only to look across the water to southern Africa to see the killer wave headed its way. Nine of the world's ten most HIV-ridden countries are in southern Africa, with infection rates of more than 37 percent in Botswana and Swaziland.
If AIDS takes hold in Madagascar, it could explode. Madagascar is one of the poorest countries in the world, and some of its people take the risk of sex work to live. It also has a high rate of sexually transmitted diseases, a sign of vulnerability to AIDS.
The response to AIDS starts at the top. President Ravalomanana makes it a point to take AIDS tests in public, in contrast to his South African counterpart, Thabo Mbeki, who has publicly questioned whether HIV causes AIDS. Health care is such a priority in Madagascar that the national AIDS office is in the presidential palace, where the top adviser can report to the president at a moment's notice.
"The AIDS campaign is a personal initiative from the president," said Dr. Fanjaniaina Rajoelisolo, who runs the AIDS office. "He himself negotiates with the donors. The president tells me to go and see out in the country — he wants to see the impact of his policies."
Prevention seen as key
The crusade against AIDS ripples from the palace through this country of about 19 million people. Prevention messages scream from billboards and posters, and condoms are readily available. More than 100 screening centers have been set up, and mobile testing units are sent to remote areas. The government hopes to distribute 400,000 HIV test kits by the end of 2007.
In villages, hundreds of local AIDS councils take action in their own ways. The village of Maroambihy, for example, held a carnival, showed films and organized home visits reaching more than 8,000 people. Young players in the football club were taught to carry condoms, and women demonstrate their use at regular health service sessions to weigh children.
Groups considered at risk get special attention, including young people aged 19 and under who make up half the population of Madagascar. Thousands of teachers are trained in how to convey the AIDS prevention message to their students. Young people can get check-ups at a discount, and training kits are passed out to scout troops so they can talk about AIDS.
At a small private clinic in one of Antananarivo's poorer neighborhoods, Dr. Voahirana Lalao Raniriharisoa ushers her last patient, a young woman, to the door. The office is spartan, with a cluttered desk and dingy white equipment cramped into about eight square feet.
The doctor said the AIDS prevention campaign is helping, and more young people are going for treatment.
"There is a lot of sensitivity now to health issues," she said. "Health care is improving, and now more people are aware of their own health."
General push for better healthcare
Along with AIDS prevention, Madagascar is trying to help those who already live with the disease. In August, the island passed the first law in Africa that introduces hefty fines for discrimination against AIDS patients or disclosure of their status.
Anti-retroviral treatment is readily available, and Madagascar hopes to get 90 percent of its HIV-positive people on it within five years. In nearby South Africa, the government dragged its feet on providing anti-retroviral medicines to those with HIV until a court-ordered action.
Madagascar's campaign against AIDS goes hand in hand with a general push to expand its clinics, hire more doctors and upgrade health care. Madagascar is using the one disease it has little of so far — AIDS — to fight all the other illnesses it suffers from in abundance. As long as its HIV rate remains low, it can spend aid money on both HIV problems and general health.
In Antanetikely, a village in the central highlands south of the capital, mothers and young children stand in line for hours in the sun for a few minutes of simple treatment that the government hopes will save 40,000 children this year alone.
People in such rural areas rarely get to a clinic because of vast distances and poor roads. So twice a year, medical teams visit to give children a dose of vitamin A, de-worming tablets, a measles vaccination and a chemically treated anti-mosquito bed net to stave off malaria. Health workers cajole wailing toddlers in the shade of a makeshift clinic, as village men abandon their crops for the day and gather in the shadows to watch the spectacle.
The village has two-story houses with the long elegant lines, narrow shuttered windows, steep roofs and gables reminiscent of the French countryside. But instead of streets, Antanetikely has dirt footpaths. The houses have no electricity or running water, and are built beside large mosquito-breeding rice paddies. Families live in one room, cook on homemade charcoal burners and die from malaria or respiratory diseases worsened by the smoke.
There are almost no elderly people in Antanetikely. Life expectancy in Madagascar is only 52 years, and shorter in rural areas. People die from treatable and often preventable diseases made worse by poor hygiene and diet, and a lack of access to medical care. Mostly, they die of poverty.
Making a difference
The focus on medical care is making a difference. Child mortality is down by about 40 percent, according to the United Nations. The island aims to lower unwanted pregnancies by 50,000 this year by training young people in both sexual health and family planning.
About a third of Madagascar's money for health care comes from international donors, who spend millions more on individual programs to fight AIDS and malaria or improve nutrition. Adm. Tim Ziemer, the coordinator of a U.S. anti-malaria initiative, said Madagascar is among the very best in Africa at forging collaborations.
These partnerships work because the government knows the importance of showing results.
In a neighborhood clinic, doctors spend the slow hours of the afternoon painstakingly making records of every procedure, every consultation. At a small table at the makeshift clinic in Antanetikely, health workers carefully document every injection, mosquito net, vitamin drop and de-worming tablet under the name of the patient.
The information helps the government prioritize its programs. Precise record keeping also gives donors a detailed accounting of how ever dollar has been spent, said AIDS adviser Rajoelisolo.
"Donors see exactly what their money is doing and are more willing to contribute more," she said. "We do a lot of analysis. We compare ourselves with other countries. We then analyze all of that and plan a strategy that will fit us."
Madagascar also uses the aid money to train staff — a huge problem in much of Africa, where brain drain to the West has left a crippling shortage of doctors and nurses. More Ethiopian doctors are thought to practice in Chicago than in Ethiopia, for example. Madagascar is hiring young doctors around the country and giving them money to start their practices.
"We have the right people," said Dr. Yollande Rabetokorany, a government official who gets training and equipment for doctors and nurses in private practice. "Some of our doctors are so motivated they go to places so remote they must walk for more than a week, carrying their medicine and equipment, just to get there."
'It is getting better'
Ask Saholy, the prostitute, if Madagascar's anti-AIDS programs are working, and she puts down her cup of tea and shrugs.
"We reach some of the sex workers, and that is something," said Saholy, whose greatest fear is that her daughter too will one day be a sex worker. "I feel really good about what I do when one of them calls me and asks me to take her to a doctor. I think I might have helped someone."
But many men pay a lot more if they don't have to use a condom, and it is difficult for a sex worker who makes little money to resist, she said. And many men believe they can cure themselves of a sexually transmitted disease by passing it on to a prostitute through unprotected sex.
Saholy pauses, swirls what's left of her tea around in the cup and then drinks the last.
"It is getting better," she said. "More people are having safe sex. But we still have to change a lot of behavior, destroy old myths and educate a lot of people."