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In urban, government-run hospitals in Malawi, patients are grouped together in open wards, regardless of their illness. Tuberculosis patients lie next to AIDS patients. One nurse and one or two paid attendants may look after 40 very ill patients, Norr said. "The situation is overwhelming." The training program she helped develop aims to teach AIDS education and prevention to everyone in the hospital, including maintenance workers and security guards.

"Because very little testing occurs and the majority of people in the hospital are HIV-positive, there's really no such thing as an AIDS nurse," she said. "Most health workers have no idea whether they themselves are infected."

Educating hospital workers about how to prevent HIV infection is difficult because hospitals and clinics have little money for protective supplies, she said.

Norr has seen nurses use a cardboard box to dispose of used needles. She has seen workers sweep used needles from the floor and deposit them into an open incinerator, where curious children might pick them up.

"There are a lot of things that health care workers can do something about" to protect themselves, she said.

Even when the supplies are available, she said, hospital workers continue to treat them as scarce commodities. "Nurses put on one pair of gloves and wear them all day," she said. More gloves may be available, but these are kept locked up. Family members, who do much of the feeding, bathing and basic bodily care in a Malawi hospital, usually receive no protective supplies or instruction on how to protect themselves.

In some ways, the situation for health care workers in sub-Saharan Africa now is similar to what it was in the United States in the early 1980s, say nurses who have worked there. Some governments are unwilling to spend money on AIDS/HIV prevention and education. Talking about AIDS is a social taboo. People don't want to admit they have the disease.

But Africa's situation is also far more dire than that of any other country dealing with an epidemic, nurses say, because of the continent's extreme poverty, hunger, civil unrest and wars in some areas, a mix of languages, traditions and cultures and an exodus of health care workers.

Deadly silence

Educating communities about AIDS is difficult, nurses say, partly because of the stigma of the disease and partly because nurses and other health care workers are not used to talking to young people about sexual practices.

Although the epidemic has been going strong for several years and so many have died, in many countries the stigma of having AIDS has not abated.

"The major problem is the silence," Makoae said. "At home, we don't talk about AIDS. If a man is known to be infected, the community believes his whole house is infected."

Because fewer than 1 percent of people with HIV in sub-Saharan Africa have access to or can afford drugs, people see no reason to get tested, Norr said. "Most people die without being tested."

In Malawi, many young people learn about sex culturally through ceremonies, Norr said. "Parents don't talk to their children about sexuality and generally, adults don't talk to young people about sexuality." In Lesotho, as in other parts of Africa, women can't talk about things like condom use with their husbands, Makoae said, let alone talk to their children about safe sex and HIV transmission.

Such attitudes mean that solutions from the United States and Western Europe will not always work in Africa, nurses say. "We are so different," Makoae said. "We don't have resources like your countries do. Culturally, we are totally different. We need to understand the stigma of this disease from our perspective."

Maria Kosmetatos, MS, FNP, arrived in Mutare, Zimbabwe, two years ago carrying a box of donated medical supplies for a rural clinic and about $20,000 she and other community members had raised in Portland, Ore. She found nothing as she had expected it to be-even though she thought she was arriving with almost no expectations.

The clinic where she had imagined she would be working had been leveled because it was ready to fall down. The community she intended to work with was an Anglican mission village called St. Werburgh, where tribal leaders and clergy worked together. It was in a rural area, where nearly half the adults were infected with HIV, but no one admitted to having AIDS. Most were cared for in homes without even basic pain medications.

"I got there and it was one of those eye-opening experiences," said Kosmetatos, an HIV nurse practitioner at the Multnomah County Health Department HIV clinic in Portland. At first, she felt overwhelmed. Then she realized that the best way to help was to offer whatever support she could to grass-roots organizations already working in Africa.