AIDS AND THE AFRICAN A CONTINENT'S CRISIS AIDS and the African
'Unless there is a fundamental change in behavior, there will be
no drastic change in the evolution of the epidemic.'
By Kurt Shillinger, Globe Correspondent, 10/10/99
First of four parts
JOHANNESBURG - Two million Africans south of the Sahara died of
AIDS last year, five times the number of AIDS-related deaths in the United
States since the disease was discovered nearly two decades ago.
But that is just the beginning of the devastation to come.
More than 22.5 million people in the region carry the AIDS-causing human
immunodeficiency virus. Of the 11 people worldwide infected every minute
with HIV, 10 of them live in sub-Saharan Africa. Half of all babies born
there are infected with HIV.
Five countries bundled together in southern Africa now form the global
epicenter of the epidemic. South Africa counts 1,600 new infections a day,
the highest rate in the world, while in Namibia, Botswana, Zimbabwe, and
Swaziland, one in four adults carries HIV. It is estimated that 90 percent of
those infected do not know it, and therefore aren't aware when they might
transmit the virus to their partners.
Within five years, 61 of every 1,000 children born in the five countries won't
reach their first birthday, the United Nations estimates, and by 2001, it is
projected that there will be 13 million AIDS orphans in sub-Saharan Africa.
Companies are overhiring to keep pace with AIDS deaths in the labor force.
The statistics indicate what few officials are willing to admit: that this region
faces a crisis of shattered mores, where sexuality is no longer guided by
traditional norms. In an environment where old rules have clashed with, or
been eclipsed by, rapid social change, African men are killing themselves -
and their women and children - with sex.
Hiding behind a historical reluctance to speak openly about sex, African
political and religious leaders have failed to acknowledge this deeper cultural
crisis at the root of the AIDS epidemic. And international experts, averse to
sounding judgmental or racist, tread lightly on the epidemic's behavioral
undercurrents. Behavior, consequently, has been narrowly defined as simply
having safe sex. But as effective as condoms are in stopping the transmission
of HIV, they do not stop epidemics.
"Without addressing behavior, the response to prevention strategies will
always be limited,'' said Elhadj As Sy, head of the United Nations AIDS
program for Eastern and Southern Africa, based in Pretoria. "We'll create
some results here and there, but unless there is a fundamental change in
behavior, there will be no drastic change in the evolution of the epidemic.''
HIV is transmitted primarily through heterosexual contact in sub-Saharan
Africa. The alarming spread of the disease has been fueled by larger factors:
rapid political and economic change, Westernization, migrant labor, poverty,
and gender inequality. Promiscuity, however, is quickly dismissed in Africa
as a racist term: code, in fact, for the myth of the black man's unbridled
But AIDS experts throughout the region agree that far too little is understood
about sexual dynamics in modern African societies. Important questions thus
arise: Why, for example, are teachers the third highest HIV-infected job
group in Namibia, after truckers and the military? Is a man who lives at home
but takes many partners abiding by traditional sexual norms? Why does HIV
spread fastest among youths, the age group most informed about AIDS and
"People don't want to do this research, so there are patterns of black
behavior no one wants to acknowledge,'' said Mary Crewe, director of the
Center for the Study of AIDS at the University of Pretoria. "They'd rather lay
blame on the apartheid past, which I'm not sure is right.''
Contrary to what infection rates in sub-Saharan Africa suggest, HIV is not
easy to contract. In a stable and healthy environment, the probability that an
infected man will transmit the virus to an unprotected woman is less than 2 in
1,000, according to World Bank figures. But it is easy for that risk to rise. A
person afflicted by other sexually transmitted diseases, which are rampant
across the region, is two to nine times more likely to contract HIV if exposed
to it. And if a man has 10 partners, and the partners have each had 10
partners, he's potentially been exposed to 100 people.
In addition, several socio-economic factors lead to high levels of casual sex
in sub-Saharan Africa, experts say. The region has seen serious upheaval for
decades, the past 10 years being among the most turbulent. Genocide in
Rwanda and the end of apartheid in South Africa caused the movement of
masses of people; porous borders, regional development corridors, and
political change have reshaped and extended sexual networks. Poor health
care facilities, meanwhile, leave many without access to quality treatment and
prevention, while high unemployment leaves youths idle.
"When you see such an epidemic as we have, it points to a very stressed
society,'' said Clive Evian, a South African doctor who helps industries cope
with AIDS-related labor costs. "HIV epidemics go with a package: an
emerging economy, transitions from traditional cultures into industrial
economies, high levels of other sexually transmitted diseases, and economic
stress on families.'' Among the factors fanning the AIDS epidemic, migrant
labor and gender inequities have perhaps been the most damaging.
Throughout the century, men from around the region were drawn or
conscripted to work in distant gold, mineral, and diamond mines. They left
their families behind in rural villages, lived in squalid all-male labor camps,
and returned home maybe once a year. Lacking education and recreation,
the men relied on little else but home-brewed alcohol and sex for leisure.
A man who makes his living deep inside a South African gold mine has a 1 in
40 chance of being crushed by falling rock, so the delayed risks of HIV
seem comparatively remote. Mining companies pay out $18 million a year in
wages to 88,000 workers in the pits of Carletonville, the center of South
Africa's gold industry. The wages buy, among other things, sex. Some 22
percent of adults in Carletonville were HIV-positive in 1998, according to
UNAIDS, a rate two-thirds higher than the national average.
"High alcohol and sexuality are symptoms of things going wrong on a big
scale,'' Evian said. "They reflect a kind of aggression, the sad social state of
the man. They have been thrown into horrible lives and become frustrated. It
would happen to any man anywhere.''
Most African women, meanwhile, live in poverty. They have little or no
economic control, and therefore virtually no say in sexual relationships.
"Women know they are in danger, but there is nothing they can do about it,''
said Lahja Shiimi, HIV/AIDS health program officer in northern Namibia.
"Men decide when to have sex, with whom to have it, and how.''
Physiologically four times more susceptible to HIV infection, women in the
region are contracting the virus at a faster rate than men, and at a younger
age. Most of the women who tested positive for HIV in Namibia in 1998,
government figures show, were in their early 20s, while most men were in
their mid-30s. According to the latest UNAIDS statistics, 46.7 percent of
Namibian women at rural prenatal clinics tested positive in 1996.
If mobility, migrant labor, and gender imbalance are conducive to the swift
spread of HIV, they also underscore the breakdown of social cohesion.
When truckers and miners go home, they take the virus with them.
Sometimes they infect their wives, sometimes women become infected
through sexual contact with other men while their husbands are away. Rural
infection rates are catching up to urban figures. The role men traditionally
played as head of the family has broken down. Boys grow up without
fathers. Wives are left impoverished and unprotected. A South African
woman is raped every 26 seconds, the highest rate in the world.
But socio-economic arguments about AIDS do not fully explain how sexual
relationships are changing as African societies evolve. Notions about
masculinity and fertility vary widely among Africa's diverse ethnic groups.
Health workers across southern Africa agree, however, that traditional
cultures had strict rules governing sexual relationships. Those codes have
broken down and nothing has replaced them.
"In our culture, having a lot of women is a kind of status,'' said Milka
Mukoroli, the HIV/AIDS coordinator at Rundu Hospital in Rundu, Namibia.
Under the old rules, "a man might marry two or three women, but he would
never stray from home, and the first wife had to be consulted about each
Now, Mukoroli said, wives never know about their husbands' other women.
Men take lovers furtively. Many traditional cultures frowned on premarital
sex. Today, older men look for young girls to take care of, seeking sex in
exchange for providing school fees and nice clothes, often in the mistaken
belief that sex with virgins can cure AIDS. Health workers say many male
secondary-school teachers sleep with their female students. A new study of
Carletonville conducted by the Pretoria-based Council for Scientific and
Industrial Research found that 60 percent of women are HIV-positive by the
time they are 25. Throughout sub-Saharan Africa, infection rates among
teenage girls are significantly higher than for teenage boys. Infected by older
men, the girls then infect boys their own age.
"Social pressure should be put on older men to avoid forcing or coercing
young girls into sex, or enticing them with sugar daddy gifts,'' a UNAIDS
study on behavior released last month concluded.
Changing behavioral patterns are not restricted to men, AIDS workers say.
Traditionally, women were not supposed to enjoy sex. Increasingly,
however, they are asserting their own sexual needs and priorities.
"Promiscuity is prevalent predominantly because heterosexual relationships
are changing,'' said Peter Schmidt, a German doctor serving as chief medical
officer in the AIDS-afflicted Ohanguena region of Namibia. "This is a very
sensitive subject and very difficult to tackle. So many dependencies in
African societies relate to sexual relations.''
The heterosexual nature of the epidemic does not rule out the probability that
HIV is also transmitted between men, but homosexuality is deeply closeted
in African societies and there are comparatively far fewer same-sex
infections, according to AIDS experts. Youths provide a compelling reason
to think differently about behavior. Across the region, young people have
been exposed to more education about HIV and condoms than their elders,
yet they have the highest infection rates. Knowledge about risk and condoms
hasn't slowed the epidemic.
A new study of sexual behavior among youths between the ages of 11 and
24 in KwaZulu-Natal, South Africa's hardest hit province, indicates why:
Young people are on their own in an aggressive and evolving sexual
environment without the communication skills necessary to negotiate the
function or frequency of sex in relationships.
Consequently, the social ills governing gender relations among adults
reappear among youths. Both men and women in the study said that
condoms threatened trust within the relationship. Most women said they
were powerless against male sexual coercion. Many from both sexes said
they would prefer abstinence or monogamy, but said peer pressure is a
"For young people, sex is a must to be taken seriously by their peers,'' said
Christine Varga, research fellow at the Australian National University in
Canberra, currently based at the Reproductive Health Research Unit in
Significantly, said Varga, who conducted the KwaZulu-Natal study, young
people feel increasingly isolated from the adults in their lives. Traditionally,
cultures included some mechanism for passing on the rules of sexuality and
intimate relationships to adolescents. Parents, however, never spoke to their
children about sex. Unmarried aunts or older sisters informed younger nieces
or sisters coming of age. Uncles and older brothers did the same for boys.
Now confusion prevails. Rural youths in particular "are much more likely to
evince attitudes that are a combination of old conservatism and new
sexuality,'' Varga said. They combine new attitudes like "sex is a must'' with
traditional mores such as "condoms are for prostitutes.'' The result is
From 1997 to 1998, infections rose 65 percent among South Africans
between the ages of 15 and 19. All too quickly, HIV is claiming another
"The way to fight the epidemic is not just with condoms. We have to change
mores,'' said Patricio Rojas, the World Health Organization representative in
Namibia. "Openness happened fast in Africa, and it happened wrongly.
There is no grooming of boys and girls as partners in a relationship, so sex
has no aspects beyond the instinctively physical. We have to create an
environment of normality again.''
This story ran on page A01 of the Boston Globe on 10/10/99.
© Copyright 1999 Globe Newspaper Company.