'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

new wife.''


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

strong influence.


"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

high-risk sex.


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.