AIDS in Africa: Death and Hope on a Ravaged Continent

To date, the vast majority of AIDS deaths have occurred in Africa, primarily in sub­Saharan nations, which contain about 10% of the global population but are home to approximately 70% of all people who are living with HIV/AIDS (Kelland, 2011). Of the millions of global AIDS orphans—children who have lost their parents to the dis­ease—more than 90% reside in sub-Saharan Africa. Children in sub-Saharan African nations also often serve as the primary caregivers for parents living with HIV/AIDS (Skovdal, 2011).

For many years scientists and health professionals mistakenly assumed that the explosive spread of the pandemic in Africa, where HIV is transmitted primarily through heterosexual sex, was largely a function of risky sexual behavior reflected in a propensity of Africans to have sex at an early age and with a large number of partners. The false­ness of this stereotypical notion about sexual behavior in Africa is revealed by numerous surveys indicating that sexual debut in Africa tends to occur in the late teens, just as it

does in Europe and the United States, and that African men and women report similar, if not fewer, numbers of lifetime sexual partners than do heterosexuals in many Western nations (Epstein, 2007; Stephenson, 2010; Wellings et al., 2006). Why, then, are HIV infection rates so much higher in parts of Africa than in Western nations?

The answer to this question is perhaps best presented in a recent book written by Helen Epstein titled The Invisible Cure: Africa, the West, and the Fight Against AIDS (2007). Epstein, a molecular biologist, spent many years in Africa investigating the sky – high HIV infection rates in some regions of that continent. In her book she focuses on multiple, concurrent partnerships as the primary contributing factor to Africa’s HIV/ AIDS pandemic. In sub-Saharan African nations, a relatively high proportion of men and women are involved in simultaneous ongoing relationships with a small number of people—perhaps two or three—and these concurrent relationships might overlap for months or years. This pattern differs from the serial monogamy that is more common in Western cultures, and these "concurrent or simultaneous sexual partnerships are more dangerous than serial monogamy, because they link people up in a giant web of sexual relationships that creates ideal conditions for the rapid spread of HIV" (p. 55).

While relationship concurrency is clearly a major contributor to the HIV pandemic in sub-Saharan Africa, other factors also play an important role, not the least of which is a marked inclination among African youth to avoid using condoms during sexual inter­course. As pointed out elsewhere in this chapter, condoms are an important component of efforts to slow the HIV/AIDS pandemic in Africa. However, in many sub-Saharan nations, where young people account for about half of all new HIV infections, reported condom use among them remains low (Winskell et al., 2011).

The spread of HIV/AIDS in Africa is also strongly influenced by extremely limited health resources and government inaction (Dugger, 2008; Nullis, 2007). The absence of efficient health infrastructures has created major barriers to effective administration of antiretroviral drug treatment programs. This serious problem is further complicated by the reluctance of many African governments to recognize the seriousness of this pandemic and to mobilize whatever limited health resources are available to combat it. An especially disheartening example of government inaction or outright opposi­tion to HIV/AIDS programs is provided by the nation of South Africa. For many years officials in this government, including former president Thabo Mbeki, refused to acknowledge that HIV causes AIDS (De Cock et al., 2011). Only recently, under a new government, has this nation finally begun to mobilize efforts to combat a disease that claims over 350,000 South African lives each year.

Cultural factors also play a significant role in perpetuating the African AIDS plague. African nations are male-dominated societies in which most women find themselves in relationships of economic dependency and sociocultural subordination to men (Hig­gins & Hirsch, 2007; Hindin & Muntifering, 2011). Women’s lack of rights within rela­tionships and their difficulties in negotiating safer sex with partners who dislike using condoms and typically refuse to acknowledge and discuss their other concurrent sexual relationships result in elevated vulnerability to HIV infection (Heisea et al., 2011; Onoya et al., 2011). Recent research conducted in 13 sub-Saharan African countries revealed that condom use by married couples is relatively uncommon (de Walgue & Kline, 2011). It is not uncommon for married African women, who are not engaged in extramarital sex, to be infected by their husbands, who are engaging in unprotected sex in outside relationships (Stephenson, 2010). Furthermore, the combination of poverty, economic inequity, and relationship power imbalances experienced by many African women often leads them to exchange sex for money, alcohol, gifts, and goods, a practice that significantly increases their risk of acquiring an HIV infection (Higgins & Hirsch, 2007; Watt et al., 2012). Research in Africa indicates that transactional sex can increase

the risk of HIV infection in both sexes via involvement with multiple partners and inconsistent condom use (Watt et al., 2012).

Another cultural contributor to the spread of HIV in Africa is the practice of female genital cutting described in Chapter 3. The increased HIV risk associated with this practice is related to several factors, including possible HIV-tainted-blood contamina­tion of cutting tools, increased risk among cut women of genital infections associated with increased susceptibility to HIV infection, and a stronger inclination to engage in anal intercourse, a high-risk behavior for acquiring HIV (Yount & Abraham, 2007).

Against such a grim background, can there be any hope for Africa’s future? The answer is a cautious yes. Many government and nongovernment organizations (NGOs) are flooding Africa with disease specialists, financial resources, and affordable drugs to treat AIDS. Drug treatment-based programs have benefited from a dramatic decrease in the cost of antiretroviral drugs in recent years. The availability of generic versions of these medications, coupled with the willingness of Western pharmaceutical companies to provide them at "not for profit" prices, has, for example, dropped the cost of one widely used multiple-drug treatment regimen to 25 cents per day. In contrast, antiretroviral drugs can cost $20,000 or more a year for infected people in the United States (Tasker, 2011). While this increase in the affordability of treatment drugs in African nations is a marvelous improvement in the battle against HIV/AIDS, it is far from a panacea. For example, in Botswana, where antiretroviral drugs are widely available and where infec­tion rates have stabilized and even declined slightly among some populations, the overall incidence of HIV infection is still "astonishingly high" (J. Cohen, 2008).

In recent years a number of educational programs focused on reducing HIV risk behaviors have been designed and implemented in developing countries, especially those located in sub-Saharan Africa. These innovative intervention methods use trained community members as peer educators to reach out in a grassroots educational effort that includes providing information and resources, a format for talking openly about sexual issues, and a supportive context for positive behavior changes. A major advantage of peer education is that this method places health-related knowledge in the hands of ordinary people, who act not only as peer educators but also as role models for posi­tive behavior change. A number of studies have demonstrated that such grassroots pro­grams increase the likelihood that people will engage in health-promoting behaviors (Campbell & Mzaidume, 2001; Crooks & Tucker, 2006; Wheeler, 2003).

A peer-educator-based HIV/AIDS intervention program was established some years ago in the Makindu region of southeastern Kenya, with planning and guidance provided by Bob Crooks and his wife, Sami Tucker, in collaboration with a number of Kenyan citizens and with the assistance of a German NGO. This program, partially funded by royalty revenues from this textbook, is described at the website www. ithelps. org. The involvement of Crooks and Tucker includes developing a research strategy to evaluate the impact of this grassroots program, designing and implementing a peer – educator-based educational strategy, and conducting 2-week training sessions for peer educator staff. Research evidence obtained via administration of anonymous pre – and postworkshop questionnaires has revealed improved awareness of HIV/AIDS risk behaviors and prevention strategies and significant increases in safer sexual behaviors among all categories of participants as a direct result of the Makindu program (Crooks & Tucker, 2006). In the fall of 2009 Crooks and Tucker launched a similar program in the South Coast region of Kenya.

Perhaps the best hope for Africa lies in the development of the ultimate weapon against any virus—an effective preventive vaccine. However, as discussed elsewhere in this chapter, progress on this front has been slow, and the likelihood of having such a vaccine soon is slight at best.