Africa’s HIV superhighway

I’VE BEEN REPORTING on AIDS in Africa for nearly 15 years, but on a 2005 visit to KwaZulu-Natal, the province with South Africa’s highest HIV infection rate, the hush surrounding the epidemic was so spooky that it surprised even me.

The Catholic Church had been running an AIDS treatment program for more than a year at a local hospital there. Outreach teams set out each day to care for sick people and encourage them to be tested for HIV and, if necessary, join the treatment program. I spent a week following these caregivers on their rounds and, as we went from one homestead to another and sat with dying patients and their families, no one, not once, said the word “AIDS.”

Patients told us they were suffering from “ulcers” or “tuberculosis” or “pneumonia.” Orphans said their parents had been “bewitched” by a jealous neighbor. Many AIDS patients died in their houses, cared for with compassion but in silence, their condition shrouded in euphemisms.

Occasionally, I was told, those known to be HIV-positive have been thrown out of their houses, scorned by their relatives or quietly fired from their jobs when their status became known or even suspected.

The stigma surrounding AIDS is profound, as it has been since the early days of the epidemic. But, for several years, I have been wondering whether perhaps a misunderstanding of the epidemiology of HIV in Africa has not exacerbated it.

The AIDS epidemic in southern Africa is uniquely severe. About 50% of new infections occur in this region, home to less than 3% of the world’s population. Unlike other regions of the world where the epidemic is largely confined to what epidemiologists call “high-risk groups” -- prostitutes, migrants, gay men with many sexual partners and injecting drug users -- in such countries as South Africa, Botswana and Lesotho, everyone is at risk: teachers, doctors, market traders, Cabinet ministers, everyone.

Why is that? Sexual cultures around the world vary, but the differences are not always obvious. For example, southern Africans do not seem to have more sexual partners over a lifetime than people in the U.S. However, what epidemiologists do know is that southern Africans are more likely than people elsewhere to have more than one -- perhaps two or three -- long-term sexual partnerships at a time, and they may overlap for months or years.

This pattern differs from the “serial monogamy” more common in the West, or the casual and commercial sexual encounters that occur everywhere.

Studies conducted by the World Health Organization in the 1980s and by Martina Morris at the University of Washington have found that, depending on the country, between 10% and 50% of men and between 5% and 20% of women in southern Africa engage in long-term, concurrent relationships. This practice of formal or informal polygamy links sexually active people not only to one another but also to the partners of their partners -- and to the partners of those partners, and so on, creating a giant web that can extend across huge regions. If one member contracts HIV, then everyone else in the web may too. This pattern of behavior has a powerful historical, social and economic basis, but it also serves as a kind of “superhighway” for the spread of HIV.

The network puts everyone at risk -- not just those who engage in concurrent relationships themselves but anyone who is roped into the network, including monogamous men and women whose partners engage in concurrent relationships or did so in the past. By contrast, “serial monogamy” traps the virus in a relationship for months or years at a time, and this considerably slows its progress through a population.

But if everyone is at risk (rather than just those who engage in high-risk lifestyles), many southern Africans seem not to be aware of that fact. In 2002, Deborah Posel, a sociologist at Witwatersrand University in Johannesburg, set out to study attitudes to AIDS in South Africa’s Limpopo province, where about 20% of adults were then estimated to be HIV-positive.

“AIDS is a disease of shame,” one respondent in a focus group said.

“It means you were practicing prostitution,” another said.

“It is something morally unacceptable to the people,” a third said.

Some of the people Posel interviewed were almost certainly HIV-positive themselves -- including some who held the deepest prejudices against people with AIDS. Most likely none of the women were prostitutes, and few of the men would ever have had sex with a prostitute. Few would have had more than five or 10 sexual partners in a lifetime -- hardly outrageous behavior in this day and age.

But some would have been men supporting a wife and one or two mistresses; some might have been monogamous young women whose boyfriend or husband had another girlfriend. Perhaps a small number of these women had more than one boyfriend.

Because of this network of concurrent partnerships, they would all have been at high risk and would not have known it.

One source of their confusion may have been the region’s AIDS campaigns. Even though evidence of the dangers of long-term concurrency has been available for at least a decade, the topic of concurrency is absent from school-based AIDS education curriculums and, until recently, from all national government AIDS strategic plans and media and billboard AIDS campaigns. Until last month, when a discussion of it appeared in a report on HIV prevention by the Joint United Nations Program on HIV/AIDS, it also has been all but absent from the policy documents of international public health organization working on the epidemic in the region.

Instead, the main sources of AIDS information in southern Africa have been abstinence-based programs for schoolchildren and condom social marketing campaigns for the general population, many of which have had a ribald tone. Anthropologist James Pfeiffer has described billboards along major roads in Mozambique displaying a cartoon “condom-man” winking at passersby.

Radio ads broadcast at midday when families were sitting down to lunch advised, “When you have sex next time with your lover, do not forget to use Jeito condoms!” Some campaigns bordered on the misogynistic. (One, for instance, shows an Angolan condom pack shaped like a machine gun; another, in Botswana, depicts a red boxing glove and a condom, and reads: “It can take the fiercest punches!”)

The condoms ads were intended to encourage frank discussion about sex among normally reticent African populations and to promote the idea that casual sex was nothing to worry about as long as condoms were used. But it is possible to imagine how these lusty ads might have had the opposite effect, clashing disastrously with local sensibilities concerning decency and self-respect.

By associating AIDS with beer-drinking, casual sex, prostitution, and arguably -- in the case of the boxing glove and machine gun ads -- womanizing and rape, the campaigns may well have reinforced the idea that victims of the disease are those who are promiscuous rather than ordinary people in relatively ordinary relationships. The ads also may have further inflamed the prejudice, denial and rumor-mongering that have featured so strongly in the epidemic and in virtually all epidemics since biblical times.

The theory that informed the design of the condom campaigns was based on a model of the epidemic proposed by epidemiologists in the late 1980s, according to which, HIV was spreading not because of concurrency but because of high-risk groups -- meaning prostitutes, truck drivers and rogues who had frequent casual sex.

The implication was that targeting campaigns at these high-risk people could staunch the epidemic at what these experts thought was its source. Because preaching to prostitutes and truckers about abstinence wasn’t likely to get you very far, you had to reach out to them in their own language, hence the raunchy ads.

Obviously, it hasn’t worked. Public health agencies must do more to inform southern Africans about the dangers of concurrency. Condoms are important, but they alone won’t stem the epidemic because they are seldom used in long-term relationships.

What kind of program might work? In Uganda, the first African nation to see a dramatic, nationwide decline in the HIV infection rate, a massive government campaign was launched in 1986 that promoted partner reduction and fidelity using the vernacular slogan “zero grazing.” There were posters and radio ads, and field workers fanned out across the country and held meetings about AIDS in churches, schools and under trees in village clearings. One key message of the program was that everyone was at risk, not just prostitutes and truck drivers.

Outsiders are often baffled by the apparent complacency of some African populations in the face of such a devastating epidemic. One thing that tends to rouse people into action is a common enemy. In southern Africa, campaigns for high-risk groups and “abstinence-only” programs may have unintentionally sent the message that the common enemy was people with AIDS. Ugandans understood early that the enemy was HIV itself.