AIDS Cases in Africa: an Everyone Epidemic

The visitor to a major African capital had a startling experience in 1987 when he was taken out to dinner by his host, a physician at the local university hospital. Nearly everyone in the city’s best restaurant seemed to know the man and greeted him enthusiastically--not just the other patrons, including businessmen, lawyers and government officials but also the entire staff. Waiters tripped over each other to make him welcome. Finally, as his guest looked at him in puzzlement about the display, he leaned over and explained, “They’re all my patients. They all have AIDS.”

Such an experience was not uncommon in the late 1980s in many of the major cities of Central and East Africa, where between 8% and 10% of the urban population is believed to be infected with the human immunodeficiency virus (HIV) that causes acquired immune deficiency syndrome. It is the particular pattern of AIDS in Africa that has panicked those in charge of managing the economies: Because the disease appears to be transmitted primarily through heterosexual practices and blood transfusions, women and men are affected in almost equal numbers, as are virtually all socioeconomic groups in the urban areas. The consequences for economic development and social order are profound.

The short history of AIDS in Africa, and of knowledge and research about it, is troubled. The first reports that the continent might have a serious problem appeared in Western scientific literature only in late 1983, well after alarm had begun in the United States and other Western countries about a syndrome that appeared to infect primarily homosexual men, hemophiliacs, intravenous drug abusers and Haitian immigrants.

In fact, the first known African cases of AIDS were identified two years earlier among well-to-do Africans visiting or living in Europe. Investigation soon revealed substantial numbers of people with AIDS or seemingly related afflictions and symptoms in such cities as Kinshasa and Kigali, the capitals of Zaire and Rwanda respectively.

Yet at first, the attempts to analyze and understand AIDS in Africa came across to some as an effort to assign responsibility for an international problem to the poorest continent, and to stigmatize Africans for their social behavior. Indeed, certain researchers hypothesized at one stage that HIV had originated in Africa, having mutated from a virus commonly found among African green monkeys. How it was thought to spread to humans was never clear. Beneath the science lurked the implication of some improper form of contact between humans and animals.

Although there was no reason to believe that such speculation about Africa as the birthplace of this modern-day scourge was explicitly motivated by racism, Africans often interpreted it that way. As they saw it, AIDS had first come to light as a symptom of decadent Western behavior, particularly in the United States, and this was just an effort to use scientific verbiage to pass the buck and blame the victims.

This placed a stigma on Africans living abroad. After it was revealed that seven African students in India had tested positive for HIV, there was an outbreak of public hysteria: University officials immediately expelled several Kenyan students and others from Tanzania, after having their beds and eating utensils destroyed. They were driven out of the town and eventually forced to return home. All 16,000 foreign students in India, more than half of them Africans, were soon required to be tested for the AIDS virus. In Belgium, where more than half the known AIDS cases involve Zairians, all African students must be tested. The many Belgians who routinely travel back and forth to their former colony of Zaire are not subjected to the same requirement on their return to Belgium, however.

African physicians and clinical investigators were rarely included in the early scientific meetings examining the nature of the disease. As outside scientists struggled to understand and explain the spread of AIDS in Africa, they produced other, questionable theories. For a time, it was fashionable to suggest that HIV was spread by insects common in tropical areas. Another focus was on certain African cultural practices, such as female circumcision and ritual scarification. Because of the unhygienic circumstances associated with these practices, it was argued, Africans would likely be at greater risk to AIDS. However, data demonstrated little direct correlation between these practices and the disease--largely because such customs are now more prevalent in rural areas and AIDS, with a few exceptions, is more common in African cities.

Another sensitive issue in the study of AIDS in Africa involved accusations of greater sexual promiscuity on the part of Africans. Understandably, given the pattern of the disease’s spread in the West, researchers at first looked for evidence of homosexual or bisexual practices in the countries most seriously affected. But homosexuality is still illegal in many African countries and there seems to be less of the overt homosexual activity found in other parts of the world. The disease seems to spread in Africa primarily by heterosexual intercourse.

What does appear to be true among heterosexuals, as among homosexuals, is that people who have a large number of sexual partners are more likely to contract AIDS. In many of the affected African countries, prosperous upper- and middle-class men tend to have many sexual liaisons at the same time, whether or not they are married. Indeed, among the elite of Zaire and Rwanda, it is commonly joked that men often take a long time to arrive home from work because they must make a stop at their “ deuxieme bureau ,” or “second office.” In Kenya, polygamous marriages are still quite common among the Kikuyu and other groups, and women are traditionally not considered marriageable until they have become pregnant.

It would be difficult to prove that all of this amounts to greater promiscuity than exists in, say, Paris, Rome, Bangkok, Manila, Rio, or even New York. What can be said, however, is that other sexually transmitted diseases, such as genital ulcers and chlamydia, are rampant in African cities, and the medical disruptions associated with those diseases may cause increased susceptibility to the transmission of AIDS.

For several years many African countries were reluctant to cooperate with international study of the disease. Furious over being made scapegoats, they reacted by denying there was a problem. In late 1986, only seven African nations were willing to submit official figures on AIDS cases to the World Health Organization (WHO); a year later, 36 countries were cooperating with WHO, but it was not clear how many governments were truly prepared to take the political risks associated with an aggressive AIDS reporting and prevention program. Some regimes were apparently worried about the effects on tourism.

The exact number of cases in Africa is not known. WHO officially counted 14,000 people with AIDS in Africa as of July, 1988, but the agency itself admitted that the true figure might be 10 times that; and some researchers believe that upwards of 5 million Africans may now be infected with HIV. (By contrast, the number of people in the United States thought to be infected with the virus stood between 1.5 and 2 million in 1988, and there were about 81,000 actual AIDS cases.) In Uganda, which has been more open to discussion of the issue than most, the number of acknowledged cases went from 17 in 1983 and 29 in 1984 to 1,138 in 1987; according to some speculation, half of all Ugandan adults may have AIDS by the year 2000.

Perhaps most worrisome of all is the growth in the rate of infection among children, many of whom are infected before or at birth. Between 2% and 15% of pregnant women test positive for HIV in some areas of Central and East Africa.

One of the most compelling explanations for at least part of the spread of AIDS in Africa is also one of the simplest--that the disease has followed the path of the heavy trucks that haul food and other material from Indian Ocean ports into the interior of the continent. Along the way, there are plenty of bars and prostitutes catering to drivers; at least 30% of the truckers tested, according to some reports, are infected with HIV. To the extent that this urban disease has reached small towns and rural areas, those places invariably lie along or near the truck routes.

But nowhere in Africa--in urban or rural areas, in large countries or small--has anyone been equipped so far to handle the magnitude of the AIDS problem. Some nations still have only one doctor for every 25,000 people and ordinarily spend an average of $10 per person per year on all health-care costs. Just the test to confirm a single suspected case of HIV infection now costs about $20, and the price of caring for 10 AIDS patients in the United States is more than the annual budget of a large hospital in Zaire.

The cost of the tests most frequently used to screen for HIV and the time they take to perform are a major barrier to dealing with one of the most common source of the disease--contaminated blood. Transfusions are used widely in Africa, sometimes as a substitute for expensive medications that cannot be obtained. Yet if the blood being transfused is not to be trusted, it may create more problems than it solves. WHO, as part of its ambitious program for dealing with AIDS in Africa, has provided money to some countries for the screening of blood donors, but what is really needed is the development of a reliable new, cheap, rapid HIV test. (One test developed in the United States takes only five or 10 minutes to perform; its cost is less than half that of the test commonly used, but unfortunately, it seems to be less accurate.)

For the time being, the main hope for dealing with AIDS in Africa lies with public education about the disease and how it is spread. Meanwhile, the U. S. Agency for International Development has launched an ambitious effort to distribute condoms. USAID and other national and international assistance agencies are also encouraging the use of disposable or sterile needles and syringes in Africa, so that the growing immunization programs against other diseases do not have the accidental effect of transmitting HIV.

There is, however, far to go. The appearance of a second virus, dubbed HIV-2, in Africa has raised many new questions. Initial epidemiological studies show that it is widespread in West Africa, particularly in Senegal, Ivory Coast and Guinea-Bissau, where there have been relatively few cases of AIDS thus far.

There are many debates and problems yet to come. If AIDS compromises recent improvements in infant mortality rates and thus comes to be perceived by the African public as a major killer of children, it may also set back many African countries’ halting, but necessary, programs to reduce the rate of population growth. Yet wise policy, supported by culturally sensitive help from the outside, could actually make African countries the leaders in this fight against a serious international problem.