The Spread of HIV in Africa

HIV sign on tree

Africa is home to roughly two thirds of the world’s HIV/AIDS cases, and the enduring question is: why? The popular explanations include extreme poverty, lack of HIV education, and insufficient access to condoms and healthcare. But epidemiologists crunching the numbers are finding that certain assumptions just don’t hold up — and that conventional wisdom doesn’t explain or help the AIDS epidemic in sub-Saharan Africa.

Last month’s circumcision buzz could be one piece of the puzzle. It turns out that if you’re a heterosexual male, you’re 60% less likely to contract HIV if you’re circumcised than if you’re not. This might be one reason that North and West Africa, which have high rates of circumcision, are less overwhelmed by HIV than southern Africa, which has much lower rates of circumcision.

What may be more significant, though, is an old idea made new again. In Uganda’s successful “ABC” campaign that dates back to the mid 1980s, “A” stands for Abstinence, “B” for Be faithful (or “zero grazing,” as President Yoweri Museveni likes to call it), and “C” for Condomize. In the Western aid community, Christian conservatives emphasize “A” (abstinence). Others — based on what’s worked in the West’s gay communities and in Thai brothels — preach “C” (condoms). The “B” has sort of fallen through the cracks. Data on the effectiveness of “A” and “C” in Africa seem murky at best, but there’s growing recognition within the world of HIV prevention that the neglected “B” really does seem to work. And that it might a ticket out of the hell of African AIDS. The evidence from Uganda shows that its homegrown campaign for fidelity — based on fear and education — has worked better than anything else in sub-Saharan Africa.

‘The whole thing is too big now, too heavy,’ said Sam Okware, a top Ugandan health official who designed early, frightening anti-AIDS campaigns. ‘It has adapted too much to international guidelines instead of sticking to our own methods, which were very controversial at first but which worked.’

Uganda’s Early Gains Against HIV Eroding, Washington Post, 29 March 2007

It’s tricky, of course, both morally and practically, to influence people’s sexual behavior. Especially if you’re a foreign aid agency trying to be culturally sensitive. But emphasizing monogamy could be critical for southern Africa (as opposed to western countries, or even North Africa) because of the common practice of having multiple concurrent sexual partners. Americans and Europeans, it turns out, average more sexual partners over a lifetime, but southern Africans tend to have more at once. A small but increasing number of HIV epidemiologists believe these sexual networks of multiple partners are at the heart of Africa’s AIDS epidemic.

Can we filter politics and political correctness from the data to ask what new strategies could slow the spread of HIV in Africa?

Update, 5/14 4:16pm

Last week Chelsea recorded a phone interview with Dr. Sam Okware, a top health official in Uganda. Because the phone connection was so bad, we decided that we couldn’t broadcast the interview. The following are highlights from the conversation.

I think A and B are the most important. Abstinence is important because half of our population consists of children. B is important because two thirds of the transmission is happening among the married people of Uganda. I’m most optimistic about abstinence. Since we have launched the ABC campaign, the age at which people first have sex has increased from fourteen to eighteen. So when you consider that half of our population is in that age group then you can understand that it is a very big group who can avoid HIV, and can avoid HIV without a lot of financial input.

Dr. Sam Okware, in a conversation with Open Source, May 11, 2007

Being faithful has worked. We have reduced the percentage of extra-marital sex by 60% but unfortunately, in the last two years there has been a rise in the number of people who are having sex outside of their marriage. This number has increased by 14% for men and 4% for women.

Dr. Sam Okware, in a conversation with Open Source, May 11, 2007

The biggest obstacle right now is condom use. Ugandans do not like to have the word “condom” in their vocabulary. Then there are the issues of economics. Uganda is a developing country and a person has access to fewer than seven condoms per year. As you can see, this is quite a problem. What we have to do is stress the importance of abstinence. If people cannot abstain from sex then they have to be faithful and if they cannot be faithful then they must use condoms. Condoms are extremely important because 68% of consenting adults do not use condoms. Secondly, there are a lot of sexually transmitted diseases among adults and infidelity has gone up so all of these people need to use condoms. In Uganda we’re talking about a group of people who will have sex at any cost so it is not possible to emphasize only A, you have to emphasize A, B, and C.

Dr. Sam Okware, in a conversation with Open Source, May 11, 2007

Unfortunately because the anti-viral drugs are available we are having a degree of complacency. People think that HIV now is like diabetes and high blood pressure. They think that HIV is curable and once they are on drugs they think that they are no longer infectious. That is one thing that we are working on now. We have to get a new strategy to handle HIV/AIDS within the era of antiviral therapy.

Dr. Sam Okware, in a conversation with Open Source, May 11, 2007

Daniel Halperin

Senior research scientist working on HIV in Africa, Harvard School of Public Health

Epidemiologist and medical anthropologist

Gillian Cassell

Botswanan working on HIV prevention

Worked with HIV patients at Botswana primary care hospital

Ran a voluntary counselling and testing center in Botswana

Cathy Dott

Zimbabwean musician who has lived in South Africa and Botswana

Social sciences student in London

Bongani Langa

Coordinator, Swaziland’s National Church Forum on HIV/AIDS

Serara Selelo-Mogwe

Former associate professor, Nursing Department, University of Botswana

Former Chief Nurse, Botswana Ministry of Health

Extra Credit Reading
Craig Timberg, Speeding HIV’s Deadly Spread, The Washington Post, March 2, 2007: “The most potentially dangerous relationships, researchers say, involve men and women who maintain more than one regular partner for months or years. In these relationships, more intimate, trusting and long-lasting than casual sex, most couples eventually stop using condoms, studies show, allowing easy infiltration by HIV.”

Daniel Halperin, Old Ways and New Spread AIDS in Africa, SFGate, November 30, 2000: “‘All our men used to be circumcised, creating improved health and hygiene; it should never have been stopped,’ Sarara Mogwe, a well-known Botswana public health nurse, told me. ‘Now we women are also paying the price.’”

Ethan Zuckerman, Everything you know about AIDS is wrong, my heart’s in accra, March 9, 2007: “How about poverty and AIDS? We know that trade increases economic development in Africa. But it turns out that increasing exports is correlated with higher rates of AIDS. If you double trade, you quadruple AIDS – this makes some sense, as we known that migrants and truck drivers are much more likely to be affected.”

Jennifer, AIDS and aid, I Will Read 10 Pages, May 7, 2007: “For one thing, the type of campaign for condom-use that works well in a western country like the United States – where we’re comfortable with discussing sex and comfortable with limiting offspring, does not work in countries where virility must be constantly proven, both through having several partners (if not several wives) and having numerous children.”

kusala, Men Are, In Fact, Dogs, kusala, May 10, 2007: “Of course, nothing about [infidelity] should be shocking to anyone who lives in the real world, which is why it’s infuriating to me that we persist with the “A-B-C” anti-HIV measures (about as juvenile as the “A-B-C” name sounds) that are so beloved by the Bush administration (even while his erstwhile “AIDS Czar” recently had to resign in embarrassment over revelations that he patronized a high-class “massage service”.)”

HIV/AIDS education in Botswana is in the workplace, The Nata village blog, May 11, 2007: “Everyone present (like everyone in Botswana) has lost someone to AIDS. Vino (the supervisor, standing left) encouraged his staff to participate in “zero grazing” which means to stick with one partner.”

Peter R. Lamptey, Reducing heterosexual transmission of HIV in poor countries, BMJ, January 26, 2000: “Interventions to reduce risky behaviours are aimed at high risk sexual behaviours such as frequent change of sexual partners, unprotected sexual intercourse, sex at a young age among adolescents, and poor behaviour in seeking treatment for sexually transmitted infections.”

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  • http://www.scienceblogs.com/gnxp razib

    Can we filter politics and political correctness from the data to ask what new strategies could slow the spread of HIV in Africa?

    no. if “we” means people in the west. i think it’s too touchy, though it seems pretty obvious that the sexual networks are a major problem (the same basic dynamic which spread HIV in bathhouses, and from prostitutes to the general population in thailand). and it is isn’t just monogamy, i think one problem is that matrifocal systems in parts of africa have resulted economic independence for women, but also an expectation by men that they won’t have to invest that much. some women can’t support themselves and can’t find one partner who will be dependable, so they have to enter into looser liaisons with multiple men who together can supplement her income enough to survive. of course, these men themeselves may have a primary wife at home. you don’t have to be a mathematician to see how the numbers can work out.

  • rc21

    There is an excellent article on the TCS daily website by Michael Cook called ” This should have been anthropology 101. describes what has been going on with this new idea. Uganda has senn the prevalence of aids go from 30% in 1992 to 6% quite a dramatic decrease.

  • tbrucia

    The dynamics of any epidemic — including AIDS — are mind-numbingly complex, involving feedback loops, non-linear dynamics, and a host of mathematical ‘counter-intuitives’. Somehow, all this has to be linked to the everyday realities. I always wonder why a nation with 30 percent of the population infected with AIDS — and no treatment available — doesn’t suffer a 30 percent drop in population within a few years. It is hard to see how women infected with AIDS, giving birth to infants infected with AIDS, squares with exploding populations in Africa. I hope someone explains this seeming paradox!

  • nother

    Katherine, thank you for this show. There does seem to be in elephant in the room though, that wasn’t mentioned in the lead up – the Catholic Church’s stance on contraception.

    Wouldn’t you say that the detrimental effect of this stance (even in indirect ways) is incalculable?

    I remember when the Aids epidemic hit in the US. I remember the sex education that was thrust on even the youngest of us. I remember the conservatives screaming that having condoms in the nurse’s office was encouraging sex. We now know all those fears were unfounded.

    Growing up, I’ve witnessed first hand the change in perception of condoms in our culture. (similar to seatbelts) I remember when it wasn’t cool and I’d hear guys talking about ways to avoid using a condom. Now we’ve come to a point in the US where is assumed you will use a condom with a new partner.

    Sure it’s great to talk about using “B” as a secondary tool for the problem. But the primary tool to save lives should be a two front campaign of sex education (it’s cool to use condoms) and a fundamental revaluation of Catholic Church doctrine – with respect to sex.

  • nother

    To summarize my point, it would seem obvious to me that the governments are pushing “B” more than “C.” The “C” is a minefield of sensitivity – and thus politically dangerous.

    What’s also abvious to me is my ignorance of African culture and Aids. I’m looking forward to learning more.

  • Katherine

    Hi nother. One of the things I hope this show will highlight is the cultural differences that haven’t been taken into account enough in Africa by well-intentioned Western aid agencies. From what I understand so far, resistance to condoms in Africa hasn’t been the problem; the problem is that they’re not used enough in the sexual networks of trusted (read: don’t need to use protection) partners. I hope to learn more, too.

  • rc21

    Nother, pushing A and B more than C has actually helped people pass through the mine field known as aids.

  • nother

    Hi Katherine, as I reread my post, I regret my phrase “it would seem obvious to me.” I should have written – it would seem to me that the governments are pushing B more than see because…

    There is nothing obvious about any of this – except of course my ignorance.

    The cultural differences you discuss sound interesting. I want to read some more and hopefully post again. I’m just trying to get involved (even on a tiny level) in such an important conversation. Thanks.

  • rahbuhbuh

    This isn’t from art director Tibor Kalman’s notorious upsetter run on “Colors,” but here is their entire Aids issue, including articles about Africa:

    http://www.colorsmagazine.com/issues/67/index.php

    I don’t know how much Colors actually did for AIDS in Africa, but it surely hooked the West’s attention. Maybe that attention turned into donations which turned into condoms? Who knows. I want to hear more about the local approach, and why it works better than a Manhattan advertising agency donating services as a tax write-off. Were western ad campaigns ignoring the metrics, or did we just not understand African cultures therefore wasting AIDS relief funds?

  • enhabit

    while i recognise that this may be a little off point…please note that

    @ 1.6 million children under five years of age die of diarrhoea every year. this is largely due to poor sanitation and lack of access to clean water…a solvable problem?

    http://www.unicef.org/wes/index_wes_related.html

    with @ 2.9 million total hiv/aids deaths with @ 380,000 children under 15 dying.

    http://www.nat.org.uk/page/426

    make no mistake hiv/aids is a tremendous problem. just thought that this would make an interesting footnote for consideration.

    other aids data

    http://data.unaids.org/pub/EpiReport/2006/20061121_EPI_FS_SSA_en.pdf

    http://data.unaids.org/pub/GlobalReport/2006/2006_GR_ANN2_en.pdf

  • enhabit

    @ 2.3 billion children that’s almost 7% of the world’s population of children dying before they are five years old…from lack of sanitation.

    malaria kills an estimated 1 million children under five as well..every year!

    according to the who

    http://www.who.int/ceh/publications/en/poster1.pdf

    hiv/aids accounted for 4% of all deaths of children under five in 2002

    measles = 5%

    malaria = 11%

    diarrhoea = 15%

    respiratory infection = 18%

    malnutrition (often associated w/ the others, hence the funky math)= 54%

    please forgive this digression but some of these other causes get very little attention compared with hiv, bad as it is.

  • enhabit

    sub saharan africa is vastly more affected by these other sited conditions.

  • http://enkerli.wordpress.com/ Alexandre Enkerli

    Glad to see that comments on this thread are thoughtful and respectful.

    My work in Africa is quite unrelated to HIV/AIDS (music and language in Malian hunter associations) but many colleagues do work in this field. There’s a few things even I noticed in Mali, as a non-specialist.

    As has been said here, many other diseases affect Africans and receive much less attention. In many ways, malaria is much more salient a problem in Mali than HIV/AIDS can be.

    Life expectancy in Africa is probably increasing overall, despite major diseases, but many Africans are still accustomed to seeing people die at a relatively young age. People I have met in Mali and Africans I meet here tend to be extremely philosophical about death and dying. There are obvious connections, here, with some previous ROS shows. Despite the “badness” of death, overpopulation can be a tricky issue.

    Talking about sexual behaviour explicitly is a difficult thing to do, in mainstream Malian society. Not necessarily because of taboos but because direct communication is not considered the most appropriate mode for such topics. For this reason, humorous skits about STDs have been having a more direct impact than “education campaigns.”

    The ABC formula has some embedded assumptions as to both the disease itself and about “proper sexual behaviour.” It might work in some contexts but Malians I know seem to react negatively to this formula. AIDS is sometimes perceived as a fictitious disease “created by Europeans to prevent us from having sex.” The ABC formula may serve to convince more people of this “conspiracy theory” about AIDS. Even if the perception of AIDS as fictitious is marginal, the ABC formula may make this perception more mainstream. The term “interference” (as «ingérence») comes to mind.

    Women are often forgotten in these programs, except as victims. My experience is that many women in Mali have a lot of control over their sexuality but that they tend to be very discreet about it. It might be difficult to work directly with women but it might be more effective. I tend to think that Europeans and Americans working in Africa simply assume that Africans are sexist, thereby decreasing the value of women’s input in African societies.

    In Mali, traditional healers can be very important figures. Regardless of their claims about healing, they serve as important nodes in local health systems. Not that Malians have anything against the biomedical paradigm. But traditional healers are often trusted interlocutors in discussions about health issues. There’s a wealth of research on this but it’s lost in the disconnect between media and academia.

    For those who understand French, there’s been an award-winning series of show about the 25th anniversary of HIV/AIDS on Radio-Canada’s science show, Les années lumière.

    http://www.radio-canada.ca/nouvelles/Science-Sante/2006/06/02/024-accueil-planete-sida.shtml

    (Available as a podcast or «balado-diffusion».)

    They do talk about some of the unwanted effects of some campaigns. And about the non-sexual methods of transmission for HIV/AIDS. And on alternative programs to prevent the spread of HIV.

    The same show had interesting things to say about HPV, which is involved in uterine cancer in North America and could probably be erased easily.

    Looking forward to this episode and to other shows about Africa.

  • jscientist

    how can our gov handle the problem in africa. we can probably help if we had the will.

  • http://velociraptor.info/notes amanda

    The circumcision buzz makes me nervous — 60%?

    I think some of the problem is the way that news has to be so … new, but when every third article is trumpeting the advantages of circumcision, a man might start to think that he’s safer if he gets circumcised, safer enough that they can relax about safer sex in general. 60% still sounds like Russian roulette to me.

    We focus too much on what is new and not nearly enough on what hasn’t changed at all, or what is nuanced and hard to tell well. I don’t know African AIDS so well, but the narrative in Cambodia a few years ago was that fishermen in Kampot and Koh Kong were shooting up with amphetamines, to fish all day and all night for long stretches, visiting brothels in between, and then heading home to wives and villages. I’m sure that African AIDS is also full of these micro ecosystems, stories about how a combination of culture, denial and economic stress carry HIV across a continent.

    We sit around in New York City and say “well, so how do we persuade those Africans to stop being so promiscuous” and we’ll get no where. The Soros Foundation might be a good place to start finding local case studies about effective campaigns, both in changing behavior and promoting treatment.

    (email me directly if you want a run down of who at Soros might be able to help identify some organizers and advocates based in Africa who would be great subjects for an interview.)

  • http://www.circles-salon.com allison

    Someone mentioned the skepticism of Africans towards Westerners, especially regarding the topiic of AIDS. Is it possible that the Ugandan approach was so successful because it was homegrown? I don’t where their funding came from, but if the program was perceived to be homegrown, that may have helped it be received well.

    Sometimes we need to know when to back off. If we want to help. or feel responsible, perhpas we need to let go of control of the programming and simply fund local organizaitons, allowing them to figure out how best to address their local population. It would be awesome if we didn’t need to take credit.

  • tbrucia

    Relative to ‘B’ (Be faithful), I find it interesting that so little discussion is given to ‘cheating safely’. Growing up many years ago, a lot of sexual activity was going on — but it involved mutual masturbation (then known as ‘heavy petting’), or non-genital touching (then known as ‘light petting’). Today, it seems that everything is digital (i.e. on/off) and that ‘having sex’ automatically involves intercourse, and ‘not having sex’ involves abstinence or ‘solitary sex’ (another forgotten phrase…). I suspect that prudery is causing BIG problems insofar as couples simply don’t think of sexual intimacy without full genital intercourse…

  • nother

    Here are some “Vital Statistics” from a site that my friend (a statistician in the AIDS field) directed me to:

    Worldwide:

    -Over 22 million people have died from AIDS.

    -Over 42 million people are living with HIV/AIDS, and 74 percent of these infected people live in sub-Saharan Africa.

    -Over 19 million women are living with HIV/AIDS.

    -By the year 2010, five countries (Ethiopia, Nigeria, China, India, and Russia) with 40 percent of the world’s population will add 50 to 75 million infected people to the worldwide pool of HIV disease.

    -There are 14,000 new infections every day (95 percent in developing countries). HIV/AIDS is a “disease of young people” with half of the 5 million new infections each year occurring among people ages 15 to 24.

    -The UN estimates that, currently, there are 14 million AIDS orphans and that by 2010 there will be 25 million.

  • patsyb

    I wonder: did anyone from ROS attend the South Africa Partners (http://www.sapartners.org/) conference that took place in Boston, this past Friday? A fascinating set of alternatives to the ABC strategy were mentioned in passing at several turns. That’s because the main question of this conference had to do with what those who work in sub-Saharan Africa have learned and can bring home to help sub-Saharan Africans in Massachusetts who are living with HIV/AIDS.

    FYI: according to the MA Dept. of Public Health, between 2003 and 2005 28% of HIV diagnoses are people born outside the US; of those 35% are from sub-Saharan Africa. (See http://www.mass.gov/dph/aids for more details and information).

    Thanks for re-opening this discussion.

  • punditwannabe

    interesting….

  • rc21

    patsyb, if the abc stategy is working why not look to expand it. Go with what seems to work put the alternitives on the back burner or atleast minimize the resources being wasted on them.

  • dsaklad@gnu.org

    Public health officials have not observed the phenomenon going on where potential sex partners get tested TOGETHER BEFORE having sex for A VARIETY of sexually transmitted diseases. The strategy of let’s get tested TOGETHER BEFORE we have sex for A VARIETY of STDs is going on unobserved. Even as a thought experiment the idea brings forward concerns people have been ambiguous.

  • dsaklad@gnu.org

    Even as a thought experiment the idea of the strategy of let’s get tested TOGETHER BEFORE we have sex for A VARIETY of STDs brings forward concerns where there is ambiguity.

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