AIDS in Africa:

The Epidemic and Possibilities for Intervention (Part One)

With 70% of the worlds HIV cases, there is no doubt that Africa is at
the center of the global war against AIDS.

Despite generally high levels of basic knowledge, millions of Africans

are still vulnerable to HIV because they do not know the basic facts.
Pockets of ignorance and misinformation survive even in the worst
affected populations. In the South African town of Carletonville, for
example, only 40% of men or women knew that an individual could live
with the virus for many years without any outward sign of infection.
Around a third of respondents were mistakenly convinced that all HIV-
positive people would show symptoms of their infection, while a
quarter had no idea what to expect.

In other places, ordinary citizens are still reluctant to acknowledge the

relevance of AIDS to their own lives because of the shame and fear
that surround this fatal disease, and the discrimination directed at
those affected. People with or suspected of having HIV infection may
be turned away by health care providers, denied jobs and housing,
refused insurance and entry to foreign countries, thrown out by their
spouse or family, even murdered.

Not surprisingly, the great majority of individuals who suspect or know

they are infected do not wish to disclose their status publicly. In the
absence of support for sharing the news, most people shrink from
telling their spouse or partner that they have HIV. Families protect
their loved ones from disclosure during and even after illness and
death, and those who care for them often collude in the denial. In a
city in South Africa with a high prevalence of HIV infection, one hospital
runs a training program for providers of home-based care for the dying
in which the word "AIDS" is never mentioned.

It takes no great leap of the imagination to see that, for individuals,

this wall of silence hinders both prevention and care. If people are so
afraid to acknowledge or even find out that they are infected, they will
lose precious opportunities for warding off or treating illnesses brought
on by the infection. If couples cannot talk about risks that either one
may have taken, it is hard for either partner to bring up the issue of
condoms or HIV testing as a way of preventing further spread of the
virus to the spouse or child.

This dilemma has particularly endangered African women of all ages,

who are more likely than men to become infected with HIV during
unprotected vaginal intercourse. This vulnerability is especially marked
in girls whose genital tract is still not fully mature.

Compounding their biological vulnerability, women often have a lower

status in African society at large and in sexual relationships in
particular. This gender vulnerability, again, is particularly acute for
young girls.
It is the interplay of biological, cultural and economic factors that
makes young girls particularly vulnerable to the sexual transmission of
HIV. While both girls and boys engage in consensual sex, girls are more
likely than boys to be uninformed about HIV, including their own
biological vulnerability to infection if they start having sex very young.
Girls are also far more likely than boys to be coerced or raped or to be
enticed into sex by someone older, stronger or richer. Sometimes the
power held over them is mainly that of greater physical strength.

Sometimes it is social pressure to acquiesce to elders. Sometimes it is

a combination of factors, as may be the case with older ‘sugar daddies’
who offer schoolgirls gifts or money for school fees in return for sex.
In a recent comparison of HIV infection and behavior in two cities in
East Africa with a high prevalence of infection and two in West Africa
with a lower prevalence, few striking differences were found in the
frequency of extramarital sex or condom use.

However, there was a major difference in the proportion of girls aged

15–19 who said they had started having sex before turning 15, an age
at which virtually none are married. In areas where HIV is common,
greater sexual activity during the early teens translates inexorably into
a high prevalence of HIV among girls.

In South Africa, 10% of respondents in a study in six provinces said

they had started having sex at age 11 or younger. The study,
commissioned by the South African Department of Health,
recommended that sex education be introduced to children around the
age of 12 if it was to reach most of them before they became sexually
active. This policy is of particular importance because the other crucial
factor pushing up HIV rates in young women is age-mixing. If the girls’
sole sex partners were boys their own age, they would run little risk of
becoming infected; there are few if any HIV infections among boys
before the late teens. However, girls also have sex with older men who
have been sexually active for many years and who therefore tend to
be more heavily infected than younger males.

In rural areas of the United Republic of Tanzania, some 17% of

unmarried teenagers reported having had sex with ‘a man at least 10
years older’ than themselves. In a nationwide study in Zambia, over a
quarter of the men who had extramarital encounters had casual sex
with women ‘10 years or more their junior.’ Men who have sex with
younger women may also have other high-risk partners. Among men
identified as clients of sex workers in a study in four African cities, for
example, around one-third had also had casual sex with teenage girls.
Clearly, it is important to complement education on AIDS and life skills
with vigorous action against sexual abuse and rape and campaigns to
discourage older men from seeking out young girls for sex. (to be
continued)