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MRC KZN HIV/AIDS Forum - October 2002
Judith King. HIVAN Media Team. 16 October 2002.
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At the first MRC KZN HIV/AIDS Forum held in association with HIVAN on 15 October 2002, HIVAN Fellow, Emeritus Professor Jack Caldwell of the Australian National University, presented his paper entitled "The African AIDS Epidemic - Reflections on a Research Programme".
With almost 70% of the world's HIV-infected persons and almost 80% of AIDS deaths occurring in sub-Saharan Africa, this region has suffered the major impact of the global AIDS epidemic. The primary source of infection has been heterosexual transmission, and, in the absence of a vaccine, the only protection has been through behavioural change. In order to assist in the acceleration of such change, a collaborative programme between research teams of the Australian National University and three African universities spent 12 years investigating the social and behavioural context of the African epidemic, with the aim of providing an understanding of the social dimension of the epidemic. Professor Caldwell's paper provides a history of the project's activities and summarises its findings.
In terms of the global history of the pandemic, Prof Caldwell points out that HIV/AIDS began in Africa at the same time as it did in North America, Australia and Asia (1982). In Africa, it was first detected in Rwanda and Uganda, spreading to East Africa and then, voraciously, to the South. In studying the factors and co-factors sustaining the epidemic, it further became clear that the profile of the African epidemic was heterosexual, and that determining the means to contain it would have to involve studies of heterosexual activities and networking.
This research was first conducted via studies of family planning strategies, which, given the immense cultural and language barriers in communities and villages, proved very difficult; however, through close engagement with local leaders, methodologies were developed for surveying sexual relations which were both multiple and concurrent; what emerged was that, although levels of sexual activity were similar to those of North America, for varying reasons African males had many more sexual partners.
Studies undertaken on the role of the practice of scarification and the favouring of "dry sex" showed that these were not significant factors in the rapid and extensive transmission of HIV. Condom use and women's control of sexual relations and reproductive health were also examined. Two major research foci were on (a) the belief systems supporting risky sexual practices and (b) the unusual geographic pattern of HIV infection across the continent. These belief systems included the attribution of AIDS to witchcraft; a strong sense of predestination and an attendant resignation regarding early death; the perception of AIDS as non-threatening because of the delay in full manifestation of the disease syndrome and mortality.
Ultimately, the project results showed that one of the primary factors giving rise to the African epidemic is the number of sexual partners (whether through polygynous societies accepting this as a male need, or through relations with commercial sex-workers, or through long-distance truckdrivers having semi-regular partners at their numerous night-stops, who in turn had other partners) so setting up chains of sexual contacts and a massive network of infection. Even female promiscuity is, to a degree, accepted by men who acknowledge that poverty-stricken women need to sell sex to survive.
Another major factor is poverty, which not only drives sex as transactional process, but also results in poor hygiene and inadequate healthcare, both of which ensure that STDs remain undetected and untreated. Alcohol was observed as a notable stimulant generating an uncontrollable urge for sex, particularly amongst males. Another co-factor is uncircumcised men being more vulnerable to chancroids (untreated, ulcerating STD infection) through which HIV gains an easy entry point.
Reasons for people ignoring the epidemic despite the mass deaths include the fact that AIDS is unlike any other "plague", so complex and mysterious that people feel more comfortable with the customary belief in one's destiny being to fall ill and die. Also, the stigma around the disease exacerbates the lack of disclosure, so that in entire families, only one member might know that a death was the result of AIDS. This silence, particularly about prominent social figures dying of AIDS, is maintained in the media.
Why have African governments been so silent about HIV/AIDS? Research indicates that governments will not tackle issues with a low likelihood of success, for fear of destabilisation and loss of power. In Uganda, the only real "best practice" example in Africa, visible and strong leadership engagement with HIV/AIDS has proved effective, and its pyramidic political structure enables the filtering down of presidential messages to grassroots communities.
Overall, Caldwell concluded, there is very little sign of success in halting the spread of HIV/AIDS across tropical Africa. Although we now know a great deal about the social and behavioural context of the epidemic, this knowledge has not helped much or effected behaviour change in 15 years. He noted that, for example, although warnings can be made about early sexual debut being a risk factor for females, such debuts are often forced, precluding the element of choice for girls and young women. Nonetheless, he noted, we know that sexual practices do change, over time, within societies - in our grandmothers' day, full vaginal penetration was not the norm.
His paper offers three practical ways of lowering infection rates that are complementary to the development of a vaccine, interventions by government and ongoing safe-sex education programmes: the Thai approach of enforcing condom use by commercial sex-workers; targeting the youth for condom promotion; and focusing on the early detection and treatment of STDs.
Responding to a question about the severity of HIV prevalence in KwaZulu-Natal, which enjoys higher standards of healthcare than many other parts of Africa and in which communities practised non-penetrative sex until relatively recently, Caldwell feels that surreptitious multi-partnering, cultural beliefs about the sanctity of male sexual rights, the size of the migrant labour force and greater mobility (through transport routes) are major factors driving the spread of HIV in this region.
To download the full paper in MSWord, click on the link in the righthand column
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Prof Jack Caldwell and Pat Caldwell
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