October 2003 Public Health HIV/AIDS Journal Club

The October 2003 session of the HIV/AIDS Public Health Journal Club featured presentations by two prominent academics who are colleagues of long standing:

TONY BARNETT is a Professor of Development Studies in the School of Development Studies, University of East Anglia, and Overseas Visiting Professor at the Institute of Development Economics, Tokyo.

ALAN WHITESIDE: established, in 1998, and is currently Director of, the Health Economics and HIV/AIDS Research Division (HEARD) at the University of KwaZulu-Natal, Durban. His main research interest is the economic and development impact of HIV/AIDS. He initiated and has edited the newsletter AIDS Analysis Africa since 1990, and in 2000 he co-authored, with Clem Sunter, AIDS: The Challenge for South Africa, published by Human and Rousseau/Tafelberg. He has carried out training around the world and worked in much of Africa, Ukraine and parts of Asia.

In 2002 Barnett and Whiteside co-authored an important book, AIDS And the 21st Century which focused on the driving forces behind the HIV/AIDS pandemic, its impact on global economies, and how international governments, business corporations and civil society need to coalesce in formulating urgent and effective multi-layered responses to the wave of infection and death.

Their presentations to the Journal Club revolved around the topic ?“Why Africa??”, giving a broad overview of the possible origins and socio-economic determinants of HIV infection on our continent, the rapid spread of the disease syndrome, particularly through the sub-Saharan region, and projected outlooks for its populations in the face of the epidemic.

Tony Barnett began by recommending a book entitled The River by journalist Ed Hooper, which offers excellent insights into the patterns of HIV infection and why these emerge earlier in Africa than in the US and Western Europe. The book looks at complex issues of phylogeny, and at theories of how a passive simian virus could have entered the human chain through experimental polio vaccine cultures.

Barnett also referred to the work of David Gisselquest(et al) in 2002, which suggested that the misuse of injection equipment over the past 20 years was a more likely cause of HIV infection than unprotected heterosexual intercourse. Despite some plausibility, this theory caused intense reaction and controversy amongst scientists, HIV/AIDS activists and international monitoring agencies, and was swiftly seized and sensationalised by the global media.

(Rapporteur?’s note: - An article in the British Journal of Obstetrics and Gynaecology, commenting on the findings of last year?’s Nelson Mandela Foundation-sponsored HSRC survey that there was significant ?“non-vertical?” transmission of HIV to children, said: ?“HIV infection of children in the South African sample through non-sterile medical procedures is a more reasonable hypothesis than the sexual one.?” Other researchers in Germany also rejected the commonly held theory that the high child rate of HIV infection was due to unsafe heterosexual sex and resultant MTCT or sexual abuse, adding their voices to those supporting the idea that unhygienic immunisation programmes in poorly resourced health clinics could account for the infection of young children. These statements revived the media?’s ?“nose for news?” on the subject, and the debate resurfaced, only to tail off again in about April 2003.)

Barnett?’s view was that this hypothesis, which the media tagged as the ?“dirty needles theory?” late in 2002, is interesting but probably flawed and would need much more interrogation.

Turning to social and behavioural explanations as to ?“?… why so early in Africa??”, Barnett referred to the massive body of work produced by Professor Jack and his wife Pat Caldwell around this issue. The Caldwells have conducted research around the world on issues of population growth, reproductive health and epidemiology for over 40 years, and are leaders in the area of African HIV studies, having examined the HIV/AIDS epidemic in the 1990s from a perspective of African history and culture. The nature of the language and discourse inherent in these disciplines make it very difficult to distill empirically ideas about social and family patterns, evolutionary arguments, theories of descent and ancestry, and the idea of ?“lineage for survival?” (i.e. vociferous procreation for the benefit of a group and a ?“typically?” African emphasis on fertility and fecundity). They suggest that this social ethos provided the setting for rapid spread and mutation of the virus as well as other sexually transmitted diseases. Barnett noted, however, that African ethnographic studies covering all African societies do not uphold this theory.

He then referred to Professor Suzanne Leclerc-Madlala?’s work on African sexual culture and the gender inequalities prevalent across all sectors of society in the African continent. Her research focuses on more specific and contemporary issues affecting the spread of HIV, such as the ?“importation?” of Western culture, the expectations raised amongst social groups through access to foreign media and the influence of marketing strategies, with her broad response as a researcher indicating that the Caldwell theories have illuminated some of the picture, but not all of it.

Barnett then spoke on a number of key projects, the first being one conducted in Rwanda where the issue of ?“wife inheritance?” was examined, generating the questions: ?“How do care and sex go together? What is ?‘sex?’? (i.e. the sexualisation of sex)?”. He described as ?“excellent?” a project dubbed ?“The Four-cities Study?”, which looked at cultural as well as socio-economic factors such as poverty and the distribution of wealth, and he noted that in Europe and the US, where there is free and confidential treatment for STIs, the HIV infection rate is far lower than in Africa.

In closing, Barnett referred to Chapter Five of the book he co-authored with Alan Whiteside (AIDS in the 21st Century), which covers the issue of social cohesion, the question of how much sexual control can be exerted, and the extent to which rulings about and over sexual behaviour can be imposed by and through societies. His own studies undertaken in Rakai in 1986 emphasised that the epidemic could not be viewed as a discrete phenomenon, but that it falls within a more complex environment of global inequality in the allocation of resources; (he also recommended the work of Paul Farmer in this regard, specifically a book entitled Infection and Inequality).

The full report can be downloaded on the righthand side of this page.