AIDS, Culture, and Africa

15. Conclusion: It’s Not Just About AIDS—The Underlying Agenda to Control HIV in Africa

15 Conclusion It’s Not Just About AIDS—The Underlying Agenda to Control HIV in Africa Douglas A. Feldman The life of man: solitary, poor, nasty, brutish, and short. —Thomas Hobbes, Leviathan, 1651 The world can only be grasped by action, not by contemplation. The hand is more important than the eye. —Jacob Bronowski, The Ascent of Man, 1973 Clearly, the work of anthropologists on HIV/AIDS in Africa has been enormous and crucial since 1985. It is likely that this trend will continue over the coming decades as well. The role of the applied medical anthropologist is no longer seen as peripheral by those in the public health community, but central to both an understanding of public health and to effectively promoting healthy change. Africa is a rich, culturally diverse continent with enormous promise. At the same time, however, it is beset with challenging problems. In sub-Saharan Africa alone, 25.4 million adults and children are living with HIV. There are over 3 million newly infected persons with HIV each year. Across the continent south of the Sahara, 7.4 percent of all adults are HIV positive. Indeed , 2.3 million died of AIDS in 2004, while 13.3 million women are living with HIV. Unlike the developed nations of North America and Europe, HIV is transmitted mostly heterosexually—between husband and wife, husband and mistress, husband and multiple wives in polygynous rural areas, and husband and female sex worker. There is certainly same-sex transmission of HIV among men, but more research is needed to learn the extent of this on the overall HIV epidemiol- 277 Conclusion: The Underlying Agenda to Control HIV in Africa ogy. There is some transmission of HIV through unclean needles, but it is likely that this plays a relatively small, but not necessarily negligible, role in the transmission of HIV in general. Infants often become HIV infected through the birth process and through breast-feeding. Unquestionably, the key epidemiologic question concerning HIV transmission is: why is it spreading heterosexually so freely in sub-Saharan Africa , but not in North America and Europe? Quite amazingly, by the second half of the first decade of the twenty-first century, we still do not know. It is possible, however, though not yet proven, that HIV-1 subtype C, which is common in Africa, is more transmissible vaginally than HIV-1 subtype B, which is common in North America and Europe. Helen Epstein and Daniel Halperin have argued quite persuasively that the prevailing custom throughout much of Africa of men having mistresses functions to significantly augment HIV transmission. While this is undoubtedly true, it is not clear why this not equally true in the West among those white suburban men who also have a mistress. Other biosocial factors may also play a role in the difference between transmission patterns in the West and in Africa. The combination of lack of male circumcision and poor genital hygiene appears to increase HIV transmission risk, when compared with populations where male circumcision is common and/or genital hygiene is routinely practiced. “Dry sex,” the common practice in many parts of Africa where women decrease vaginal secretions prior to sexual activity, is likely to increase genital abrasions, which may lead to increased HIV risk. Ritual “sexual cleansing,” where a widow is expected to have sex with her deceased husband’s brother, can increase HIV risk. The traditional practice of “curing” sexually transmitted infections by having sex with a young virgin has been extended in some parts of Africa to “curing” AIDS, with tragic results. Other sociocultural factors also increase HIV transmission. While HIV spread initially among wealthier Africans, poverty today is clearly exacerbating the spread of HIV among the poor. Quite often, female sex workers are paid more by their male clients to have them not use condoms. Teenage girls who are AIDS orphans (born to an HIV positive mother, but HIV negative themselves) are forced to quit school and marry early, putting them at increased risk for HIV. The unequal status of women in most of Africa makes sexual negotiation for safer sex between married couples difficult, if not impossible. AIDS is only one of many problems, although certainly the most devastating problem, facing Africa today. The population of Africa has grown from 227 million people in 1950 to an astounding 916 million people in 278 Douglas A. Feldman 2006, resulting in enormous population pressure. In addition...