Recently UNAids announced a steep downward revision of the number of HIV-infected people, especially in Asia. If the latest figures are accurate, the epidemic is even more concentrated in Southern Africa than previously thought. According to UNAids, of the 33,2-million people living with HIV worldwide, more than two-thirds of them (22,5-million) live in sub-Saharan Africa. South Africa remains the country with the greatest number of HIV infections.
What can be done? We better not wait any longer for a magic bullet. Earlier this month, the Merck pharmaceutical company announced that its prototype Aids vaccine, the most promising of its kind, makes people more rather than less susceptible to HIV infection. Consistent condom use reduces the likelihood of HIV transmission, but people seldom use them consistently. Male circumcision can also reduce the likelihood of HIV transmission, but it is still rare in many of the most highly Aids-affected countries.
One thing that we can do is explore what happened in places where the epidemic did turn around. I’ve been thinking about this for nearly 15 years, and it’s become increasingly clear to me that the key to fighting Aids lies in something for which public health has no name or programme.
It is best described as a sense of solidarity, compassion and mutual aid that is impossible to quantify or measure. It has to be this way. Because our sexuality is shaped by society and because sex itself involves more than one person, behaviour change is a collective act, not one of individuals acting alone. That’s the reason why social mobilisation is so important. And that’s also why HIV prevention is so difficult.
But sometimes it works. Almost as soon as the first bulletins about a new disease affecting homosexual men appeared in United States newspapers in 1981, the entire gay community rose up against it. They argued about bathhouses and condoms; they chained themselves to government buildings to protest official inaction; they nursed their dying friends. If you visit the Aids section of any library, you’ll find a wall of literature from that time: poems, plays, memoirs, art books, philosophical essays. It was like a mass conversation. During this period, a huge shift in sexual norms occurred, and the incidence of HIV infection fell by about 80%.
Something similar happened in Uganda when the HIV rate there plummeted by about 70% during the 1990s. I was working in Uganda at that time, and I remember thinking that although the epidemic was different from the epidemic in the US gay community, the response was remarkably similar.
There were plays, vigils and marches, and everyone talked about Aids in highly personal ways. There was vigorous public debate about condoms and about how men and women treated one another. For historical reasons, Uganda had a vibrant women’s movement, and Aids fitted right into their agenda. People cared for the sick and their orphaned children. Some of these carers were supported by donors and churches, but most simply volunteered.
As one man who remembers this time explained to me: ”You’d go over, take care of the kids, sweep the floor, just sit and talk to the patient; you couldn’t just do nothing.”
We’ll never know why people in other African countries did not respond to Aids as rapidly, but for a while, I’ve wondered whether it didn’t have something to do with the fact that Ugandans, like gay men, knew where their risks were coming from, and this enabled a more open, pragmatic response.
In 1986, long before foreign donors came on the scene, Ugandan health officials designed their own HIV-prevention programme. It was based on a crucial epidemiological insight that has, until recently, eluded most outsiders working on Aids in Africa: HIV rates are high in this region not because people have so many sexual partners, but because they are more likely than people elsewhere to have more than one — perhaps two or three — overlapping long-term partnerships at a time.
This ”long-term concurrency” differs from the ”serial monogamy” more common in Western countries, and the casual and commercial sexual encounters that occur everywhere. But long-term concurrent relationships are far more dangerous, because they link people into a giant network that creates a virtual superhighway for HIV.
Health officials increasingly recognise that the frequency of ”concurrent relationships”, along with lack of male circumcision, largely explains why HIV spreads so rapidly in East and Southern Africa. A 2006 Southern African Development Community/UNAids meeting also drew this conclusion.
Uganda’s original Aids campaign had two main messages. First, ”Zero Grazing” — local slang, meaning roughly, ”try to stick to one partner, but at least avoid casual partners, and cut down on concurrent partners if you can”. And second, everyone is at risk — not just prostitutes, truckers and other so-called promiscuous people.
What was going on in the rest of Africa? One thing I have noticed is how many Aids campaigns in Southern Africa suggested that Aids was only for the ”promiscuous” or ”deviant”. When I was visiting Botswana a couple of years ago, a US government-funded campaign to promote condoms was under way. Like many such campaigns, it had a ribald, sexy tone. One poster showed a boxing glove, a condom and the slogan ”It can take the fiercest punches”. Ads like this were meant to help supposedly reticent African populations talk more openly about sex, but it’s possible to see how they might send the opposite message, associating Aids with unruly ”others” who misbehave and have lots of casual sex, and even beat women.
In Botswana, the boxing glove ad and others like it may have promoted a false sense of security. Also, by associating HIV with womanising and violence, the ads may also have unintentionally reinforced the shame and denial that have featured so strongly in the Aids epidemic and in all epidemics since biblical times.
In 1992, as donor funding for Aids programmes began to increase, Uganda phased out its Zero Grazing campaign and replaced it with an initiative emphasising condom use for ”people at high risk” similar to those in the rest of the region. But a few years ago, officials began to worry because although the HIV infection rate had fallen rapidly in the 1990s, the decline had ceased by the end of the decade.
Yet instead of reviving Zero Grazing, the officials, with support from the Bush administration, mounted an ”abstinence” campaign, which ironically sent a message very similar to the condom ads: only immoral people get Aids. To everyone’s horror, the HIV rate in Uganda is beginning to rise again.
People often ask me: ”So, fighting Aids requires a social movement. How do you generate a social movement?” Well, one thing that always galvanises people is a common enemy. Too much reliance on donor-funded Aids programmes has divided people: HIV-positive from HIV-negative, ”moral” from ”immoral”, high-risk from low-risk. Such programmes send the message that the enemy is people with Aids. Ugandans and gay men knew early on that the enemy was HIV itself.
Helen Epstein’s book The Invisible Cure: Africa, the West and the Fight against Aids was recently published by Viking/Penguin. She is visiting South Africa this week