The African AIDS epidemic: a history

Tames Cun':.: 7 3 Kot!ey g{,ad Oxford OX2 nns VV\ published material, put into a historical form. A Ju,l.urical account offers four advantages. First, it suggests an answer to the question posed most provocatively by President Mbeki of South Africa: why has Africa had a uniquely terrible HIV I Aids epidemic?' Mbeki attributed this to poverty and exploitation. Some earlier analysts suggested that Africa had a distinctive sexual system. 2 This book, by contrast, stresses historical sequence: that Africa had the worst epidemic because it had the first epidemic established in the general population before anyone knew the disease existed. Other factors contributed, including poverty and gender relationships, but the fundamental answer to Mbeki's question was time. Like industrial revolutions or nationalist movements, Aids epidemics make sense only as a sequence. Second, a historical approach highlights the evolution and role of the virus. Because HIV evolves with extraordinary speed and complexity, and because that evolution has taken place under the eyes of modern medical science, it is possible to write a history of the virus itself in a way that is probably unique among human epidemic diseases. At the same time, the distinctive character of the virus - mildly infectious, slow-acting, ineradicable, fatal - has shaped both the disease and human responses to it. Third, many aspects of the epidemic come into focus only when seen in the longer context of African history. Although HIV/Aids was profoundly different from earlier African epidemics, it arose from the human penetration of the natural ecosystem that is the most continuous theme of the African past. That

2

Illtentions

tbe virus created a continental epidemic, however, was a consequence of Africa's massive demographic growth, urbanisation. and social change during the later twentieth century. Everywhere the took its shape from lbe structure of the commercial economy lhal had grown up during the colonial Human responses, in turn, became p;:,ri of rrn of IllV in Asia, and responsible for at least two-thinb of West Ali·ican fHV infectim1s. 1'' Recombination is probably at ieast <JS important as : .. _. iun _i11 accelerating the evolution of I-! IV, but irs implications for dating ba,cd on a-!nokcular clo..:k Me complex and obscure. By blurring dill"ercnces between subgroups it might mai.:.c evolutionary ever:ls seem more recent than they were. but by tlie number of strains it might make the events seem more ancient than !hey were. The two IL:ams who estimated dates for the diilcrellliation or the l\I group tried to exclude the effects of recornbination, but geneticists feared that the problem was more di!licult and that ,:onclusions based on a molecular clock 'may he of very limited value'. 20 I-:!o\VC\Ter uncertain their findings, at1crnpts to dntc the epidetnic daritied several prublems in Together with the identification of the t9 59 case in Kinshasa. ruled out the theory, propounded in Edward Hooper's book, The River. thut. 1he IJIV-l t~pidemic had been caused by a polio immnnisation campaigu in the Congo region during 1')57-60 that allegedly used a vaccine bred on SlY-infected chimpanzee kidneys- a theory also conlradicted by negative tests on surviving vaccine samples. Instead, attempts at stimulated interest in the interwalence among antenatal women !her'" had reached l. 6 per cenL 17 French doc!ors blamed the epidemic on sexual behaviour in a rapidly expanding town duminated by (l!Jmarried young people from a couurry,;ide with traditions of considerable sexual freedom. ln 198 7, 'i8 per cent of respondents aged l 'i -+1 had had a child before the age of 20, 54 per cell! rcpCU(Jle called lhe n',IV v tlr· sc,ase 'c']' "' 1m ' l)ecausc wasting was commonly ils most Fisible symptom. 'lu the lirst six m,mtJJs,' Dr reponed J!,om Rakai in 1984, rhe patient e.\_perienccs genefal rnabise, and on-JtHl-off 'fevers'. For vvhkh he 1nay be· treated 'self' or othe1 wise with Aspirin, chloroquine and chloramphelllcol etc, In due CfHH'St.:, the patient devdops gradw.d In-s ...; of appetite. ll. In lhc next six months, diardwea appears on-and-oiL There is gradual weight loss and the pattent is pale. fvtost patients at this point in time will rely CHI traditional healers, ;::s the diseuse tv rnany is at1ribuled tu \'•Jitd1crafL

~.:L Afh;r L)~le. y~ar, the patient develops a skin disease 'iVhich is very itchy. c:pparenily 11 IS all over the body. 'fhc skin bccomcs ugly with hyperpigmcnted scars. 1 here may be a cough usually dry but or her rimes productive. IV. Earlier on after a )rear, the patient nwy be so weak that even vvhen taken tu hu~pi1al (not iThJch can be done dut: to late reporti11g;, goes into chr\micity a 11 d

death.''

Llke I he [()cal people, Lwegaba blamed Slim on the young ibhcrmen and smugglers who had !locked to the lakcslwrc lo exploit the Nile perch fisheries and the Jlla!Jelldo economy. 'Since began,' an inves1igaior noted, lclnpnrary li~[:ing camps of grass huts and sht~ds have growu up seastH1tliiy on the lakcshure, wnh predominantly male popula!ionc;, Miile labour relies, tor food. drink ~tnd 6CX~Eil serv.ices, on cafes, teashups, and bars. tdrgely run by Vl.'orncn. Each carnp IS assocwted \VIth particular f~1nnlng connuuniUes. which rnay be at a distance of up to 15 kilometres from the shore.''

24 Tile Drive io ilw East It was probably in l.hese Hshing camps and neighbouring villages that partner exchange reached the frequency required lo raise lliV to the eprdcrmc levels elsewhere f{mnd only iu lhe urban environments of Kinshasa or Krgah. Fifteen years later researchers studied such a fishing community in Masaka district.. Its men had on average one new sexual partner every twelve Some 4J per cent of their partners were regnlar and 59 per cent casual; 8 S per cent were contacts within the village, 8 per c:ent in other !bhing villages, and 6 per cent in the nearby trading town. The village women, m turn, had 90 per cent of their sexual contacts with other villagers and 4.2 per cc;nt wHJ: casual, puying clients . Such promiscuity was highly localised, so that fHv prevalence in dilTerenl parishes o[ the district in the mid l':l90s w it likely that it would have died away if it. had not been carried to more open sexual networks in trading centres, the caprlaL and eventually !be entire Ea;ot African region. The rcsearchers in Masal0s spread far the west hike region. Three caL:gones_ ul mobile men appear to have rMricd it. One was the . , . (;eneral Amin's soldiers retrellllt occaswna . · . 1 1 ·t•. , . ·ciallv in a culture with ncar·universal male circumcrstorL ; 1e 111 ': study, of a Muslim area in eastern Hararghe,conduded ,. , prot"ct·d from infection by its Muslim social order. aud ns lac:k uf exposme v. as "·" · 1· ! t · t 'V'lS the mcst to high·preva!ence urban grm?s. Perhaps t us .. as· IJ.'~lll ,~. . . . t 'l'l1e'Il'l\'! opidermc eastc.rn Ah!Ld had1been. sl.~,.,ptd mJfJortan ·. 1 n·'r'cls •· · · lbroughou.t · ' · b/ the ~dwork of communication provided by commercia econot~le,s. Vigorous around l.ake Victoria and along the lrans-A!ncan . _ r ., ,hey were less integrated in Rwanda and Burundi or the emplmess Ch ':"l.1tr:1l Tanzania. The particular weakness of its commerCial economy had shape(] , ·b of Ethiopia's modem history, notably its uncompletcc! revululwr~. Nuw HhlL · · countrysl · 'd e aga !1St m[·· "tlUP, the same circumstances helped to protect its I · · . .::L

~l~~~iled ~rural

th~t

5

The Conquest the South

:t

.' '·,, . ',

r r h e countries of southern !\.lhc<J, infected with l-HV later than those further north, nevertheless ovcriook eastern Africa's .

. levels ol prevalence dunng the nlld J 990s and then expenenced the W(Jrld's most terrible epidemic. By 2004 the region had 2 per cent of the world's population and nearly 30 per cent of its IIIV cases, with no evidence of overall decline in any national prevalence, which in several countries eXL·eeded 30 per cent uf the sexually active population. 'fhe chief issue in sou!hc:rn Africvhere the main road crossed into Zimbabwe and anlenatd prevalence reached 24 per cent in l9Y2 and 34 per cent in 1993. Gaborone soon followed, as did the mining town of Selebi Phikwe; in 2000 thl'C>e t!JJ·ee towns registered antenatal prevalences of 44, 36, and 50 per cent respectiveJyl' Yet this initial urban predominance was reversed as thc epidemic grew. By 1999 prevalence among pregnant wom~n was 22 per cent even in the Kgnlagadi dese~t area, while !he highesl reported prevalence among them at thiil t1me was ) l per cent in the northern district of Chobe. Overall, according to !he governmeHt. 'the 2002 survey reveals slightly higher rares in rural tl!an in urban areas'. The annual incidence of new infections for the whole country at !bat time was estimated lo bc; 6 per cent, roughly three-quarters of the level readwJ amoug young people at Rakai dming the J 980~." 1 ,\u early attempt to explain the speed and scale of Botswana's epidemic highlighted three lhctors: 'tbe position of women in society, """-"~~'1"''''1 their

40 The Conquest of ! he South lack of power in negotiating sexual relationships; cultural attitudes to l~rtility; and social migration pattcrns'n Gender inequality fostered the qlldenllc throughout Central Africa. Commercial sex, driven mainly by female poverty and lack of opportunity, has been little studied in Botswana, but elsewhere 1! was important especially in initial urban. epidemics, although p~obably Ic~s centrCJI. than in Nairobi or Kigali. Women held only 8 per cent of Znnbabwe.s and 15 per cent of Zambia's formal sector jobs in the early-rnid l99Us.- 2 'Divorce, rurul poverty und superior earnings were the principal . ''ns cited' by sex workers in Harare in 1989; 70 per cent of them. wen; divorced. probably with children to support, and nearly came from drought-stncken southern Matabelelaml. Six years later, 86 per of sex workers tested there had HTV, like 7U per cent of those working the main road between Zimbabwe and Zambia in 198 7, 56 per cent in Blantyre in 1986, and 69 per cent in Ndola in 1997-8. 13 Alihough willing to use condoms, only about half of those in Harare in 19 8 9 and one-quarter of those in Blantyre and Ndola in the mid 1990s could overcome their clients' opposition 24 Studies of young male factory workers in Harare during the 1990s showed both their fecklessness and their dilliculiy in avoiding ri:;k where HIV was so widespread. Their annual incidence of new infections was 2 per cent, meaning that hal! were likely to contract HIV during a normal working lifespan. Similar levels of infection existed among long-distance drivers.h A Malawian villager later recalled how passing tanker drivers infected local women: The wives were spreading the virus to their busbands. tlw unmarried women were infecting the young men, the young tnen tnaklng rnoney front srnuggling vvere going into Lilongwe and having sex there. People were behaving very freely and they haLl no idea that anything had could buppen to them .... By 1996. 12 oyears a!lcr the trucks first started arriving, the death rate in the village ptaked at lour a week .... Our neighbours from other villages would not come to help people who were sick or help at a funeral because of fear of contracting lhc disease .... \Vc

became cumpleteiy isolated. 26

More commonly, however. infection passed from promiscuous men to their wives. In one small enquiry in Lusaka, lasting a year, 26 per cent of HIVpositive husbands infected their wives, while only 8 per cent o!· Hl,V-positive wives infected their husbands. 'Men generally acqmre mfectwn lHst, a carelul studv in Manicaland reported, 'li·equently during spells of labour migration in tow~s or commerciai areas, and then pass on the infeclion to their regular female partners based in rural areas.' By 1998 twice as many women as men there were infected, including four tilnes as many amo;~g people uged 1 7-2-1. owin to the disparity of age between sexual partners.-' Ne~·crthcless, women too could be 'movious', as Central Africans described it Most were not: even the highest self-reported accounts of sexna! behaviour s~ggest that only about 2 5 per cent of women had non-marital sex. YeL of those attending antenatal clinics in two areas of Manica land ir~ 1993-4. 16 per ceni of married women, 43 per cenl of single women, ..and '>0 per cent ol formerly married women were infected 28 Among the many !actors encouragmg extra-n~arital sex. one of the most important was marriage, due chiclly

'The Conquest of the South 41

1u educalion, labour migrauon, and rhe dedine of ln Botswana in :!UO 1. i(Jr example, the median age al first lllilrriage or cohabitation was 28 f(,r men und 2 3 for women. in 199 5 over 60 per cent of never--married women aged 20-·24 there were mothers, while 41 per cent of boys and l 5 per cent of girls nged 1 5-16 had scxnal experience. In Loba1se illHl Francistown. with very high HIV prevalence, 47 per cent of men and 39 pee cent of women aged l 7-18 had a Cil>tta! par1ner over a twelve-month period; 21 per cent and 16 per c.:nt had at !east two. Of teenage girls who bore children .in the late 1980s, 40 per cent h"d t·hem with men six or more years older than themselves. Young Tswana had adopted an experimental attitude towards sexthemselves' as it was known - ·so lhat you L'r l!lV--2 antibodies rcveakd an intriguing pattern? Apart !\·om one obscure rekrcncc to an ulleged case in Mali in ] 9 57, the earliest may have been a Portuguese man who had lived in l;uinea-Bissau between 1':!56 and I'Jt.!J. Olhc;r infections there during the l 960s are also recorded. Five cases wt:~e found in Ci'lte d'Ivoire during the l ':!60s. Stored blood taken in 1967 also revealed two cases each in Nigeria and Gabon, both outside the range of sooly maugaheys and presumably infcded tlmmgb travel. They were followed in 1he transI 'F\ls by inf("clions ii'Oill 1\ilali, SenegaL and Angola, the last mitted through the movement of Portuguese troops from By the 1980s scattered cases were reported from many parts ol western Aihca, often from lhe countryside, sugges!i!lg a low-intensity disease much like Hl\1-J in its pre-epidernic days in western equatorial Africa. In Guinea-Bissau, hmvevec the liberation war of 1960-74, the presence of Portuguese lmops, the movunent of refugees, and perhaps especially the widespread use of inj,:dions by Portuguese military dodors appear to have bred localised and probably unique epidemic. Hospitals in Portugal later treated many cases cor!lraded in Guinea-Bissau al this time. A study in Bissau town in the late l 9 'Hls showed thai levels of infectiou peaked among men in their sixties and wumen io their fifties who would have been sexually most active during the I ')60s. Prevalence there among men who had served in the Portuguese army was 23 per cent; among the nineteen women who had had sex with white men it was 37 per cent. This wartime gavt: l;uinea-Bissau much the highest pre\·alence of HIV-2. ln the mid 1960s, 26 per cent of paid blood donors there tested positive, as did 8.6 per cent of Bissau's pregnant women and 36.7 per cent of ils sex workel's in 198'7 9 Ten years later IHV-2 infec1ed ll.S per ceut of people over 35 liFing on the outskirts of the town. High levels wm·e also reported i11 rural areas and spilled over (largely through migrant sex workers) to southern Senegal and The Gamhiaw Yet the epidemic never beyond this region, That would presumably have required a virus more inlccdious than HIV-2. Ill.V-1 was such a virus. c.rrivdl iu vVest A!Hca (ns dist.ind from weskrn ecjt!Ulorial Africa) is diHicult lo trace but possibly touk place in about 1960, slightly after its appearance in East and Centred Africa. A claim to have

50

Til~

Peneiral.io11 of ilw West

The T'enetrathm o( lhe West 51

L [ H

I. .(; E It I

_\

~2

The Pt:netmliu11 of tlie West

discovered one case in stored blood taken iu Bmhina in l9b3 can almost cc:rtainly be dismissed. i\ Mulian migrant who had never visHed equatorial Africa died in Paris in l 'J~ 3 with Aids-like symptoms, although this could as well have been HlV-2 a:; HlV-1. Ghanaian doctors came to believe that t!Jcy had sct?ll !\ids cases as as 1981, but no dcr.mls arc available and HIV- 2 would again have been possible. 1 1 Otherwise, the earliest evidence comes lhnn Cote ffivoire. Retrospective 1cc;ts on stored blood laken there bel ween 19 70 mhl 1983 all proved negative. Adult in declin;;d until] 985. the year when its Jirst Aids cases were diagnosed. and then began to increase rapidiy. ln 198 S. 38 of 79 sex workers were fmmd rn be infectul there, together vvilh 10 of 71 in the northern Ivolrian town of l\orhogo. /\ year l ., IHV-J prevalence was 3.0 per cent among pregnant women and -1.9 per cent among hospital staff in Abidjan. French researchers concluded thai tbc tlrsr HJV infections there probably Look place in about 1980. 12 Observers sngge-,ted ul the time that the city's sex workers 111.ight have been intl;cted by European tourists, but this is unlikely because the B Sllbtype ofHTV-1 prevalent in Europe did not become established in /\bidjan or elsewhere in \Vest Hathet. the dominant strain came to be CRFU2 1\G, the circulating form r;;re in the DR Congo but common in c;;-menmn and Gabon, implying a northward dilTnsion compariible lo the eastward dil!i1sion of subtypes A ancl D into East Africa -- a difiiJsion that in West Africa could have been carried in the !lrst instance along the coast by sex workers and their clients moving between LibreFille. Dona!<J, llnd Abidjan. became dominant among West Afl·ica's coastal sex workers. throughout Cote d'Ivoire (where in the late l9':!0s it was responsible lln- over 'JO per cent of !HV-1 infections). in southern Nigeria (causing 70 per cent of the entire country"s iufec!ions). and in most coastal areas a:, far wesi as SencgaJ. 1 l ln some inland sanmna regions. including northern Nigeria, another recombinant form. CRF06 cpx. was sometimes more common (cpx ~ignil}ring a complex of more than two snbtypcs).H There were several reasons why Abidjan and Cote d'huire shm.!d have become the focus of West All-ica's HIV-1 epidemic. Neglected until late in the colonial period but endowed with vast ar..;as of virgin tropical iiJrest, Cote d'lvoire experienced rapid development during the lirst two decades of independence, with a 6. 8 per cent annual growth rate of re::JI (;mss Domestic Prod1tct between 1965 and 198().1 5 Sparsely populated, il~ prosperity attracted immigrants both from economlcally faltering neighbours like Ghana and from the poorer savanna countries to the north. Hy the lule 1980s some two million migrants from Burkina, over one million lrmn Mali, and lnrge numbers from Niger were present in Ci\le d'Ivuire at any Lime. Alilwug!J many migrants worked in agriculture, over half lived in cities, especially in Abidjan, whose development as a major port increased its population between 19:55 and 1')84 fl·om ] 20.000 to nec;rly ! ,800,000. ln l 9 7 5 some 40 ver cent were non-lvoirian immigrants. ln older \Vest African cities the control of retail trade by vwmen fostered a rough equality of numbers between the sexes. but Abidjan, alone in \Vest t\Jrica, had lhe large male majority amoug adults that in East African ciries like Nairobi led lo highly commerciulised sex, although in Abidjan it led ulso to more sophisticated tim11S of t:m,rlesansbip, owing to

The I'crwtraU,m u( the West 53 the g1earcr ecnnomic independence of women in West Ali-ica and the regi,m's less CcJJIIstraincd sexualtradi!ions."' Like Nairobi, Abidjan was a primate city on which the whole of COte d'Ivoire's excellent Iransport system l(JCused. And as Vinh-Kim Nguyen has shown." two other features of Jl,bidjan helped to mitke it au epicentre of HlV infection. One was an aspiration to modernity that bred individualistic choice, extreme dillerences of wealth, sexual adventllrism the median age of sexual debut was fifteen"'- and compkx, disassor!ative networks through whid1 HIV could pass. In I 994, 51 per cent of i\bidjan's men aged 20-~4 saitl they h;;d casual sex and SG per ceut never used a condom."" The olbccr circmnslance an epidemic was the econ<Jmic crisis !hut struck Cote d"Ivoire during !he l ')80s as the world economy faltered and the easy gnm lh opportunities of the l97Us were exhausted. This bred unemployment, sexual commercialisation, weakened heailh services, and resort io Abidjan's 800 inf(,rmal dispensaries 'that sprout like mushrooms 11ftcr rain'2o When HlV I prevalence was first measured in Abidjan in 1985, the city was on the verge of an epidemic more explosive than those in Kinshasa or eveu New York. with un annual incidence of new infc;cliuns of over l per cent in l 'l8'J." 1 The core were the city's sex workers am! tbeir male clients. Bet11cen 1 ':!86 and l 99 J HIV prevalence among sex workers rose from 58 to 86 per ceul; vith the energy displayed in Senegal and llgandu. Some launched ihdr plans late: The Gambia in 1992, Chad in 199"1. Several programmes, as in Ethiopia and Nigeria, were interrupted by civil contlict or military itJlervenlion. Others suffered long intervals between one plan and lhe next - four ye;:rs (1993-7) between Botswana's first and second medium·term plans. for example, at lhe time when the epidemic was spreading most quickly. Several experienced the 'lack of a strong political will and commitment on ihe part or the Government' of which Tanzania's planners complained in l 99H. Whereas Senegal benefited from continuity of medical leadership, Cameroun's Aids Council had eighr dir.octors between 1985 and 1999.'" All programmes were severely short of funds after the donors' initial entb usiasm waned. ln Congo-Brazzaville, for example. 'the peripheral care structures no longer received any funds from the state' between 1992 and 19')7, all funds being retained in the capital or allocated directly to NGOs, so lhe Aids programme, like Camc;roun's, was said to resemble the earlier partition of lhe country between concessionary companies."'' Even in relatively weal1hy Cfll.e d'Ivoire, the extreme concentration of medical services in Abidjan hamstrung the initial programme. In poorer countries like Tanzania or Malawi the problem was rather a lack of remurces ami administr;,\ive capacity. At Kbesa in northern Tanzania in 1994 .. ij, 'The district budget l(Jr 1\lDS control activities was ... barely sniticlent to pay one Ministry of Health 'ta!T member with a motorbike lo supply condoms and provide AIDS educution at government heaHh facilities in a district of more lhan 300,000 people, including an estimated 10,000 infected adults,'1l The most disastrous failure of policy at this period, however, was in Nigeria. When Aids was tlrst reported there, the able Minister of H.calth, Dr Olikoye Rausomc-Kuti, developed an elaborate lt:deral programme. Bnt donors were unwilling to subsidise an oil-rich country with military rulers who look no interest in the subject. In 1996, when ihe programme's sixth director resigned, federal spending on Aids was about 5 per cent of Uganda's, which had only half as many people witb HIV. Three years earlier only one of the country's 589 local government areas had submitted the Aids report required from it. ln 199 7 the government published a policy statement first contemplated in 1 'J'Jl Y The power and limitations of international orthodoxy in Aid~ policy were best displayed in South Africa. Expelled from the WHO, its white regime did not participate in the planning fervour of the late 1980s, when its main concern was the small homosexual epidemic aml ils models were American and European. 'When Aids Training, Information and Counselling Centres (ATlCCs) were established in major cities from 1988, they were located in white areas and initially had a largely white clientele. Only in l '!89 did oifio.:ials begin to take seriously the danger of a large-scale heterosexual epidemic among the black populallon. Even then aclion was inhibited by a health system divided between l 7 autonomous regional bodies. the indiJTer· ence oi political leaders preoccupied wilh preserving white supremacy, and a

Respa11ses ji·mn .1/Jave conservative prudery that vetoed an Aids education programme in schools. Instead, and uniquely, South Africa's HlV / A1ds programme was formulated from below, and here the WHO orthodoxy proved powerfuL /\J'ricun National l~ongrcs,; (ANC) leaders in exile in tropical Africa became aware of the emerging epidemic during lhe !ale 1 Y80s. Once the party was legalised in February 1990, contacts were made with the Department of Health and a.:rivisls in South Afi·ica. leading to a conference in April at Mapulo where it was agreed to establish a task force to prepare an HIV /Aids prugranmw. 44 Amid recurrent pulitin•l con!lid, a National Aids Convention uf South Aidca (NACOSA) was created during 19<J2 embracing the ANC, government health bodies, and repcesentatives of lmde unions, business, chm·ches, and NCOs, charged witb developing a national strategy. lis drafting committee included lh;~ two 1\NC leaders mainly concerned with health, Drs Nko~azana Zuma and Manlo Tsbabalala-Msimang, and drew on the expertise of doctors, ATJCC sla[f. aud acth ists. The plan they presented to the new ANC government in July J 99± was drafted with WHO ao,sistance and embodied all the current intcrnutional priorities. A mul!isecloral Natiunal Aids Control Programme vvas w be established in the President's Of!lce and implement schemes covering education, prevention, couaselling, care of all kinds, welfare, research, human righ!s, and law rdorm, all integrated into the prim~ry health care programme and invoh'ing participalion by people living with HIT/Aids. The annual cos! was estimukd at 256 million rand, against a current public health expenditure on HlV/Aids of 31-36 million rand. Appended to !he 23 l·page duL·umenl vvas a 4-pagc 'Priority Programme of Action' !iJr the llrst. year, to be met from the Department of Hcallh budget, embradng only prevention ociil'ilies. strengthening the primary bcalth care system, and tackling discriminatory practices with respect to TIIV/Aids."' This was the real plan, trirnmed lo <Jccord with the ANC's larger health programme, which concent1 a ted on creating a single and equitable national health system 'based on the Primary Hea!tll Care approuch'. Like gm'ernmcnts in tropical Africa eight ycorneone infected wilh !IIV? That was al l 0.00 in the moming. Ar 3.00 1har aiter_nnou she \·\~as fired fron1 her job. -w

Con!iict was e:;pecial!y likely when, as was often the case, the lirst member of a fuwHy 1\nmd infected was a baby, for then husband aml wife might blame

one aHoliler and lbe husband's family might insist on expelling the wife Jest she in!(,d him Yet HlV·positive men were generally even less willing to ink>rm their fl.ti till' ;11 8olswana in 20CJI, 29 per cent of men and 3h per cent of wome11 sJ!Jared their results"' despite the fact that they could normally rdy

8 6 Views fro /II Below upon a wile to care for lhem, from both a!Iection and interest An Ethiopian explained: She tells me that she will always be by my side up lu tbc end of

!H\

Hfe ... This is

because she suspects that she could have the virus in her body too .... Her !"ear lies in the fact that if J die of this disease, she may be left alolle. She is ail·aid that her parents and relatives tnay not want to support her if she is sick. She fears the stig111a

that other people rnay shovv agalnst her as a \vidov\l tvho lost her husband due to AIDS. 42

Evidence t!·om Mahrwl, huwever, showed that the proportion of women thinking it legitimate for a woman to divorce a hu;,baud suspected of inftcction increased as the epidemic progressed-" 3 Rather than inform their partner, infected people often told their mothec especially in West Africa where this was the closest relationship and the one most likely to yield care. Others informed siblings of the same gender or close friends. Women often had particular di!Iiculty in telling their children, because of the pain it would cause them and the pm;sibility lhat might reject their parents. Failure to disclose infection, of course, an uninfected partner, f(Jr it was virtually impossible to chang1hi. be presented as a tiny insect Ethiopians tried lo explain a littul but symptr~mless disease by the analogy of termites hollowing nul a tree before it fell, yet manv doctors fuund it impossible to convey the profoundly alien idea that peopl~ 'are undt'rstood as ill before they are ill' 75 Some patients thought the doctors were lyiug. Even if their ability to test liJr HIV might give them credit, their Inability to cure il, reinforced by their obligation to say so, gravely damaged their prestige. The conclusion of the Durban Declaration of 2000 - "Science '.vill one day triumph over AIDS, j tlst as lt did over smallpox' - sounded like bravado. lt certainly sounded that way to traditional moralists, for whom the epidemic was primad:ly an evil consequence of vVcstern innovations, of towns, prostitu-tion, prumbc;,,. 'ykr that lw puts over my whole body. J had a big ulcer on my back and Lhe hc:,iier applied h~rbs that took the sore away, 'l'be bea!er allows me to drink hospital 111edicine for my TB. He prays Lu God, ndt tbe anceslors, for llw cure. He will be uble to make me bdler but he will not be able to cme the virus, 85

As this quotation shows, although healers were individualistic entrepreneurs, tbey were often kt~cn to incorponde mndern practices and gain olllcial recognitiou. One successful specialist in Cote d'Ivoirc maintained a 1 00-bed 'ho,;pilal', a hostel for visitors, a pharmacy, a plantation of medicinal herbs, and d factory to process them. 86 \!Veslern trained doctors bad long resisted merging of the two medical systems. Mernberc; of the Nigerian Medical Association declared t!Jut recognising traditional healers would be like licensing kiJlers. 87 But some nationalist regimes, led by Zimbabvve in ! 98 I, ll«d given them legal recognition and many moved in this dirc;ction during the Aids epidemic, arguing, in Museveni's words, 'that since modern medicine hns no answer to this problem. let us encourage our people to carry out their own research either by scientific nwthods or by empirkal obcrvation'. Even ~ligeria admilkd that traditional healers might be useful 'when armed with accurat,studied in Zambia. If the moiher died, the household was more likely to disintegrate, as did 65 per cent of such house· holds studied in Zimbabwe. 25 As this evidence suggests, the impoverishing eiTects of Aids commonly fdl especially heavily on widows and their children. Despite TASO's prompting, in 2001 only 6 per cent of its clients made wills 2 " Instead, the fate of property and survivors was generally left l(Jr the family to decide in accordanc·e with current custom. The husband's kinsmen might blame lhe widow for his death and seek to appropriate his property and children. Noerine Kaleeba lost her marital home in that way, while a spokesman l(Jr people with HIV/Aids in Senegal complained in 2004 that chiidren contracting the disease from their parents were usually barred from inheritance. Alternatively, the husband's family might press the widow to remarry one of their number, but widows potentially infected with HfV were not always in great demand. instead, a young widow might be left on the land, often in poverty. to manage i! for her children t.o inherit. In Rngalema's village none of the 3 7 widows remarried. A Zambian study in the !ale 1990s found that 16 per cent of households were beaded by widows and 2 per cent by widowers, who f"mHl it easier lo remarry. In 2002 almost three-quarters of i\.iJs-all'ected households in South i\[dca were female··l1Cadcd. 28 ln 2004 sub-Saharan Africa had an estimated 2 million Aids orph
142 Comainment countries, but in the meantime another reverse transcriptase inhibitor, nevirapinc, entered trials in Uganda and wential if they were to be selected for antiretroviral treatment. By contrast, acct)ptancc of testing and anl.iretroviral treatment elsewhere was often low, both from fear of stigmatisation and possible violence anJ because no treatment was oll'ered to the women themselves 23 Botswana was ihe first Al'rican country, in 1999, to launch an extensive programme io prevent mother-to-child transmission. By late 2002 some 3,1 per cent: of pregnant women with HIV were receiving AZT, transmission was estimated to !lave fallen by 22 per cent, and the main hospital at Gaborone was the largest antiretroviral treatment site in the world 24 Uganda, with more infected women and Jess money, also began in ! 999 but had fewer than 5 per cent of eligible women under treatment in 2002 and perhaps l 5 per cent in 2004. when every district hospital o!Iered the serviceY UNAIDS estimated that in 2003 only 10 per cent of pregnant women with HfV in sub-Saharan Africa were offered antiretroviral medication. 'My concern as a parent who has lost a child to AIDS,' a Swazi woman declared, 'is the luck of drugs that prevent the transmission of the disease to babies. Those drugs are the only way we know thut bas been elfective in the fight ugaim;t this disease.'"' This issue became especially acute in South Ali"ica. Once the /\.!bean National Congress had taken power there in 199'!, its alliance with Aids activists began to break down. The government could nnt a!Tord N,·\COSA's unrealistic Aids plan and gave higher priority to unifying lhe cmmiry's health

"'·'u... w'JS expenditure ou high-quality hospital trealrneul, giving lh~e treatment lo infants and pregnant women, expanding primary health care ll>r the poor, and decentralising i!s provision w the provinces. real public health expenditure per capit;; fell during the later !990s, the percentage aihxated to 'basic health services' rose between 1992-3 and 1997 8 from JI to .i I per cenl. By 1998 the new goveroment had bui!t some 560 rural cliuics27 Yct this drastic reversal of policy threw medical struci ures ancl starting into disorder for a decudc, noi least because it was curried through with lhe jealous authoritarianism of an inexperienced and il!sccure regime. Demoralised nurses struck over pay and conditions while doctors withdrew to private practice ur left lhe country. fn the poorest provinces like the Eastern Cape:, health systems were gravely weakened. As a result, the HlV/Aids epitbnic was neglected at the moment of its most rapid expansion, apart Ji·om measures like coudom distribution and the treatment of STDs and tuberculosis that c:ould be given through the primary health care system. For much of the later l990s a large proportion of lhe national Aids budget was not spent. ]u contrast to Uganda, the regime refused to work in partnership with NCOs exccpt as its agents, cutting their state support in 1998 li·Oln 19 million to 2 million rand." .Instead i.he government marginalised the (largely white) acrivbts and the Aids Treatment, Information, and Counselling Ccnit'es whose experience of the epidemic was though! to be outweighed by their location in highrisk urban areas anJ !heir inability to flt into the primary health care

syslccm. (\mflict between Aids acilvi,;ls and the regime escalated during 1996·7 wl!cll scandals in the Department of Health also embroiled the ANC executive and the Deputy President, Tbabo Mbeki, who was uppoinled during 1998 tu head an inter-miuislerial committee controlling Aids lvleauwhi!e the capacity of !\ZT to prevent mother-to-child transmission had aroused excitemen!, especially at the Vancouver Aids Conference of 1996, which also focused worid atteniion on inducing the patent holders to make AZT available more dwiiply to poor countries. Doctors at major Suuth Afdcan hospitals began to experiment wilh :\ZT, sb.uwing in 199/:l, a~ in Thailand, that a shorter and cheaper course of the drug was effective. At the same lime Glaxo-Wellcome sought to divert pressure by reducing !be price of AZT l(n' pregnant women in poor cou;,· ·by 75 per cent. Although doctors argued that AZT was cheaper than trea!illg pediatric /\.ids, South Aii,ica's Department of Health decided in October i 998 thm it could not atiord the drug and ordered pilot tests to stop. 'If you have limited resources,' the Minister explained, 'you may decide to put your resources into preventing mothers gelling infected in the llrst place. The;,e are difficult issues we have 1o face.' Many suspected that other reasons included the overburdened health syst,~m's dilllculty in implementing an AZT programme, lhe !:ear that it would encourage pressure to supply AZT to adults wilh HIV /Aids, and the government's desire to oblige pharmaceutical companies to reduce their general price levels."" This was a vitd decision in the history of the African Aids epidemic because it pruvoked the lirsl major political action by lHV-positive Alhcans, the intervculion by patients into their own treatment t!tar was a distinctive feature

144 Conwillmcut

of the epidemic aud was, once mm e, a consequence of the long incubation period that enabled patients to organise themselves in substantif H!V-posilive people led by \Vinston Zulu, the lirst Zambian to make hb condition public. Jt provided both cm·c and udvocc;cy. 30 By contrast, another body formed in 1991, in Senegal, was inspired by a Dakar hospilal aS the first of many associations stimulated from ahuve by N(;Os or governments, often to provide national representatives ut international gatherings or to popularise oHkial programmcs. 31 An international umbrella organisatic1n, !he Ndwork of AJhcan People Living with was also formed in Dakar in 1993 and was estimated in 2005 to a!liliated organisations with some two million members. 12 Another early organisation was Lumiere 1\dion, created in 1994 by HIV -pcJSitive people in Abidj<Jn; its JiJundL~r-president, Dominique Esmail, died in 1996 a!l:er refusing antiretroviral treatment until ii became generally availablc.' 1 Normally, however, these Ali"ican associations lacked the radicalism lhal made people with HJV;'i\ids such a po\1\:crful l(Jrcc in epickmtcs in the United States, Auslralin, and Brazil. In those countries homosexuality provided a community basis and often a tradition of activism on which to found powerful pressure groups, advant«ges lliJt nvailable to heterosexual Afrkans with HIV/Aids, who were also slow lo declare themselves publicly !i)r lear of a stigma to which homosexuals were already accustomed. Instead of homosexuals. therefore. many activists in Alhca, as in Thailand, were women, sometimes in separate organisations like NACvVOLA in Uganda, so !hat the epidemic h<Jd the c!Iect of empowering numerous women.H It has been suggested, also, that Africa's c!ienteiisl politics !(Jslered private manipulation rather than public agitation, but, if so, it was a recent pattern due to the depoliticisation of the continent by ils one-party states once the activism of !he nationalist period was quelled, and it was a pa:;sivHy broken again by the democratisation movements of the 1990s to which concern with Aids contributed. South Africa was an exception to tile otherwise remarkable Jack of pulilkal turbulence crealel· Aids, Tuberculosis, and Mialaria with an ambitious target of providing lJS$10 billion a year for low- and middle-income countries, whereas total tllV I Aids expen .. diture there iu 2001 was only !JS$2.1 billion, ln reality, by January 2005 the Fund had approved some liS$ L 7 billion in grants for HlV /Aids projects, mostly in Africa. Tn addition, the United States governmem announced in January 2003 a PresiJenHal Emergency Programme for Aids Relief (PEPFi\R) to make available US$15 billion over five years to fitteen countries with high HIV prevalence. twelve of them in Africa, Some US$2.4 billion of this money was allocated during 20(J!l,b 3 Other limds were made available at the same perioJ. wilether by philanthropic bodies like the Gates Foundation (especially in Bohwana). debt relief (as in Cameroun), bilateral donors. or other sources. Between 200 l and 20()4 global t\mding for HlV /Aids in low- and middleincome countries trebled to IJS$f, I billion per yt~ar, UNA[!)S reckoned at that time that such aid provided 50 per cent of all BIV /Aids spending ill subSaharan Afi·ka, national governments provided 6-10 per cent and the remainder came h·om development banks or from families and individuak64 Not all uf this money was spent on antirctrovirals. By 2004 some llS:£550 million per year were devoted to vaccine research and there was talk of multiplying this by factors of two or ten, 65 Tbis was a new enthusiasm. In principle a vaccine was the only known way to end a viral epidemic [n the early days of HlV/Aids optimism was high, A leading American spcocialist estimated in 1984 lhat it might lake two years to produce u vaccine, ln 199 i

l 50 Contaiwllmt Montagnier stretched that to Jive. Before long, however. it was realised tbm this 'will be one of !he most formidable challenges ever assigned to health sciences' -" 6 Three fundamental difficulties faced tbe scientists: whether a vaccine could stimulate an etfective immune response if the virus itself did not do so; whether a vaccine could overcome tbe defensive effect of HTV's extraordinary speed of mutation; and whether any single vaccine cuuld be ell\x;iive against the many lliV subtypes."' In practical terms, moreover. there was no animal model 011 which potenliul vaccines could be tested and no researcher dared produce an attenuated live vaccine of the kind generally most effective, le,;t it should only too live. ln addition, there was no great public pressure in countries for a vaccine, since HfV was rclalively easy to avoid there, and little incentive !(Jr pharmaccuiica.l firms 10 invest in it, since any profits lil,ely to come Jhnn poor countries after a lung research programme would be far outweighed by the costs of lawsuits if the vaccine failed. By l 997 only about l per cent of international HlV /Aids research spending had been devoted to vaccines,"B but it had become clear thal publicly funded research was essentiaL Ii began snbstantially in the late 1990s in the {Jnited States and through the International Aids Vaccine Iaitiative. Several African conn tries were involved in the new vaccine experiments. In 1999, after much controversy, ffganda undertook AJhca's lirst small-scale trial, which 'demonstrated the feasibilily of condudiug scienlilkally valid vaccine research' there."'' Five year;.; later a more ambitious trial in Kenya was successfully conducted. but dcmonslraled the indli:cliveness of the vaccine. An important South African research programme began in 1999 aud pul its first vaccine into iniiial trials in 200 3.7° By 2004 none of the 30 vaccines subjected lo trials had shuwn any serious promise, but 22 were still being tested. The responsible v\'HO otlicial warned at that time thalno vaccine ctruld be ready for administration before 2015 at 1he earliest. Sceptics fean;d that none might ever be possible. There was more optimism about the possibility of developing a microbicide that women could use to prevent IHV entering their bodies during intercourse. Long neglected, this wa:; hoped to yield a marketable product by 20 l 0 or soon ali:erwards.i 1 Before lhe ilnance mobilised by !he Global Fund and other institutions could be used f(Jr antiretroviral programmes, it was essential to expand lliV testing facilities to identitY who needed the drugs. Voluntary cnunsdling and ~testing (VCT) had been pioneered by TASO in 1990 at the Uganda Aids In!ut marion Centre, which by 2002 bud expanded to 70 sites, had tested over 700.0ll0 people, and had probably contributed signiflcanlly to Uganda's declining prevalence rates. VCT sites were opened in sever in centrd 1\frica. 'l'he river: a journey back to the soun:e of HIV ~wd

Hunw.n Gent:lics, ] 8 (1 Y66 ), 514 ·l 6-;

( 9 50.' Lancet. 19Hh/i, 12 79--~0; E. 11ITX-,- \lt.:printed, Londtm. 2000), Pur detailed accounts of these cases. St:'e IIllOpt:r. l in Llt:ntc:d df:grce

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in th~ Democratic H.elmblic of suggests that }-UV-1 pandemic originoled in ,\!rica.' /Ollfllal of' Virology. 74 10498 50 I. This account b hxken chiefly J.\-1. C'ofiln, 'Molet.:ular l>iology of Ill\.' in K.1\.. CranduH (ed.), The n•ollldon of U1V (Ballimnre, J Y9Y). ch. l; J.F. Hukbinsun. 'The biology and evoJuriun of filV,' :illtJI!al RevieH7t:{ ilnthrupologlJ. 30 (2UOJ), g_5 .. J08. Cn1ndaH. 11voiiilion. p. xiL

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B. l-\c)!.bcr, Mnlduon, a.u,J dthcrs. 'Timing tl1e yndromc epid~I.niL dUd humun illllllutwddiciency \'ifUS evo!utiorJ, l'inl. rums. R. B, 156 (2UO I). 857. ~- [ :-lcdPtni, K. Strimma, and others. 'D,ding the .._·uum1on ancestur uf SlVq_,z and IHV- J grO!lp l\"1 rHd lhc drigin of lHV-1 using a nc-\'\- mdlu_;d to tmun,er clock-!the mokcular cvulution,' g-J.:)TB Journal, l). 27l>-B. Eailcs and ol.he.cs, 'Jl_ybrid B. I~urber, J. Theiler, and 'LimH.tiions of a multYular clod; apylkd to COJl~,idcration~ of the orlgi11 of Hl \' -1 ,' Sdew.c, 2 KO (199(:·n, 1 H6S. M. l;:nnc:~-Ct!rdlo, J.lcxual population in Zain.': Lailcet. J 68; lvicCormick and Fish(x-Iloch. Ld.~vel 4, p. 17 5; n. Fassln. "Lc domaine de h1 sante publique: pouvoir, polit.ique tl sidu au Congo.' Awwles ESC, 49 ( 1994), P. Aubry. G. Kthen. 'Gend!c of HIV l in Lik3si. southeust of 1 he Dcmocratk Republic uf Congo,' A RHR, 20 13 52-

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4 The Drive to the East (pages 19 - 3 R.C~. Dtn1ming. and uOll-:rs. ',.-\. molecular cpidemiu!ogic Sllrvc:y of JHV In LliD8, 12 (19Y8). 52~1. T Jonckbccr, I. Dab. anJ others, 'Cit1::,vr of HTLV Ill, 'LA\/ infection in an ~-\.frican fu1Hily,' Lancet. 19S S/i. 400 I. F. H,;nper, The river: a ioumelJ back to the scaucc of WF wd AIDS lreprinleJ, London, 2000), p. 91, ntentions another possible cut~e. l\'1. CaraCl, '\Vumcn. AIDS, and STDs in ::->ub-Sahcmm Alhca: the impan d nwrriage cllange,· in C. Cabrera, D. Pitt, and P. (eds), AlDS and the problems, chalienws awl opportu11ities (Gaborone, 1996), Van de Pcrrc D. and l-)tlicrs, 'Acquired 'LanccL, 1984/ii, 62. immunodetlcie.ncy syndrome iu ]. i\1orvan, B. Cartenon. and others. sCr{H~pldemiologiquc sur le::. infections U UIV BurunJi entre l9RO et 1981.' de ln Socifti de Pat!wlogie ExoUque, ?12 (1 SJ89L 130· 3; R. Laroche, i-"loch, anJ others. 'Principaux aspect.::; Ju syndrome d'imnmnudtpressi\Jil acquise de radultc au Bunnhli,' fvledecme Ttt)picale. ,jf) (1988) J59, Hd.

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e[JiJelltiology ul Afl)S virus iurecUon In N~Jirobi populations,' joumal l:{ lnjCctious /)i::,cases, 155 ( 1':>:57). llOo- i2; I.N. Simonsen, F.!\ Plullnner, and otbcr~. 'lii\' i11f~ctiou among lmver socioeconomic stratu prostitutes in Nairobi,' AlOS, ·± (19~0)_ 139. PitH Ltlhi others. 'RclrospeC!ivc epidemiology,' ]lOti; D.\'V. Lamcron. L j. IYCu~ta, and othL:t"S. 'Fcmak: to male transmission of human inimwwdcticiency virm; type l: rbk factors for scrOCt)llvcr~ion in rnen,' l.aun:t, 1l)("j9/ii, -10--l. A. O'Connor, The !llrican (London, 1983 ). ') ~i.H. Dawson, ';\JDS in Africa: hishH"ical Hockv11dl .:liDS in :lfi ica: lhe S'vcial ami policy impacr roots.· in N. Miller and {Le\viston, J 9t;H), h2. j.K. Krebs, D. a.nd others, '/\JOS virus: infection in NairuLi prostitutes: spread df I he epidemic lo East \!rica,' NE]A1, J H i1 ~86), 4 I ·l l 5; F.A. Plummer, E.N. and S. 1\Joscs. "The Purnwani experience: evohniou of a Jn disease control, in Nctv,,ork uf AlDS Hc~sei-ln'llers of Eastern und Southern Focusiuy iuterventions tlllwny vuloerahle ~Jroilp:. ji>r i i dime e;rperiem:cs ji·vlll wster11 and ::.outhern (Nairobi, 19~H ), p. 75; E. Huoyt~r . .)'lim: a own story qj L4flJS in E'list A{ril'a J 990). p. )1 0. Cameron and 'Female to male transmission,' p, 403; S. Muses, E. i'dui t l ~J9:_l), 1 65--:l: lJNAHJS, Co/lsultu.twn on STD iiLlerFt:ntivnsjin· preventing HlV L()()(J). p. 32: E. Pisani. (;.P. Garnett. and other~. '1-ku:k lo ba::ac:. in HJV prevention: dfi exposure,' B~\tlf, :L?.O (2003), 1385. ii~AlDS. Cm1.'lUftaUvuoniilFmterventiuus, p. 32; O.A. 1\nLala, N.J.O. Nagelkerke, and others, '1\apid progreti&ion to Jisease in African sex wod•. crs 1Nitlt human immuHoddiciency virus 1 infect!Uu,' jlJllrtw.lofli~FecLiousDiseases, 171 (1995), 68h-9. and Moses, 'Tbc Pumwani experience.· and F.A. Piummer and E.N NgugL targeted interventions.' 111 Network of iUDS Researchers, Focusinu inlerventions, pp. 77 tnun'~"'"' African city of and ,,,Jomen still married lo their lirsr husband,' 323, 32R; \Voubalem, 'HIV/::i:.JDS in Et.hiopi.iey of senior high S\ honl students,' 1::/HD, •1 (19'J0i. 12l. Federal Ivfinistry J-leahh, '/dDS in Ethiopia' (Slh edu. lUU-1), pp. :J. 25, ~"'''"'IV0UlDIUOLlL!JUl (accessed '1 February 2005). Fontanet, Tsehaynesh and ot.h.:rs, ':\ge- and ~.;ex-specific UlV-1 pr;~ov~dence in the urban community setting of Addis Ababa, Ethiopia.' AIDS. 12 (l99b). 320: Fontanet and TiL.:1bun \V/Michaei. 'Elhiu--NetherlanJs Pn}ject.' p_ 13; 'Update on HlV/_,_'-\IDS: prevalence of HIV inii:'ction lNomen attending antenatal care clinic.-> by centre. Addis Ababa, Ethiopi<J. ' Ethiopim1 Aledicnl 41. i2003), sup!Jlemerrt l, p. 89; Deregc Kebde. :Mathias /\kHlu, and E. Sanders, IHV epid,~mk and tht' state uf its surveillance in Ethiopia.' ibid., 38 (2GOOL '287. 'AIDS in Ethiopia' pp. \', 6, 9. 26: lVorld Bank, lVin"ld development report (Nen.: York, 2'76; lVuubalem, 'UJV/AIDS,' p. ~)_);Daily Ala11ilur 1_,-\ddis Ababa), 21 December 2004. (accessed 29 December 2U04)" Quoted in l. epidemic in South Omo Zone, southern Ethiopia,' African Studie~. 52. Ethiopia: National ATDS Control Programme. 'Second mcdiHm term phm J 992--lY96 and workplan and fnr ] 992-1993,' duplicated, Shabbir fsmail, and othen:;; 'Kr1mvledg,e, in a rural comrnunHy, Erhiopilln factors pertaining to 3--·4: L Shahbir and C.P. Larson. 'Urban to rural routes cf HTV infection f(mrnal of Tropical 1\ledicine and Hygiene, 98 (1995), 338--42; Gegu Degu and pr;;;_clH\' of condom in preventing }HV//-\IDS infection among comn1ercial sex \.Vorkers in three small tm.vns of northwestern Elhiopla,' F.]UTJ. 16 (2002), 27'7-80. C. 'The chaHenge oi' l.he HIV/AIDS epidemic in rural Ethiupiu: ;;wening the [\JDS··impuctcd communities: from f1eldwork in Kc:r.sa \Voreda, Eastern Bararghe :lone, Oromiya O.J0402dl_cn.doc (accessed 6 ScltJteml,er

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HlV cpiJemic in dbtrkt Malavvi,' AUJS, 15 (2001 ), -~025---9; C.P. GIV!ili. anJ evolution of the human immunodeficienL:y virus ll)idcmic l11 tl.L-ti Maluwi,' journal 76 (2002), 12800-9, and HIV type 1 group Jv1 sequences in distckt, rvlaluwi in the ,iRHI intlucnciug !he tran.smissi011 f,fl11V in BotS\N~tna,' .)'S'A,f, -±~ (l~J96), i1:.25 A.iL1, 1V1arch 1 Sl92: T Comvbdl ond i\'L Kelly. '\Vomcu and AIDS ltJ. Lambia: tEilm-ullzwntm reporl2000 (1-Jbabane, _2(}0 l ), pp. IJN.t\IDS, Hcp;lrt vn cfle globtd AlDS t:pitienlic i.~)l---2. Shisana and others. 1\felso/l executive Sllfllllli.lry, p. 6. 0. Shjscmu, L. Simbayi. and others, Nelson Alawlehi/1-:iSRC :-;tucly o} ff[\//,-ifVS: S,Hith A.frium naLional HIF prevalence, behavioural risks and nwss mediu: household (Ccr. 'Sexual socialisallon in South i\Jrica: a historical perspective,' Studies, 61 (_2002). 27--- 54-; K. Kelly and P. Nliabati, 'Em·ly adolescent sex in South lllV intt.~rvcution challenges,' Sodal Dynamics, 28, l (2001), 56; R-t Hunter, '1\·fasculinitics, multiple sexual-partners. and .\IDS: th~ mah.ing and urnnaking of isoka in KnraZulu.-Natai,' Tnms(unnation, 54 {100-!). i 2_3 ... 53. l1untc-r, 'I\lasculinities;, p. 141; T.-A. Selikovv, B. Zulu. and E. C:edras. ·I'he inyayam, the and the dwrry: HlV/A1DS and youth culture in contemporary urban tcnvnships, tigenda. (2UU2), 24-6: C. Campbell, Townshif!s, jlnnilies awl yow.h identily: influence 011 the social q( town::,hip in a rapidly clwnf}ing Sm1th _'ljl-ica (PreLorin, p, 75. L fawn. Flisber, L.E. Aaro. 'Unsafe s(;xual behaviour ln South African youdl( SSAl, 5(-) (_2(){B). 1'-1-9; S. Ahdool Karim, Q. Abdool Karim, and others, 'Reusons for lacl ul' c(mdum usc anwug Ligh school sludeuts, SAi\1] 82 (i9Y2}, !07--JO; A.E. Pettifor, H.l.L Hees. and others, 'HI\l and scxu;:-tl behaviour vuung South t~fricans: a national survev of 15·-24 vear-olds' (200+). Ill. (accessed 2 january -:1005); S. it:dt:rc-rAuJlala, one. all: Zuln resjJonsc tu the AlDS epidemic in Suuth Africa,' _l'v-Tedical ilnt}zrop(Jlomf. 17 (19t;6-7},

Auvcrt and others, 'l::UV infed.iou. of rape and sexual coercion in

889: R_ }e\.vkcs ~tnd N. Abmhams, 'The "'""'"'"'""u'" 1\fricu: an overvkH.r,· SSi\t 55 (2U02), 1

hu ker, c·t)fi!I/Hmilies 4 pracrice: t_,'Oill.t,\.'tlWI mt:duuors i~f' y~mt11 response to lll U [liDS (Prc:Lurid_, .2.000), p. 3 7. Dunkk aud others. ''l'rausactional p. J 588; S. Lcderc-J...f.'l. autrement: de !'cthnographie en teml-JS de panJbmie,' in Dozon and Vlda!, l,es scidh:es p. 259. I't-it?bdo11uulaire du Burk.hw (Ouagadougou). ~l lvlarch 2002; 'Pres..:~ntmion dt: la d~!0gation du Burkina Faso,' in Organi~atiou de Coordination de la Lttlte t:ontrL·~ le.s End6ruies, PrerJJier pla11 concerti pom l'h~j(wmathnl, ipidJmioloyiqw; et lu comre le sidu dansles itws memhres de l'OCCGL' (Bobu IJioulas~o, J ~FH!i, p. 6; N. Nagu!, N. J\deda, and others, 'Review of STrand HlV data fhJm 1990 to 1001 in urban Burkina Faso.' Sexually 127. 'Presentation de la delegation du Premier platJ, p. 23; LIN:\TDS, 'AlrJS epidemic upd;-Hc, December 20(1-1,' p. 27, http:,!/www.uuaiJ::-..org (accessed 18 Novdnber

2004). J.T" B(Jl·rma, P.D. Ghys. and !\I. \-Vulker, 'Estin:u.ttcs i!fV·-1 frum national population -hewed as a new t:',nld standard,' Lath't'i, -5h2 1929; Mu.H, 'Plan national htUe contre Ie VH!/StDA 2001 -2005, http:/ /wvvw .unaids.org '1 December 2lHH). ;\-fauritania, ·cudre strllt;§gique nutional Je luttt; contrt·- l:.~s LST/VlH/SlDt\ 2001-- 2007,' laccessed ·:; Decewber 2001); K. \-\'ys:~. Hulton, ··costs uHriburalllc to at household levcd in Chad,' AUJS Carl'. 16 P. Bobier, O.N. Ouwe 1Ii:;si Oukem-BoytT, c1nd otb;.;rs, 'Natiunvdde HIV pn,V<Jstlt.utct> in the Crot->s J\iver state nf Nigeria.' AILJS. 6 (l'l02), 229-lO. National :\ction Committee on HiV/A!DS. 'Hl\'/AiDS emergency aeliun phm January 2001,' http://Vv'VJ\N.unalds.org (accet:~seJ 30 November 20U3); 0. Alubo, A. Zwandor, and olhers, 'Acceptance and stigmati:t.:alion of PL\VA in Nigeria,' AIDS Cim.', 14 l 18, 120, 123; S.C. Ogbnugu and f.O. Charles, 'Survey (Jr sexu;.-:d networking in 'liTH, 3 (199·3), supplement, 105---19. follow-up to the declaration of Nigeria, ·A rcpor! on the LNGASS indicators in conHnitlnClli on l-HV/AlDS' {2U0:2). p. 4, (accessed Hl November 20(U); l~. ·raysagc fpidemiologiquc a 1 panni les prostituee~ africaincs, · cL1friqul! Noire. 4 5 (199~ ). 18 7-8, 290; l'~igtria, ·t HV /AIDS erncrgency anion plan.' E.P. RL·Jm.e. Popul11Liun w1dprogn:ss itJ a Yorubn tow11 (Londo11, 71-8; 1.(). Orubutuyc, 'Behavioural research as L'l tool in the prevention and in of tbc Natloncll Cunlcrtnce un 1-::i.IVii\llJS, r\buja, _15--_1_ 7 Dt::CL'.tl.lber surve.illallce

39

40

4i

~2

43

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p. 16; News\vatdt (Lagu:)), 2S Fl.'brnary 2005. . p" 17 dctlnstitUIPaslt:JLrJelJrilau; 1Y87, p. 51; Lemarddcy, orr:'il«"-nl'IHlll sur Ia VIc Conference Jntenwtionale sul· le Syndrome d'Jmmunodepressiuu Acqubl\' 1\-lidL'I'ine 'fi·opicale, 52 ( 1991L 201; 'Bulletin sero--bpidf:miologique IJO. 10 de surn:illance du VIIJ,' ..2003, p. 1'l, NL/rdonlyr~'::l {accessed 6 September 200-! l; l.e Sold! 3 fJecernbec 2004.

l7fl The Pcnetmtiun of the \\lest (pages 48- 57) Sl:ncgal, 'Bulletin stnJ-eplJEmilJloglque no. 10,' p. 16. MH!cn, 'The evolution of vulnerability: ethnomedidue anJ social change in the contl~xt [tfllOng the Jola of southw~stern Senegal,' PhD thesis. University of Connecticut. 2003, ch. 1 '3; K Lagarde. l~. Pison, und C. Enel, ·A ::>t.iJ.dy of sexual behavior Lhange in rural Senegdl,' Journal of lliiJS. ll 11996), 282--7. E.C Green, Rethinking ~41DS prel'entiou: learuing_fiDm s.uccess~s in det·efopiug cuuwries (\,Vestport, 2003). pp. 227-37.

Causutioll: a Synthesis (puges 58- tA) !77

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30 ').l

7 Causation; a

2

6 7 9

HI ll 12

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14 15

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(pages 5

See J.C. Caldvlie!L P. Cald\vell. and P. 'The :.;oci'-ll context of ._\IDS in sub-Saharan Africa,' Population und Developillt:nt Revictv, 989), 18 5 -234; E. Still\'vaggou, 'HI\/ /iliDS in /1frica: fertile terrain,' ]mmwl uf DcvelopmetJt Studies, 38, 6 2002), J -2 2. S. /UtJ5~' anJ its metaphors (reprinicd, LoncLm, 1 For on earlier African epidemics, see 104. For the Americ1:in epidemic, se-e R. Shilts, Lhe band played un: poliUc~. people, and the AlVS epidemic (reprinted, London, 11Jk8}; E.J. Sl)bo, C}wusing wz~t~/"e sex: ~uDS--rlsk denial tl.l"tWIIlj di.>advaniage;..J women (Philudelphia, .l9~J 5 ). ]JvL Garcia Czlleja, N. \Valker, Ull i\ll)S Control Pnlgramine, ~15 (\f>ril 19H9, Ui\lOH mmumbcred file; Health Assembly resolution. May 198?. io. \:\..'flO, Hcuufbuok resolutions and dedsitms (~{ U~t· \V(Jrld I-lealth .r1ssembly wtd the Executive HtJu:rrf: vuiwne Ill: rhiui (1985-1992) (Geneva, 19'Jl). p. 121. Sc-: esp. D. FcJssin, Les enjeux poliLitJIWs de lLl sanui: iilwks setJCyafais.:s, iquaturiennes e/. .fl'unrtlist!s (1\lfis. 200()). ch. 19. f. Cohen, 'The rise~ rtor.':.·:ahis.loryoj Lhc ll.J9tn. pp. 223, 210 L Ouuied iu Mann, D.J_l\1. Taran~ula, and in tlu~ wutld lCambridge, P- 567. Titnes of Znmbia, .l] September 1935. See B.D. Sdwub, back: international sympu:::;lum un Afrk