Why Do Africans Get AIDS?

by Alexander Cockburn

Every major campaign against AIDS in Africa, Glausiusz writes, has been based on the premise that heterosexual sex accounts for 90 percent of transmission in adults, Yet safe-sex efforts have not stopped the spread of the epidemic, which now affects 30 million people. Economic anthropologist David Gisselquist therefore suspected that HIV might be spreading primarily by another route.

After analyzing 20 years of epidemiological studies, he and his colleagues concluded that unsafe injections, blood transfusions and other medical procedures may account for most of the AIDS transmission in African adults. Their analysis indicates that no more than 35 percent of HIV in that population is spread through sex.

Gisselquist's interest in AIDS was stimulated by the guidance he received while traveling through Africa as a World Bank consultant. "They give you a syringe and say, 'Carry this with you, and avoid all the health care that you can.' We've been paying for third-world health care while advising ourselves to avoid it," he says.

Gisselquist takes up the narrative once more. When he examined hundreds of papers on AIDS in Africa, he found evidence to back up those concerns. A study in the Democratic Republic of the Congo, for instance, found that 39 percent of HIV-positive, vaccinated infants had uninfected mothers. In contrast, Gisselquist could not uncover any clear data proving that sexual intercourse dominates the spread of African AIDS. In Zimbabwe, HIV incidence rose by 12 percent per year during the 1990s, even as sexually transmitted diseases sank by 25 percent overall, and condom use rose among high-risk groups.

Gisselquist recently reported his findings in four papers published in the International Journal of STD & AIDS. Medical researchers may have overemphasized sexual transmission of African AIDS in part because condom-use campaigns dovetail with their concerns about overpopulation, Gisselquist says. They also fear that people in Africa will lose faith in modern health care. Gisselquist urges new efforts to halt the spread of AIDS: "Aid programs need to push infection control in health care. And we need to give the public the advice and the tools for protecting themselves in medical situations," such as new syringes and single-dose vials.

I liked Gisselquist's noting of Malthusian concerns about overpopulation, but then I talked to Cindra Feuer, who worked on the AIDS-oriented New York magazine POZ and has also spent considerable time in Africa. Feuer points out that the argument of noxious health care doesn't look so good if one recalls that most poor Africans don't have access to health care.

The core problem is that safer sex advisories and programs fare badly in poor regions in large part because people don't have the safe sex option.

• A woman can't negotiate a condom with her husband. Being married confers one of the highest risks of getting HIV in Africa. (I'd previously regarded the theory as a piece of rather racist myth-making, but in certain regions, Feuer confirms, African women have higher exposure to risk because of a male liking for "dry sex," which can easily cause lesions because of the lack of lubrication.)

• A sex worker gets more money from her trick if she doesn't use a condom.

• No condoms are available.

• They can't afford a condom.

Treatment, a strategy that had to overcome furious opposition from the keep-your-legs-together crowd), is the best course. If you have treatment, people will then get AIDS drugs, and they'll get tested. If they get tested, they're not as likely to have unprotected sex with their partners. If they test positive, they're not as likely to go have unprotected sex. If they test negative, they have more incentive to stay that way.

So treatment helps to boost prevention. If you don't have treatment, there's no incentive to get tested, and rates will remain high.