First of four parts
JOHANNESBURG - Two million Africans south of the Sahara died of AIDS last year, five times the number of AIDS-related deaths in the United States since the disease was discovered nearly two decades ago.
But that is just the beginning of the devastation to come.
More than 22.5 million people in the region carry the AIDS-causing human immunodeficiency virus. Of the 11 people worldwide infected every minute with HIV, 10 of them live in sub-Saharan Africa.
Five countries bundled together in southern Africa now form the global epicenter of the epidemic. South Africa counts 1,600 new infections a day, the highest rate in the world, while in Namibia, Botswana, Zimbabwe, and Swaziland, one in four adults carries HIV. It is estimated that 90 percent of those infected do not know it, and therefore aren't aware when they might transmit the virus to their partners.
Within five years, 61 of every 1,000 children born in the five countries won't reach their first birthday, the United Nations estimates, and by 2001, it is projected that there will be 13 million AIDS orphans in sub-Saharan Africa. Companies are overhiring to keep pace with AIDS deaths in the labor force.
The statistics indicate what few officials are willing to admit: that this region faces a crisis of shattered mores, where sexuality is no longer guided by traditional norms. In an environment where old rules have clashed with, or been eclipsed by, rapid social change, African men are killing themselves - and their women and children - with sex.
Hiding behind a historical reluctance to speak openly about sex, African political and religious leaders have failed to acknowledge this deeper cultural crisis at the root of the AIDS epidemic. And international experts, averse to sounding judgmental or racist, tread lightly on the epidemic's behavioral undercurrents. Behavior, consequently, has been narrowly defined as simply having safe sex. But as effective as condoms are in stopping the transmission of HIV, they do not stop epidemics.
"Without addressing behavior, the response to prevention strategies will always be limited,'' said Elhadj As Sy, head of the United Nations AIDS program for Eastern and Southern Africa, based in Pretoria. "We'll create some results here and there, but unless there is a fundamental change in behavior, there will be no drastic change in the evolution of the epidemic.''
HIV is transmitted primarily through heterosexual contact in sub-Saharan Africa. The alarming spread of the disease has been fueled by larger factors: rapid political and economic change, Westernization, migrant labor, poverty, and gender inequality. Promiscuity, however, is quickly dismissed in Africa as a racist term: code, in fact, for the myth of the black man's unbridled libido.
But AIDS experts throughout the region agree that far too little is understood about sexual dynamics in modern African societies. Important questions thus arise: Why, for example, are teachers the third highest HIV-infected job group in Namibia, after truckers and the military? Is a man who lives at home but takes many partners abiding by traditional sexual norms? Why does HIV spread fastest among youths, the age group most informed about AIDS and condoms?
"People don't want to do this research, so there are patterns of black behavior no one wants to acknowledge,'' said Mary Crewe, director of the Center for the Study of AIDS at the University of Pretoria. "They'd rather lay blame on the apartheid past, which I'm not sure is right.''
Contrary to what infection rates in sub-Saharan Africa suggest, HIV is not easy to contract. In a stable and healthy environment, the probability that an infected man will transmit the virus to an unprotected woman is less than 2 in 1,000, according to World Bank figures. But it is easy for that risk to rise. A person afflicted by other sexually transmitted diseases, which are rampant across the region, is two to nine times more likely to contract HIV if exposed to it. And if a man has 10 partners, and the partners have each had 10 partners, he's potentially been exposed to 100 people.
In addition, several socio-economic factors lead to high levels of casual sex in sub-Saharan Africa, experts say. The region has seen serious upheaval for decades, the past 10 years being among the most turbulent. Genocide in Rwanda and the end of apartheid in South Africa caused the movement of masses of people; porous borders, regional development corridors, and political change have reshaped and extended sexual networks. Poor health care facilities, meanwhile, leave many without access to quality treatment and prevention, while high unemployment leaves youths idle.
"When you see such an epidemic as we have, it points to a very stressed society,'' said Clive Evian, a South African doctor who helps industries cope with AIDS-related labor costs. "HIV epidemics go with a package: an emerging economy, transitions from traditional cultures into industrial economies, high levels of other sexually transmitted diseases, and economic stress on families.''
Among the factors fanning the AIDS epidemic, migrant labor and gender inequities have perhaps been the most damaging. Throughout the century, men from around the region were drawn or conscripted to work in distant gold, mineral, and diamond mines. They left their families behind in rural villages, lived in squalid all-male labor camps, and returned home maybe once a year. Lacking education and recreation, the men relied on little else but home-brewed alcohol and sex for leisure.
A man who makes his living deep inside a South African gold mine has a 1 in 40 chance of being crushed by falling rock, so the delayed risks of HIV seem comparatively remote. Mining companies pay out $18 million a year in wages to 88,000 workers in the pits of Carletonville, the center of South Africa's gold industry. The wages buy, among other things, sex. Some 22 percent of adults in Carletonville were HIV-positive in 1998, according to UNAIDS, a rate two-thirds higher than the national average.
"High alcohol and sexuality are symptoms of things going wrong on a big scale,'' Evian said. "They reflect a kind of aggression, the sad social state of the man. They have been thrown into horrible lives and become frustrated. It would happen to any man anywhere.''
Most African women, meanwhile, live in poverty. They have little or no economic control, and therefore virtually no say in sexual relationships. "Women know they are in danger, but there is nothing they can do about it,'' said Lahja Shiimi, HIV/AIDS health program officer in northern Namibia. "Men decide when to have sex, with whom to have it, and how.''
Physiologically four times more susceptible to HIV infection, women in the region are contracting the virus at a faster rate than men, and at a younger age. Most of the women who tested positive for HIV in Namibia in 1998, government figures show, were in their early 20s, while most men were in their mid-30s. According to the latest UNAIDS statistics, 46.7 percent of Namibian women at rural prenatal clinics tested positive in 1996.
If mobility, migrant labor, and gender imbalance are conducive to the swift spread of HIV, they also underscore the breakdown of social cohesion. When truckers and miners go home, they take the virus with them. Sometimes they infect their wives, sometimes women become infected through sexual contact with other men while their husbands are away. Rural infection rates are catching up to urban figures. The role men traditionally played as head of the family has broken down. Boys grow up without fathers. Wives are left impoverished and unprotected. A South African woman is raped every 26 seconds, the highest rate in the world.
But socio-economic arguments about AIDS do not fully explain how sexual relationships are changing as African societies evolve. Notions about masculinity and fertility vary widely among Africa's diverse ethnic groups. Health workers across southern Africa agree, however, that traditional cultures had strict rules governing sexual relationships. Those codes have broken down and nothing has replaced them.
"In our culture, having a lot of women is a kind of status,'' said Milka Mukoroli, the HIV/AIDS coordinator at Rundu Hospital in Rundu, Namibia. Under the old rules, "a man might marry two or three women, but he would never stray from home, and the first wife had to be consulted about each new wife.''
Now, Mukoroli said, wives never know about their husbands' other women. Men take lovers furtively. Many traditional cultures frowned on premarital sex. Today, older men look for young girls to take care of, seeking sex in exchange for providing school fees and nice clothes, often in the mistaken belief that sex with virgins can cure AIDS. Health workers say many male secondary-school teachers sleep with their female students. A new study of Carletonville conducted by the Pretoria-based Council for Scientific and Industrial Research found that 60 percent of women are HIV-positive by the time they are 25. Throughout sub-Saharan Africa, infection rates among teenage girls are significantly higher than for teenage boys. Infected by older men, the girls then infect boys their own age.
"Social pressure should be put on older men to avoid forcing or coercing young girls into sex, or enticing them with sugar daddy gifts,'' a UNAIDS study on behavior released last month concluded.
Changing behavioral patterns are not restricted to men, AIDS workers say. Traditionally, women were not supposed to enjoy sex. Increasingly, however, they are asserting their own sexual needs and priorities.
"Promiscuity is prevalent predominantly because heterosexual relationships are changing,'' said Peter Schmidt, a German doctor serving as chief medical officer in the AIDS-afflicted Ohanguena region of Namibia. "This is a very sensitive subject and very difficult to tackle. So many dependencies in African societies relate to sexual relations.''
The heterosexual nature of the epidemic does not rule out the probability that HIV is also transmitted between men, but homosexuality is deeply closeted in African societies and there are comparatively far fewer same-sex infections, according to AIDS experts.
Youths provide a compelling reason to think differently about behavior. Across the region, young people have been exposed to more education about HIV and condoms than their elders, yet they have the highest infection rates. Knowledge about risk and condoms hasn't slowed the epidemic.
A new study of sexual behavior among youths between the ages of 11 and 24 in KwaZulu-Natal, South Africa's hardest hit province, indicates why: Young people are on their own in an aggressive and evolving sexual environment without the communication skills necessary to negotiate the function or frequency of sex in relationships.
Consequently, the social ills governing gender relations among adults reappear among youths. Both men and women in the study said that condoms threatened trust within the relationship. Most women said they were powerless against male sexual coercion. Many from both sexes said they would prefer abstinence or monogamy, but said peer pressure is a strong influence.
"For young people, sex is a must to be taken seriously by their peers,'' said Christine Varga, research fellow at the Australian National University in Canberra, currently based at the Reproductive Health Research Unit in Durban.
Significantly, said Varga, who conducted the KwaZulu-Natal study, young people feel increasingly isolated from the adults in their lives. Traditionally, cultures included some mechanism for passing on the rules of sexuality and intimate relationships to adolescents. Parents, however, never spoke to their children about sex. Unmarried aunts or older sisters informed younger nieces or sisters coming of age. Uncles and older brothers did the same for boys.
Now confusion prevails. Rural youths in particular "are much more likely to evince attitudes that are a combination of old conservatism and new sexuality,'' Varga said. They combine new attitudes like "sex is a must'' with traditional mores such as "condoms are for prostitutes.'' The result is high-risk sex.
From 1997 to 1998, infections rose 65 percent among South Africans between the ages of 15 and 19. All too quickly, HIV is claiming another generation.
"The way to fight the epidemic is not just with condoms. We have to change mores,'' said Patricio Rojas, the World Health Organization representative in Namibia. "Openness happened fast in Africa, and it happened wrongly. There is no grooming of boys and girls as partners in a relationship, so sex has no aspects beyond the instinctively physical. We have to create an environment of normality again.''
Part 1
