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AIDS Care: Psychological and Sociomedical Aspects of AIDS/HIV Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/caic20

AIDS in Africa a

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D. Wilson , M. Armstrong & S. Lavelle

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Department of Psychology , University of Zimbabwe , PO Box MP 167, Harare, Mount Pleasant, Zimbabwe Published online: 25 Sep 2007.

To cite this article: D. Wilson , M. Armstrong & S. Lavelle (1991) AIDS in Africa, AIDS Care: Psychological and Socio-medical Aspects of AIDS/HIV, 3:4, 385-390, DOI: 10.1080/09540129108251595 To link to this article: http://dx.doi.org/10.1080/09540129108251595

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AIDS CARE, VOL. 3, NO. 4, 1991

AIDS in Africa D. WILSON,M. ARMSTRONG& S. LAVELLE

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Department of Psychology, University of Zimbabwe, PO Box MP 167, Mount Pleasant, Harare, Zimbabwe

Introduction Of 7,352 pre-registered delegates, 679 (9%) were from developing countries, 175 (2%) from Africa in particular (Science and AIDS, 16 June, 1991). Of 3,489 accepted abstracts, 409 (12%) were from developing countries, of which 240 (7%) were from Africa. The best represented African countries were Zaire, with 24 papers and Cote D’Ivoire, Kenya and Uganda, with 15 each. Of African papers, 120 (50%) were in Track C: Epidemiology and Prevention, 70 (29%) were in Track D: Social and Behavioural Science, 32 (13%) were in Track B: Clinical Science and Trial and 18 (8%) were in Track A: Basic Science. This review is largely limited to Tracks C and D, that is, to work from, or applicable to, AIDS prevention and support in Africa.

d’Ivoire, than in others, including Zaire, Congo, Gabon, Cameroon and Nigeria? For example, the HIV seroprevalence of 3.26% among STD patients in Yaounde, Cameroon (Zeking, WC3085), is far lower than that in most eastern and southern African cities (Torrey & Way, 1990). More strikingly still, the contiguous copperbearing areas of Zambia’s Northern Province and Zaire’s Shaba Province share a common economic base and agricultural capacity and have ethnic/linguistic similarities. Yet HIV infection in Zambia’s Northern Province (Kanyama, MC3301) is seemingly markedly higher than in Zaire’s adjoining Shaba province (Magazani MC3357). This review gives precedence to work examining such questions and/or attempting to incorporate possible answers in intervention programmes.

Factors that amplify HIV transmission Different incidences At the Seventh Conference and in the second decade to know AIDS, one looks to epidemiological and social research to address fundamental issues, paramount among which is why HIV spreads at disparate rates in different places (Piot, 1990). Why is heterosexual transmission more common and efficient in developing countries? Why is HIV apparently spreading faster in some African countries, including Uganda, Tanzania, Malawi, Zambia, Zimbabwe and Cote

Previous research on factors that amplify HIV transmission focused largely on (a) patterns of sexual behaviour, particularly the role of ‘core’ groups, hereafter called vulnerable groups (b) other STD, especially genital ulcer disease, and (c) absence of circumcision. This meeting added modest support for these factors. Further confirmatory findings emerged, albeit with similar methodological qualifications to earlier studies (e.g. Mertens, Hayes & Smith, 1990). What was heartening, however, as Sabatier (1991)

386 FLORENCE SUMMARIES: D. WILSON ETAL. noted, was the increased emphasis on embodying these hypotheses in interventions.

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Sexual behaviour Explications of possible origins and effects of different patterns of sexuality (e.g. Larsen, 1989) were largely absent, but a discerning paper by Knolle (MD4100) argued, applying matrix calculus to 11 sub-saharan societies, that where sexual mores, whether tolerating or interdicting pre- and extramarital sex, differ between sexes, age-discordant relations result and these facilitate HIV transmission. The economic underpinnings of prostitution are well recognized (Carael, MD4109), but this meeting also illustrated the interdigitation of commercial sex and other transactions and provided intimations of the vast, undocumented movements of women in search of economic opportunities. Ankrah (MD4246) noted that market-town women are at heightened risk for HIV infection. Wilson (WD4042) described how women in Zimbabwe who sell clothing and buy fish at fishing camps in Lake Kariba, Zimbabwe, often purchase truck and boat rides to camps with sex and exchange sex for fish. Many African trading women support families without male assistance and their resourcefulness may necessarily encompass exchanging sex, often their only convertible asset, for transportation, trading opportunities or merchandise. The role of vulnerable groups in heterosexual HIV transmission was simulated by Plummer (WC3065). Their micro-simulation involved 1,000 HIV-men and 1,000 HIV-women and several HIV-positive prostitutes. Inputs were: 30% monogamy among couples; 40% of general population change partners once every two years and visit partners 1-4 times a year and 30% change partners once a year and visit prostitutes 4-7 times a year; 0.5% probability of HIV infection in one contact with an HIV-positive prostitute; female-male and male-female infection rates of 0.2 and 0.25; and HIVpositive individuals die exponentially at an

annual rate of 20%. Without any intervention, HIV seroprevalence reached 11% in seven years. With an intervention emphasizing condom promotion and STD control, HIV seroprevalence was interrupted. This simulation attests to the importance of vulnerable groups in maintaining an HIV epidemic and to the efficacy of interventions among vulnerable groups. It illustrates that, even in areas of high HIV seropositivity, vulnerable groups, with their high incidence of STD and greater rate of partner change, contribute disproportionately to HIV dissemination. However, Elias (1991) prudently cautions that, where HIV seropositivity is high and resources are limited, any temptation to focus singularly on vulnerable groups must be resisted. Updates were presented for previously described prostitute interventions in Ethiopia (Geyid, WC3023), Kenya (Ngugi, WD4107), Nigeria (Williams, WD4041) and Zimbabwe (Nyathi, WD4001). Tuliza (MC2) presented impressive evidence of the impact of a clinic-based STD control and condom promotion programme among prostitutes in Kinshasa, Zaire. Over 22 months, regular condom use with clients increased from 4%-55% and annual HIV incidence declined from 18% to 2.2%. An increased focus on male vulnerable groups was apparent. Those included activities with prostitutes’ clients in Zimbabwe (Nyathi, WD4001), military in Ghana (Apeagyei, WD4239), fisherman in Zimbabwe (Wilson, WD4042) and truckers in Kenya (Omari, WC31 IS), Tanzania (Mwizarubi, MC3344; WD4017) and Zimbabwe (Wilson, MC104). A Tanzanian programme (Mwizarubi, WD4017), along the Dar es Salaam-Mbeya section of the TanzaniaZambia highway, which has distributed over 1.69 million condoms to truckers, travellers and their commercial partners over 20 months, is especially commendable. Several papers discussed the operations research lessons of programmes targetting vulnerable groups (Crane, WD56; Hassig, WD4011; Supulveda, TuD108; Welsh, WD4039). Fer-

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encic (TuC56) noted that most vulnerable group interventions are small scale and must be sustained beyond the start-up phase and expanded to other groups and sites.

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Circumcision

The association between absence of circum&ion and male HIV-seropositivity observed in earlier clinical and ecological studies was again reported in Kenya (Tyndall (WC4117) and Uganda (Hellmann, Other STD MC3080), where an intact foreskin conCross-sectional associations between HIV ferred a 5.9-fold increased likelihood of serand other STD were reported without causal oconversion. However, possible confounds, claims, but with perturbing discrepancies in including date of introduction of HIV to the specific STD associated with HIV (Disocieties and behavioural characteristics of ouf, MC3294; Hellmann, MC3080; Hunter, groups performing circumcision were not exWD4140; Kosia, MC3087; Mokwa, amined and the meeting was distinguished WC3251; Omari, WC3118; Pallangyo, less by the scientific impetus lent to the MC3214; Tyndall, WC3119; Zeking, circumcision hypothesis than by sociocultuWC3085; Zewdie, MC3145). Mokwa ral studies and its endorsement as an inter(WC3251) noted that STD rates among vention. Ronald (personal communication) pregnant women in Kinshasa were lower proposed offering it to HIV-males in discorthan in many other African cities and ofdant couples, both as an intervention and an fered this as one explanation for Kinshasa’s improved research design. Ankrah comparatively stable HIV prevalence. Wam(MD4086) noted that circumcision is unebugu (MC3061) noted that HIV infection venly practiced by several East African increased susceptibility to STD, potentially groups amongst whom it is culturally preincreasing viral shedding and amplifying scribed and advocated its revival. Her call is HIV transmission. O’Farrell (WC3079) realso apposite in southern Africa, where sevported that 36% of sample of Zulu men and eral cultures who advocate circumcision, inwomen reported sexual intercourse in the cluding the Sotho and Tswana, no longer presence of GUD. Fransen (MD4231) idenconsistently practice it. Sabatier (1991) emtified preoccupation with symptomatic men phasizes the desirability of reviving cultuand inability to reach less symptomatic rally sanctioned practices, instead of imposwomen as the principal gap in vertical ing culturally alien ones, for example, nonAIDSISTD control programmes and advopenetrative sex. However, Bassett (1991) cated closer integration of STD services for warns against the mesmerizing temptation, women with reproductive health proin the midst of encroaching pessimism over grammes. Her reminder is apposite: without health education, to seize on circumcision as innovative, effective approaches to STD an irreversible ‘magic bullet’ and others control among women, the resources likely question its feasibility as an intervention. to be devoted to STD control in Africa will Nonetheless, when evidence for its role is be wasted. Regrettably, with isolated excepweighed beside evidence against the efficacy tions (Hira, WC3082), the meeting consiof health education in Africa, it is hard to dered few of the broader developments beargue we have better hypotheses. ing - introduced or considered in STD control. These, in order of ascending controOther factors versy, include improvements in compliance management and partner notification, pro- Brown (MC3006) found that use of certain motion of greater STD awareness and treat- vaginal tightening agents by Zairean prostiment seeking behaviour, selective mass tutes caused inflammatory lesions which treatment of vulnerable groups and social may conceivably facilitate HIV infection. marketing of antibiotics. Hellmann (MC3079) found that sex induced

388 nORENCE SUMMARIES: D. WILSON ETAL. genital bruising or bleeding and sex during menses increased HIV susceptibility among Ugandan STD patients. Mati (WC3095) found no correlation between oral contraception and HIV infection.

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Converging medical and social foci Intimations of a constructive rapprochement between medical and social disciplines emerged within (Ankrah, MD4086; Franson, MD4231; Omari, WC3118; Ndoye, MD4296; Tuliza, MC2; Van der Veen WD4096; Van Pragh, WD59) and particularly outside the conference halls. Epidemiological research, elucidating the role of vulnerable groups, other STD and circumcision has provided windows of opportunity for intervention and while social scientists were and are right to deprecate the potentially censorious notions and phrases invoked, they were slow to focus on critical intervention implications. Interventions to protect vulnerable groups and their partners and to eradicate STD through community intervention, are likely to have been more effective against HIV transmission than the vague, diffuse responses, largely oblivious of epidemiological insights, that occurred. Tragically, such interventions are only likely to occur when HIV is widely disseminated and their relative contribution to HIV prevention, though considerable, has diminished. One hopes these lessons are not lost on developing countries still beyond the epicentre (e.g. Nigeria and South Africa). Recognition of co-factors such as vulnerable groups, other STD and circimcision enlarges, rather than diminishes, the role of social science, for medical practitioners alone cannot mount community programmes to reach vulnerable groups, people with STD, especially women or persuade communities to introduce or revive circumcision.

Condoms Condoms are clearly integral in prevention of vulnerable group infection and STD control. Much is made of putative African resis-

tance to condoms, but this meeting, as before, surely suggests otherwise. While overall condom use remains low (Carael, MD4109; Meyhyar, ThD62), the remarkable condom distribution of social marketing programmes in Cameroon and Zaire (Hassig, WD4011) and targetted interventions in Kenya (Ngugi, WD4017), Tanzania (Mwizarubi, WD4017), Zaire (Tuliza, MC2) and Zimbabwe (Nyathi, WD4001) illustrates what can be accomplished where condoms are available, affordable and actively promoted. Simply making condoms ubiquitous, affordable and intensely publicized may do more to advance their use than any amount of formal research on concomitants of condom use.

Mass education Ferencic (TuC56) reminder that targetted interventions have to date reached few people, together with Elias’ (1991) admonition against over-reliance on targetted programmes, reiterates the importance of concurrent mass education. Convisser (WD4297) of PSI supplemented the limited mass media in Zaire by promoting AIDS education through informal channels, including fairs, cultural and sporting activities, community meetings, shops, bars, markets and public transportation. The region exposed to informa1 avenues displayed better knowledge and attitudes did the control area. There was little other mention of mass education and the limited emphasis on comprehensive programmes in schools or workplaces is lamentable.

Vertical transmission This well represented area yielded sombre information: From Kenya, Datta (MC3) reported a vertical HIV-1 transmission rate of 48% and worse still, increased morbidity and mortality among HIV-negative children of HIV-positive mothers. In Zaire, both Kamenga (WC3244) and St Louis (MC3027) found maternal T 4 lymphocyte levels predicted perinatal HIV- 1 transmission rates.

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Adjorlolo (MC3053) in Cote d’Ivoire and Prazuck (MC3089) in Burkina Faso found HIV-1 more transmissible than HIV-2. Lallemant (MC3077; MC3078) in Congo and Zadi (WC3252) in Cote d’Ivoire found death of a previous infant (which may reflect length of HIV-1 infection) predicted vertical HIV-1 transmission. Disturbingly, Kreiss (MC3062) in Kenya found only 10% of infants had HIV-1 in cord blood, versus 20-40% at 1.5-9 months, suggesting peri- or postnatal infection (including breastmilk infection) may be more common than in utero transmission. Hu (WC3071) presented a decision analysis model for breastfeeding and noted that the model favoured continued endorsement of breastfeeding. Socioeconomic impact McGrath (MD4261) interviewed people with HIV/AIDS in Kampala, Uganda, who disclosed that, especially during physical wasting, they feared neighbours’ reactions and withdrew from social and economic activities outside the household. In Kinshasa, Zaire, Kamenga (TuD59) obtained an orphan incidence among newborns of 2.81100 years follow up and concluded earlier reports had overestimated the incidence of orphans. They also studied quality of care-using clothing/shoes, school attendance, purchase of schoolbooks, nutritional status and morbidity as indicatorsreceived by the orphans, all of whom were living with relatives and observed no differences between them and controls. In contrast, Haworth (MD4264) studied AIDS counsellors’ case reports in Zambia and found evidence of food shortages, family disruption and discontinued education. Zambia’s greater case burden may partly explain the difference between these two studies. Norse (TuD57) analyzed the possible impact of AIDS on food production in Malawi, Rwanda and Tanzania and concluded that, by 2000, up to 25% of farm households in these countries could be affected. He predicted that affected households would abandon labour-intensive crops, such as to-

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bacco, which requires 2,500 hours labour per hectare, for less labour-intensive crops, including groundnuts and cassava. A decline in income and nutritional levels would result. Increasing HIV infection and illness among men working in towns would erode remittances, exacerbating rural poverty. He predicted that female-headed households would be most vulnerable and advocated labour saving measures, such as providing villages with piped water, electricity and nearby tree plantations for fuelwood.

Conclusion Time has affirmed foreboding about AIDS education in a region beset by conflict, dislocation, drought, disease, illiteracy, gender inequality and economic hardship. Ferreros (WD4125) perceptively observed that, while AIDS workers have hitherto welcomed policy that simply fails to impede prevention, given the litany of problems described above and the dire increase in HIV infection, nothing less than exhaustive revamping of policy, to ensure it enables and enkindles AIDS prevention, will suffice. At each level, policy must seek to weave AIDS activities in every strand of life, to concentrate the most disparate channels and resources upon the crisis and to elevate our response to that of a struggle for our very survival, befitting natural disaster or war.

References BASEIT, M. (1991) Moderator’s comments. Presented at the Zimbabwe Public Health Association Forum on the Seventh International AIDS Conference, Harare, Zimbabwe, 2 July. ELIAS,C. (1991) Sexually transmitted diseases and the reproductive health of women in developing countries (Population Council Working Paper, New

York).

LARSEN, A. (1989) Social context of HIV transmission in Africa: historical and cultural bases of East and Central Africa sex relations, Review of Infectious Diseases, 11, pp. 716-731.

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MERTENS,T.E., HAYES,R.J. & SMITH, P.G. (1990). Epidemiological methods to study the interaction between HIV infection and other sexually transmitted diseases, AIDS, 4, pp. 57-65. PIOT, P., LAGA,M., RYDER,R., PERRIENS, J., TEMMERMAN, M., HEYWARD, W. & CURRAN, J. (1990) The global epidemiology of HIV infection: Continuity, heterogeneity, and change, Journal of Acquired Immune Deficiency Syndrome, 3, pp. 403-412.

SABATIER, R. (1991) Repwtfrom Florence. Presented at the Zimbabwe Public Health Association Forum on the Seventh International AIDS Conference, 2 July, 1991. TORREY, B.B. & WAY, P.O. (1990) Seroprevalence of HIV in Africa: Winter 1990. CIR Staff Paper No. 55 (US Bureau of the Census, Washington, USA).

AIDS in Africa.

Works on epidemiological, and social and behavioral science aspects of AIDS prevention and support in Africa are reviewed from the 7th Conference on A...
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